“Active Feedback” Fitbit-Based Physical Activity and Sleep Hygiene Intervention for Memory Assessment Service (MAS) Patients with Cognitive Deficits: Feasibility, Acceptability, Sleep Quality, Stress, and Wellbeing Outcomes

Research Background: Compared to the general population, people experiencing age-related cognitive decline are more likely to have low levels of physical activity and sleep problems. Sufficient physical activity and quality sleep are protective factors against cognitive decline and poor health and can improve coping with stressors. The “Active Feedback” intervention comprises a wearable activity and sleep tracker (Fitbit), access to Fitbit software healthy lifestyle software apps;one session with Memory Assessment Service (MAS) staff providing physical activity and sleep hygiene advice and two further engagement, discussion, and feedback sessions. Purpose/Aim: This study investigates the acceptability and feasibility of Active Feedback and the effect on stress, mental wellbeing, and sleep quality, and the links between these factors. Methods: An open-label patient cohort design with no control group was used. Pre-intervention, 4-week and 8-week intervention assessments were performed using participant self-report measures: Perceived Stress Scale (PSS), Warwick-Edinburgh Mental Wellbeing Scale (WEMWBS), and Sleep Conditioning Index (SCI). Twenty-five participants completed an eight-week three-session intervention (18 males and 7 females), with the age range of 66 - 84 years old, and average age of 73.8 years (SD = 5.09). Fifteen participants had a diagnosis of MCI, ten participants did not. Results: There were non-significant improvements in SCI scores from 21.0 (SD = 8.84) to 21.6 (SD = 6.20) at 8 weeks, PSS scores from 17.5 (SD = 5.89) to 17.0 (SD = 6.20) at 8 weeks, and WEMWBS scores from 46.9 (SD = 9.23) to 48.8 (SD = 9.69) at 8 weeks. There were negative correlations between WEMWBS and PSS. Conclusion: Active Feedback intervention was found to be feasible and acceptable. Active Feedback could be enhanced to include motivational interviewing and goal setting.

The Experience and Impact of a Fitbit-Based Physical Activity and Sleep Hygiene Intervention for Older Adults Experiencing Cognitive Decline

Objectives: This study aimed to understand the experience and impact of a physical activity and sleep wrist-worn tracker (Fitbit)-based healthy lifestyle intervention for older patients attending a memory assessment service, who are experiencing cognitive impairment but do not receive a dementia diagnosis. Methods: A qualitative design was employed. Semi-structured interviews were conducted with a purposeful sample of thirteen participants recruited from a memory assessment service. Thematic analysis, that was data driven and inductive, was undertaken to analyse the data. Results: Two global themes were developed. “Understanding exercise and sleep as part of my lifestyle” was made up of themes representing how participants viewed exercise and sleep as part of their lifestyles in terms of acknowledging the positive impacts and the barriers to exercise and sleep. The second global theme “Understanding my experience of the healthy lifestyle intervention” was made up of themes that identified the positive impact of the intervention regarding improving health and wellbeing, enabling validation of proactive behaviours and motivation to engage in healthy lifestyle behaviours, so promoting positive behaviour change. Conclusion: Patients experiencing age-related cognitive impairment, applied and benefited from a healthy lifestyle Fitbit-based intervention to facilitate and promote physical activity, better sleep hygiene and healthy lifestyles.

“Flow” Transcranial Direct Current Stimulation (tDCS) for Depression Treatment in a Primary Healthcare General Practice—An Open-Label Cohort Study Measuring Montgomery-Åsberg Depression Rating Scale (MADRS-S) Outcomes

Background: Flow FL-100 is a transcranial direct current stimulation (tDCS) device self-administered by a patient at home in combination with a software application delivered wellbeing behaviour therapy training. tDCS has evidence of effectiveness in treating symptoms of depression. Purpose/Aim: This post marketing study evaluated the effect of Flow on depression for primary care general practice patients with depression symptoms. Methods: Open-label patient cohort design with no control group. Inclusion criteria were aged 18 years or over and reporting depression symptoms. Participants self-administered five 30 minute tDCS sessions per week for the first three weeks, and then 3 sessions per week following this. Three, six and ten week assessment with participant self-report measure: Montgomery- Åsberg Depression Rating Scale (MADRS-S). Results: MADRS-S remission rates were between 29% - 30% at three weeks, 33% - 34% at six-weeks and 50% at 10-weeks treatment. There was a significant improvement in MADRS-S with large effect sizes at all time points. Conclusions: Flow tDCS can be delivered through a primary healthcare general practice service and patients will choose to use. Flow tDCS provides an effective depression treatment in addition and as an alternative to antidepressants and psychotherapy. tDCS has evidence as an effective depression treatment, and the widespread availability of tDCS in primary care general practice should be considered.

Understanding the Underlying Mechanisms of Action for Successful Implementation of Social Prescribing

There is growing evidence for the use of social prescribing as a means of facilitating healthy lifestyle behavior changes by linking patients to sources of support in the community. However, there are gaps in understanding about what works to facilitate and enable this behavior change i.e. , the mechanisms of actions underpinning social prescribing delivery. This study used a qualitative approach involving interviews with 18 Social Prescription Link Workers (SPLWs). Reflective thematic analysis was used to analyze the data. Through this, an overall theme of “Theoretical underpinning: Solution-focused and strengths-based” was identified. This was made up of sub-themes relating to mechanisms underpinning: the SPLWs’ role (comprising asking questions, motivational interviewing and the therapeutic alliance);the patients’ role, (empowerment and active engagement);and the approach adopted (solution building, goal and action orientated). To formalize this, a framework could be developed for SPLWs that encapsulates the solution-focused strengths-based approach for application within social prescribing. This framework can then be embedded into practice facilitating more successful healthy lifestyle behavior change for social prescribing patients.

“Well-Track”: Fitbit Based Physical Activity and Sleep Hygiene Intervention for Early Intervention in Psychosis (EIP) and At-Risk Mental State (ARMS) Service Patients

Background: Compared to the general population, people who are at a high risk of or experience severe mental illness (SMI) such as psychosis, are more likely to have low levels of physical activity, high levels of sedentary behaviour, and sleep problems. Intervention: The Well-Track intervention comprises a wearable activity and sleep tracker (Fitbit);one session with mental health service staff providing physical activity and sleep hygiene advice;a brief motivational interview;completing a goal setting workbook;and one or two further engagement, feedback and discussion sessions. Participants: Twenty-four participants using an early intervention in psychosis (EIP) or at-risk mental state (ARMS) service completed an eight-week, three session intervention (14 males and 10 females), with an age range of 18 - 61, and average age of 27.75 years. Methods: An open-label patient cohort design with no control group. Pre-intervention, 4-week and 8-week intervention assessments using participant self-report measures: Patient Health Questionnaire (PHQ-9) (depression), Warwick–Edinburgh Mental Wellbeing Scale (WEMWBS), and Sleep Conditioning Index (SCI);and clinician measurement of body weight. Results: Mean scores showed a significant improvement in PHQ-9 from 9.29 (SD 5.89) to 5.58 (SD 3.68) at 4 weeks and to 5.83 (SD 4.40) at 8 weeks, with large effect sizes. For those who met a diagnosis of depression at baseline, at 4 week follow-up seven participants (26%) experienced remission and nine (33%) reliable improvement, and at 8 week follow-up four (21%) experienced remission and seven (37%) reliable improvement. WEMWBS scores significantly improved, from 44.04 (SD 9.44) to 48.54 (SD 8.71) at 4 weeks and to 48.67 (SD 8.76) at 8 weeks, with large effect sizes. Body weight did not change significantly, remaining unchanged at 4 weeks and reduced from a mean of 82.8 kg (baseline) to 80.15 kg at 8 weeks, a reduction of 2.65 kg. Conclusion: Well-Track was integrated into an EIP and ARMS service and was found to be beneficial in terms of wellbeing, depression, sleep, and preventing weight gain (either as a two or three engagement point intervention). Well-Track could be delivered through EIP and ARMS services to promote healthy lifestyle behaviours.

Experience and Impact of the “Well-Track” Physical Activity and Sleep Tracker Based Healthy Lifestyle Intervention for Patients in an Early Intervention in Psychosis (EIP) Service

Background: Physical activity and sleep are interconnected with mental health, physical health, wellbeing, quality of life, cognition, and functioning. Compared to the general population, people who experience psychosis are more likely to have low levels of physical activity, high levels of sedentary behaviour, and sleep problems. Intervention: The Well-Track intervention addresses these issues through: provision of a wearable activity and sleep tracker (Fitbit);physical activity and sleep hygiene advice;a brief motivational interview;a goal-setting workbook;and three engagement, feedback and discussion sessions with early intervention in psychosis (EIP) staff. Participants: Thirty participants using an EIP service took part in an eight-week intervention. Thirteen participants (6 males;7 females) with an age range of 18 to 61 years old (M = 28 years) took part in an interview. Methods: A qualitative approach was used to conduct in-depth semi-structured interviews. Thematic and content analyses were employed to analyse the data. Results: Participants set goals, made lifestyle changes to their daily routine and integrated a Fitbit and its functions into their lives that resulted in more physical activity and enabled more effective sleep. This resulted in improved self-management, positive feelings and thoughts, motivation, confidence, social engagement, mood, health, and wellbeing. Participants made progress towards goals they had set. Conclusion: Well-Track has been successfully integrated into an EIP service and it could be delivered through all EIP and other healthcare services where there is a need to promote healthy lifestyle behaviours.

Social Prescribing through Primary Care: A Systematic Review of the Evidence

Background: In primary care, social prescribing (SP) is where a patient is referred to a “link worker”, who considers their needs and then “prescribes” or connects them to appropriate community-based resources and services. Recent policy and guidance in the UK has significantly expanded the provision of SP to improve patient health and wellbeing. Methods: This study conducted a systematic review of evidence for SP effectiveness and to report needs addressed, interventions provided, and behaviour change techniques employed. Inclusion criterion was patient referral from primary care to a SP link worker. Online databases were searched for studies published from February 2016 to July 2021. Searches were restricted to English language only. Risk of bias assessment and a narrative analysis were undertaken. Results: Eight studies were included. All studies reported some positive outcomes. There were weaknesses and limitations in study design and in reporting of results: a lack of comparative controls, short duration and single point follow-up, a lack of standardised assessments, missing data, and a failure to consider potential confounding factors. All studies had features which indicated a high risk of bias. Conclusion: Evidence for the value and positive impact of SP is accumulating, but evaluation design remains relatively weak. There is a need to improve evaluation through robust methodological design and the adoption of universal outcome measures and evaluation/analytical framework. SP should seek to assess patient wellbeing, self-management, and quality of lifeoutcomes systematically, and adopt behaviour change techniques to enable healthier lifestyles in the short and long term.

A Qualitative Study of Early Intervention Psychosis (EIP) Service Patient’s Experience of Sleep, Exercise, Sleep Hygiene Advice and Fitbit Wearable Activity and Sleep Tracker

Background: In psychosis physical activity, sleep, mental health, physical health, wellbeing, quality of life, cognition and functioning are interconnected. People who experience psychosis are more likely than the general population to have low levels of physical activity, high levels of sedentary behaviour and sleep problems. This project was innovative in seeking to address these issues through provision of a wearable activity and sleep tracker (a Fitbit) and sleep hygiene advice. Participants: Participants using an early intervention psychosis (EIP) service took part in an eight-week intervention, which incorporated the provision of a Fitbit, sleep hygiene advice as well as three engagement, feedback and discussion points with a clinician. Methods: A qualitative approach was used to conduct in-depth semi-structured interviews with 12 of the 25 intervention participants (5 male;7 female). Thematic and content analyses were employed to analyse the data. Results: Participants provided valuable insights into their experience of sleep, exercise, Fitbit use and sleep hygiene advice use. It was found that participants placed a high value on effective night time sleep, recognized improvements in physical activity and noted a positive effect on mood and wellbeing as a result of Fitbit use. The negative impact of having ineffective night time sleep and insufficient physical activity was described. Participants demonstrated a good level of understanding of the connection between sleep, exercise, wellbeing, and health. Conclusion: Participants reported the Fitbit and sleep hygiene advice received through an EIP service to be beneficial for improved levels of physical activity and exercise, and more effective sleep. This is a simple and low cost intervention which could be made widely available through EIP and other mental health services.

Alpha-Stim Cranial Electrotherapy Stimulation (CES) for Anxiety Treatment: Outcomes in a United Kingdom (UK) Primary Care Practice

Background: Anxiety disorders are the most common mental disorders, typically treated with psychotherapy and medication. These treatments are not suitable for, acceptable to, or effective for everyone. Alpha-Stim AID is a Cranial Electrotherapy Stimulation (CES) treatment with evidence of effectiveness in treating anxiety disorders. Objective: The aim of this paper is to present outcomes on anxiety, depression, and quality of life of Alpha-Stim use in primary care patients in the United Kingdom’s (UK) National Health Service (NHS) who reported symptoms of anxiety. Methods: Open label patient cohort design. Self-report measures: PHQ-9 (depression), GAD-7 (anxiety) and EQ-5D-5L (health related quality of life). Twenty-three patients with symptoms of anxiety completed a six-week course of Alpha-Stim intervention. Results: Reliable improvement and remission rates respectively were 60.9% and 17.4% for the GAD-7;42.9% and 22.7% for the PHQ-9. Significant improvement and medium/large effect sizes (n2 = 0.59 and 0.56 respectively). EQ-5D-5L results showed significant improvements in quality of life. Perceived quality of life doubled with an improvement of 0.36 on the health index score, this intervention adds 3.64 Quality Adjusted Life Years (QALYs). Limitations: The study was not an RCT, there was no control group. Conclusions: Alpha-Stim AID CES can be delivered through a UK primary care practice, and can have a significant impact on symptoms of anxiety and depression, and improve quality of life in primary care patients with anxiety symptoms. Further feasibility studies in primary care and sufficiently powered RCT are required.

Integrated Review of Lifestyle Interventions Targeting Diet and Exercise in Early or First-Episode Psychosis

Aims: Life expectancy is reduced by 10 - 20 years in psychotic disorders compared with the general population, largely due to high incidence of physical health disorders: heart attack, stroke, obesity, cardiovascular disease (CVD), and type 2 diabetes. Early or first-episode psychosis patients can be especially vulnerable to physical health, psychological and social consequences of antipsychotic medication weight gain. The aim of this paper is to review diet and exercise lifestyle interventions employed to address these issues. Method: A review of research evidence on lifestyle interventions (diet and exercise) for individuals with early or first-episode psychosis (2000 to 2020) was undertaken. An internet-based literature search employed Medline, PsycINFO, Embase, PubMed and Web of Science. Results: Nine studies meeting the criteria were identified: comprising of three exercise intervention studies, one diet intervention study, and five combined diet and exercise intervention studies. Only one study used a RCT design with prior power analysis to determine participant numbers, two had a RCT design, two had a comparison group and four had no control group. Overall, these studies show that exercise and diet focused interventions may provide beneficial physical and mental health outcomes, but participant engagement and behaviour change may be difficult to achieve in early or first-episode psychosis due to individual factors associated with the experience of psychosis and medication prescribed, and health service related factors. Conclusion: There is a need for evidence-based lifestyle programmes in early or first-episode psychosis that includes individually targeted evidence based exercise and diet interventions. Further appropriately powered RCTs are required to strengthen the evidence base.

Effectiveness of a Fitbit Based Sleep and Physical Activity Intervention in an Early Intervention Psychosis (EIP) Service

Purpose: Compared to levels in the general population, people with experiences of psychosis have poorer physical fitness, more sedentary behaviour, lower physical activity, more sleep problems, and a higher incidence of insomnia. The aim of the current study was to examine the feasibility and impact of an intervention with the goal of addressing these issues. Method: Design: intervention with outcome measure data collection, with no control group. Forty-nine early intervention psychosis (EIP) service patients took part in an intervention: provision of a Fitbit, Fitbit software apps, sleep hygiene, and physical activity guidance, and three discussion sessions with clinicians. The sample consisted of 29 males and 20 females, with age range of 17 - 54 years, and average age of 29.5 years. Measures used were Fitbit activity and sleep data, and self-rated Warwick–Edinburgh Mental Wellbeing Scale (WEMWBS) and Positive and Negative Affect Schedule (PANAS). Results: WEMWBS scores significantly improved, with a medium effect size. PANAS negative affect (NA) dropped significantly. Analysis of Fitbit activity and sleep data yielded non-significant results. Conclusion: The intervention was acceptable to EIP patients and is feasible. Improvements in mental wellbeing and negative affect indicate the positive impact of the intervention on mental health. EIP services should consider assessing sleep quality and physical activity/exercise levels, and using this study’s intervention to promote wellbeing and mental health within recovery focused practice. Further research could be undertaken through a sufficiently powered randomised control trial (RCT) comparing this intervention and treatment as usual (TAU).

Wearable Physical Activity and Sleep Tracker Based Healthy Lifestyle Intervention in Early Intervention Psychosis (EIP) Service: Patient Experiences

Background: Physical activity, sleep, mental health, physical health, wellbeing, quality of life, cognition, and functioning in people who experience psychosis are interconnected factors. People experiencing psychosis are more likely to have low levels of physical activity, high levels of sedation, and sleep problems. Intervention: An eight-week intervention;including the provision of a Fitbit and its software apps, sleep hygiene and physical activity guidance information, as well as three discussion and feedback sessions with a clinician. Participants: Out of a sample of 31 using an early intervention psychosis (EIP) service who took part in the intervention, fifteen participants consented to be interviewed—9 (60%) males and 6 (40%) females, age range: 19 - 51 years, average age: 29 years. Method: In-depth interviews investigating patient experience of the intervention and its impact on sleep, exercise, and wellbeing were undertaken. Thematic analysis was applied to analyse the qualitative data and content analysis was used to analyse questions with a yes/no response. Results: Most of the participants actively used the Fitbit and its software apps to gain information, feedback, and set goals to make changes to their lifestyle and daily routines to improve quality of sleep, level of physical activity, and exercise. Conclusion: The intervention was reported to be beneficial, and it is relatively easy and low cost to implement and therefore could be offered by all EIP services. Furthermore, there is potential value for application in services for other psychiatric disorders, where there is often a need to promote healthy lifestyle, physical activity, and effective sleep.