Background Individuals experiencing psychosis are at a disproportionate risk for premature disengagement from clinical treatment. Barriers to clinical engagement typically result from funding constraints causing limited access to and flexibility in services. Digital strategies, such as SMS text messaging, offer a low-cost alternative to potentially improve engagement. However, little is known about the efficacy of SMS text messaging in psychosis. Objective This review aimed to address this gap, providing insights into the relationship between SMS text messaging and clinical engagement in the treatment of psychosis. Methods Studies examining SMS text messaging as an engagement strategy in the treatment of psychosis were reviewed. Included studies were published from the year 2000 onward in the English language, with no methodological restrictions, and were identified using 3 core databases and gray literature sources. Results Of the 233 studies extracted, 15 were eligible for inclusion. Most studies demonstrated the positive effects of SMS text messaging on dimensions of engagement such as medication adherence, clinic attendance, and therapeutic alliance. Studies examining the feasibility of SMS text messaging interventions found that they are safe, easy to use, and positively received. Conclusions Overall, SMS text messaging is a low-cost, practical method of improving engagement in the treatment of psychosis, although efficacy may vary by symptomology and personal characteristics. Cost-effectiveness and safety considerations were not adequately examined in the studies included. Future studies should consider personalizing SMS text messaging interventions and include cost and safety analyses to appraise readiness for implementation.

IntroductionWhile nearly half of all new psychotic disorders are diagnosed in the emergency department (ED), most young people who present to the ED with psychosis do not receive timely follow-up with a psychiatrist, and even fewer with evidence-based early psychosis intervention (EPI) services. We aim to test an intervention delivered using short message service (SMS), a low-cost, low-complexity, youth-friendly approach, to improve transitions from the ED to EPI services.Methods and analysisThis is a protocol for a pragmatic randomised, single blind, controlled trial with accompanying economic and qualitative evaluations conducted at the Centre for Addiction and Mental Health (CAMH) in Toronto, Canada. A consecutive series of 186 participants aged 16–29 referred by the ED to CAMH’s EPI programme will be recruited for a trial of a two-way intervention involving reminders, psychoeducation and check-ins delivered via SMS. The primary outcome will be attendance at the first consultation appointment within 30 days of study enrolment assessed through chart reviews in the electronic health record. We will also extract routine clinical measures, including the Brief Psychiatric Rating Scale, Clinical Global Impression and Service Engagement Scale, and link with provincial health administrative data to examine system-level outcomes, including ED visits and psychiatric hospitalisations, 6 months and up to 2 years after baseline. We will perform a cost-effectiveness analysis of the primary study outcome and costs incurred, calculating an incremental cost effectiveness ratio. Web-based surveys and qualitative interviews will explore intervention user experience. Patients and families with lived experience will be engaged in all aspects of the project.Ethics and disseminationResearch Ethics Board approval has been obtained. Findings will be reported in scientific journal articles and shared with key stakeholders including youth, family members, knowledge users and decision makers.Trial registration numberNCT04298450.

Background Clinical disengagement of youth in early psychosis clinics continues to be a significant barrier to recovery as evidenced by high rates of treatment non-adherence (up to 60%) and clinic drop-out (30%). Disengagement from services results in longer durations of untreated/partially-treated illness, which in turn leads to higher rates of symptom burden, re-hospitalization, and poorer functional outcomes. Approaches aimed at improving engagement have typically hinged on efforts to increase access to clinicians either via telephone or in person, however financial and human resource limitations often undermine these efforts. This has caused a shift toward the use of SMS due to its low cost and popularity as 95% of youth in North America send and receive SMS messages daily. The current randomized controlled trial sought to evaluate the efficacy of a weekly SMS intervention delivered over nine months to improve engagement in early psychosis services. Methods 60 participants between the ages of 16 and 29 presenting with a first episode psychosis to an early psychosis clinic in an academic health centre were recruited for this study. Participants were randomized to either an active or sham SMS intervention arm, delivered weekly for nine months. Participants were blind to treatment allocation. The active SMS intervention consisted of weekly SMS messages with adaptive questions regarding general wellbeing, clinic attendance and medication adherence, while the sham SMS arm consisted of a weekly generic text message with no clinically relevant subject matter. Results All participants have been enrolled, with the final study visits to be completed in December 2019. Results presented will include analyses of efficacy of the active versus sham SMS intervention for improving service engagement, our primary outcome, consisting of self-reported medication adherence, clinician and client rated engagement, and attendance rates extracted from electronic medical charts. In addition, symptom and functional outcomes were assessed over the course of the nine month intervention across the active and sham intervention groups, which will also be presented. Feasibility data collected to date indicates a high degree of interest and acceptance by participants for the use of SMS as a means of engagement. Further, there have been no tolerability difficulties reported by participants to date. Discussion The high rates of disengagement from clinical services seen among youth and emerging adults with early psychosis indicate a need for effective interventions to promote engagement in treatment and support symptomatic and functional recovery for affected individuals. The results of this trial stand to offer insights into the potential efficacy of a simple weekly SMS intervention to promote engagement in clinical services for this population. The acceptability of this intervention by participants, coupled with its low cost and the popularity of SMS, suggest that this treatment approach, if effective, could be readily implemented within early psychosis services to support positive outcomes from an initial psychosis episode.