A Smartphone-Based Self-management Intervention for Bipolar Disorder (LiveWell): User-Centered Development Approach

Abstract

Background Bipolar disorder is a serious mental illness that results in significant morbidity and mortality. Pharmacotherapy is the primary treatment for bipolar disorder; however, adjunctive psychotherapy can help individuals use self-management strategies to improve outcomes. Yet access to this therapy is limited. Smartphones and other technologies have the potential to increase access to therapeutic strategies that enhance self-management while simultaneously providing real-time user feedback and provider alerts to augment care. Objective This paper describes the user-centered development of LiveWell, a smartphone-based self-management intervention for bipolar disorder, to contribute to and support the ongoing improvement and dissemination of technology-based mental health interventions. Methods Individuals with bipolar disorder first participated in a field trial of a simple smartphone app for self-monitoring of behavioral targets. To develop a complete technology-based intervention for bipolar disorder, this field trial was followed by design sessions, usability testing, and a pilot study of a smartphone-based self-management intervention for bipolar disorder. Throughout all phases of development, intervention revisions were made based on user feedback. Results The core of the LiveWell intervention consists of a daily self-monitoring tool, the Daily Check-in. This self-monitoring tool underwent multiple revisions during the user-centered development process. Daily Check-in mood and thought rating scales were collapsed into a single wellness rating scale to accommodate user development of personalized scale anchors. These anchors are meant to assist users in identifying early warning signs and symptoms of impending episodes to take action based on personalized plans. When users identified personal anchors for the wellness scale, the anchors most commonly reflected behavioral signs and symptoms (40%), followed by cognitive (25%), mood (15%), physical (10%), and motivational (7%) signs and symptoms. Changes to the Daily Check-in were also made to help users distinguish between getting adequate sleep and keeping a regular routine. At the end of the pilot study, users reported that the Daily Check-in made them more aware of early warning signs and symptoms and how much they were sleeping. Users also reported that they liked personalizing their anchors and plans and felt this process was useful. Users experienced some difficulties with developing, tracking, and achieving target goals. Users also did not consistently follow up with app recommendations to contact providers when Daily Check-in data suggested they needed additional assistance. As a result, the human support roles for the technology were expanded beyond app use support to include support for self-management and clinical care communication. The development of these human support roles was aided by feedback on the technology's usability from the users and the coaches who provided the human support. Conclusions User input guided the development of intervention content, technology, and coaching support for LiveWell. Users valued the provision of monitoring tools and the ability to personalize plans for staying well, supporting the role of monitoring and personalization as important features of digital mental health technologies. Users also valued human support of the technology in the form of a coach, and user difficulties with aspects of self-management and care-provider communication led to an expansion of the coach's support roles. Obtaining feedback from both users and coaches played an important role in the development of both the LiveWell technology and human support. Attention to all stakeholders involved in the use of mental health technologies is essential for optimizing intervention development.

In Search of Digital Dopamine: How Apps Can Motivate Depressed Patients, a Review and Conceptual Analysis

“…LiveWell [ 35 ] is another low complexity EMA + EMI user-centered smartphone app used primarily for bipolar disorder patients. The EMA component is Daily Check-in (sleep, routine, wellness, medication, expectations, social interactions, other personal goals) associated with “Daily Review” bar graphs that indicate the percentage bars corresponding to goal achievements over the past week.…”

“…For review, see [29,30]. IYM [31] CBT2go [32] PsyMate [33] Help4Mood [34] LiveWell [35] Smart-EMA EMA triggered by another EMA component (for example a questionnaire that is triggered by a certain location, or by a cutoff on another questionnaire). n.s.…”

A Smartphone-Based Self-Management Intervention for Individuals with Bipolar Disorder (LiveWell): Qualitative Study on User Experiences of the Behavior Change Process

“…Following the face-to-face meeting, participants completed six phone calls (weeks 1-4, 6, and 8) during which the coach used structured scripts to support app use adherence, development of personalized wellness plans, self-management strategy use, and communication with clinical care providers [ 40 ]. To provide feedback about the intervention’s impact on app usability, target behavior change processes, and clinical and recovery outcomes, participants completed a structured exit interview ( Multimedia Appendix 1 ) and an exit questionnaire after completing the pilot study [ 19 ].…”

“…The LiveWell intervention has technological and human support components that include a smartphone app, secure server and website, and coach. The smartphone app has five components: Foundations, Toolbox, Wellness Plan, Daily Check In, and Daily Review [ 19 , 41 ]. The core of the intervention is the Daily Check In, which helps participants monitor behavioral targets proposed to be important for managing BD and staying well (medication adherence, sleep duration, routine, managing signs and symptoms) [ 10 , 11 ].…”

“…Over the last decade, MHTs have been developed for various mental health challenges [ 19 - 21 ]. Among individuals with BD, research indicates high rates of smartphone ownership [ 22 ] as well as interest and willingness to access BD-related information via technology [ 23 ].…”