Hello, and welcome. Thank you for joining the Third National Conference on Advancing Early Psychosis Care in the United States presented by SMI Advisor. My name is Robert Heinsohn, and I'm the Director of the Division of Services and Intervention Research at the National Institute of Mental Health. Now I'd like to introduce you to the faculty for today's session, Mario Alvarez-Gimenez. Professor Mario Alvarez-Gimenez is the founder and director of Origin Digital, a 21st century enhancement of the landmark research, education, and clinical care program for youth mental health established by Patrick McGorry at the University of Melbourne in Australia. Over the last decade, Mario has established Origin Digital as a leading clinical innovation and research center that develops, evaluates, and implements digital mental health interventions for youth. His program of pioneering research focuses on enhancing the accessibility, long-term impact, and cost-effectiveness of youth mental health services within Australia and across the globe. On a personal note, I can attest that Mario is a scientist clinician of the first rank. He's a respectful and empathetic individual who understands the needs and perspectives of young people experiencing early psychosis. He has deep knowledge of interventions that are most useful to promote recovery. And he has a bold vision for reimagining and retooling these interventions with technology, but in a manner that deepens human connections. Today Mario will tell us about the moderated online social therapy platform that is now being rolled out across 41 youth mental health services in the Australian state of Victoria. The MOST program will constitute the first large network of digitally enhanced youth mental health services anywhere in the world. I know that our audience in the United States is going to find this talk of great interest in that so many of us have had to shift our typical practice from face-to-face service delivery to telehealth and digital interventions. Mario's work is going to give us a peek into what our future might look like. Could I have the next slide, please? Professor Alvarez-Gimenez reports no financial relationships with commercial interests and no conflicts of interest. So now it's with great pleasure that I turn the presentation over to Mario. Mario, take it away. Many things. Well, for such a kind introduction, it's really one of the, you know, the kindest interaction I ever had in a conference. And I just wanted to also thank you all for the opportunity to be here to talk to you about some of the work that we've been doing in Australia for the past 10 years. So it really is a privilege to be here with you all and have a lot of friends and collaborators in the U.S. And I also wanted to send you all the very best wishes in the midst of COVID and everything that's happening in the U.S. as well. I really hope that your families are safe and well. So a little bit about the learning objectives. You can read them there, but it's about what I would like to cover is just to summarize the state of early psychosis field and particularly with a focus on promoting long-term recovery. I will talk to you guys about models of digital interventions and how we can develop digital interventions designed to enhance and to promote and to integrate with mental health services rather than to replace what is already available. And I would like to talk to you about the limitations of digital interventions as well. Of course, this is not going to fix everything. It's just something that can be there as a tool to address some of the gaps and issues that we've got in the field. So I've got, I hope you don't mind me making a couple of little jokes. This is a slide that I presented a couple of years ago at the APA. So some of you might have seen this, but it's actually the best slide I ever found in terms of what social media has done to us. How technology has really changed the way we look at each other. And this is particularly true for young people. So just a little bit about the journey that we've gone through in technology from origin digital and I personally over the past, now coming up to 11 years. So my work was on relapse prevention for young people with psychosis, and I became really frustrated with the lack of maintenance of treatment effects for young people with psychosis beyond early intervention services and also beyond CBT interventions and pharmacological interventions as well. So when I came to technology, when I finished my PhD, I really did so from a place of hope and a lot of enthusiasm as well. I thought that technology could be the answer to many issues and challenges that we're facing in youth mental health as a whole. For example, you know that the majority of young people with mental ill health and their families have limited access to evidence-based support. And I thought, well, you know, technology is very pervasive. It's everywhere. But at least in Australia, and it's the case in many places around the world, even when young people access treatment and they get better, we can only provide time-limited support. And we know that the majority of young people with complex depression, for example, or psychosis will go on to experience relapses from their mental health conditions leading to long-term disability. And we thought, well, technology is permanent as well. We know that our interventions are not particularly engaging. In Australia, young people attend only one to two sessions of psychological treatment in youth mental health services, which is not enough therapeutic dose in many cases. And we know that engagement with first-person psychosis services continues to be an issue. And we thought, well, we know that technology is very, very compelling. And finally, our interventions are not particularly effective at dealing with some key issues for young people, such as making them more socially connected, improving their wellbeing, or even finding a job. And we thought, well, maybe social media can do something about that. So the thinking back then was, well, technology is here to help and potentially to even bring about a revolution in the field. But has it really done it? I'm just going to spend five, six minutes being quite skeptical about what technology has done, if I may. So just a little bit about what the current situation is. You know, on the one hand, we've got the tech companies, Facebook, Instagram, Snapchat, TikTok, and others. Their aim is to make money, obviously, and it's a fair aim, but that's their aim. And to do that, they need to continue to grow as much as possible. And on the other hand, we've got the field of digital mental health. And this is interventions developed for the most part by universities and researchers like us, and also some tech companies. And obviously, we don't have the same resources, we don't have the same reach, we don't have the same cool logos, but we do have an honorable aim. We really want to improve lives. But what is the current status quo here? And these are some figures that I continue to change and fish out here and there. But as you can see, you know, millennials use their mobile phones 157 times a day. We touch our mobile phones over 2,500 times a day. Many, many young people go into social media first thing in the morning, when they wake up. The percentage of teens using social media multiple times a day has doubled in recent years. And over 90% of millennials actually use social media on a regular basis as well. So it's pretty striking figures. But what about the field of digital mental health? Well, there's been 15 to 20 years of research, and over 100 trials showing that online interventions work. The problem is that no one really uses them in clinical services anyway. These interventions for the most part are associated with high attrition rates. This is despite most of them having a short-term focus, they usually focus on three to six months. These interventions are developed by us as a field. And the real issue is that many of these interventions are not designed to be integrated with youth mental health services. And the unfortunate result is that almost no young people, at least in Australia, receiving any kind of youth mental health support, receive any kind of integrated digital mental health support as well. So what is going on here, right? One possibility is that these companies are really developing things that young people want, whereas what we do is simply boring for them. This is related to this. They maybe really know what their wants and needs of young people are, and we're basically just imposing our needs, what we think is important for them, and maybe this is why they're not engaging with it. But maybe the real motivation might come from the very motivations from the tech companies and from us when we develop these sort of interventions. I'm just going to spend a couple of minutes on this, and this is something very, very topical. I'm sure that many of you have heard about this over the past few years, but the business model and a measure of success of the tech companies is time on the screen, right? They need to capture as much of your attention to make money because of the model of advertising. The issue is that the more of your attention they get, the more money they make. So they've got naturally a bottomless appetite for your attention, but there's a market share for attention. If I get more of your attention, someone else is going to get less. So the past 10 years, and more intensely over the past six, seven years, we've experienced this sort of... This is something that Tristan Harris refers to, this is an ex-Google ethicist, to a race to the bottom where the lower someone goes to try to get you to click, and I say the lower someone else has to go. And these companies have a lot of resources that have a thousand engineers on the eyes out of the screen, and the aim is to get you to click one more time. And these guys basically tap into the back doors of our minds, into the social and cognitive biases to keep us glued to the screen. I'm just going to describe just a couple of example. We're very vulnerable to social approval. This is one of the highest human motivations for evolutionary reasons, but we're also very attracted to variable unpredictable rewards, such as the ones that the poking machines use, for example. When we don't know when we're going to get our reward, that's very addictive. So now Facebook and other tech companies know that when you basically post a profile update, at that point in time, you're very vulnerable to social approval. So they can actually orchestrate when they show that profile update to your friends. So you keep on getting likes and comments at random times over a long period of time, and each time you go back online because you're getting a notification. Just one more example. This is probably my favorite one in terms of what tech companies do to illustrate how this is going. We're also very vulnerable to social reciprocity. If you say thank you, I probably will say you're welcome. If you shot me a drink, I probably do the same thing next time. But now the tech companies are really manipulating how often we experience this. For example, Snapchat created this feature a couple of years ago called Snapstrix. And what it does basically, it counts the number of days back and forth that you've been talking to a friend. So you've got a best mate, you've been talking to that best mate for 100 days every day, then you see the little number 100, a firewall next to it. So what they're creating now is this thing that you don't want to lose. Because you've got 100 days. If I don't talk to you tomorrow, I'm going to lose the whole thing. But importantly, I don't want to be the one breaking the chain of social reciprocity. And obviously, young people are particularly vulnerable to this sort of biases. On the other hand, we're doing almost the opposite. We're moving traditional therapy to online formats, with very little attention to engagement so far and up until then, and also to how these interventions integrate with mental health services. Most interventions have been developed by universities or tech companies, basically separate from clinical services without considering the constraints, limitations, and how complex clinical services are with the inevitable results of very poor engagement, but also lack of integration with services. And what are the results for young people? What are the outcomes for young people, or the consequences of this sort of attention economy? So just one slide on this. So the quest for attention has really led to the externalization of self-worth for many young people. So we are in a situation that for many young people, the number of likes and comments that they're getting becomes a very direct indication of their self-worth. So they might spend hours curating their profile pictures to attract the maximum number of likes and comments. And this has created a parallel, competitive, but completely fake reality that has negative consequences for many young people. So 7 in 10 young people say that Instagram makes them feel worse about their body image. Snapchat and Instagram are very popular amongst young people, but also very negative, or some of the most negative ones in terms of how they feel when they use social media. And social media use is more evidence that is associated with increased anxiety and depression in young adults, and appears to be driven by the very social and cognitive biases that the tech companies are using to keep people engaged, such as fear of missing out on social comparison. And as I was saying, young people are particularly vulnerable to this. And just one more thing. Social media is not bad for everyone, of course, a lot of young people can actually benefit from it. They can find opportunities for leadership, opportunities to get support and self-expression within social media. But for some of the young people, it's not the same. So this sort of fake reality has created, if you like, a situation where the rich becomes richer and the poor becomes poorer, where the most vulnerable young people are the most likely to pay the price. And there's some research showing that those young people with lower social emotional well-being, they will be the ones that will be more likely to feel excluded, to experience cyberbullying or to feel bad about themselves when they're using social media. And there's research as well showing that for people with psychosis, when they have lower social rank, they're much more likely to experience low mood, low self-esteem and paranoia when they're using social media as well. If you're interested in knowing a little bit more about this, many of you probably seen the fantastic documentary, Social Dilemma, on Netflix. You can also follow the work from Tristan Harris, he's been a whistleblower for a number of years in this area. And he has created the Center for Human Technology. And there's a lot of information there about all these bits and pieces from technology. And you might ask, and this is, again, a joke that I've used before, this is an unskeptical baby. It took me a while to find it. Talking about attention economy, it took me a while to find this online. But you might ask, why would you even use social media? This is not my baby, by the way, I just found it online. Why would you use social media to help young people when it has so many negative consequences? Well, the truth is that young people with psychosis and depression use it just as much as their peers. Many would like to get support from clinicians and professionals through social media. And also, this is important, young people want social media and digital technology to enhance and to integrate with, not to replace, youth mental health services. So with your permission, if you don't, if I may, I actually did have a baby four weeks ago. This is a picture of him. So maybe from now on, I can use my own baby in these little jokes. And I was asking my wife to take some pictures of him looking suspicious, and we couldn't do that. But yesterday, she managed to get a picture of him looking quite surprised. So yeah, I hope you don't mind me sharing this little one with you as well. Anyway, so what do we do? We were thinking, so what do we do in this space? Can we create a space in the middle where lovable technologies meet effective interventions that improve lives? Can we reverse engineer the whole playbook of persuasive techniques and technologies used by the tech companies, but in this case, to persuade young people to do things that are good for them? And this is some of the things that we're working on. So this is basically the well-being economy against the attention economy, if you like. By developing social networks specifically designed to build safe, meaningful, and supportive relationships, as opposed to just to harness social biases to harvest attention, we go in distance trying to develop fun, creative, easy-to-digest therapeutic content, rather than capitalizing on negative, outreaching, and outright false content just to capture attention. We're using more and more AI to provide personalized treatment, but also to detect risk, rather than using it just for targeted advertising. And we're putting quite a bit of effort into newsfeed algorithms that foster engagement with a focus on improving well-being, as opposed to recommendation systems designed to maximize attention at any cost, regardless of what kind of recommendation you get. And this is a little bit about the nature of what we try to do. It's a bit of a reverse engineering, trying to improve people's lives. So at Origin Digital, what we try to do is to integrate persuasive, social, but humane slash ethical technology with evidence-based novel psychological models, as well as artificial intelligence computational technology to develop new interventions that address key gaps and outcomes in youth mental health, but importantly for us, that integrate with youth mental health services. So our purpose, this is something that I put quite a bit of effort into deciding why are we doing this? What do we believe in? We believe that all young people and families have the right to effective mental health care without limits, and for us, limits is not only access, it's also limits in terms of effectiveness. The interventions have actually, they need to change lives. And our mission is something that we set out to do last year, is to make all youth mental health services in Australia digitally enhanced within five years. So we've been fortunate to keep on growing our team, and now we've got a team of 63 researchers and professionals. And the interesting thing about the way we're working, I suppose, is that apart from working in partnership with young people, I come back to that, we've got a lot of disciplines in our team. We've got comic artists, we've got experts in AI, professional novelists as well working in our team, working together to develop interventions that engage young people, but also improve their lives. As I was mentioning, we've got many young people embedded into our team. We've done over 500 consultations over the past 10 years and counting. And these young people basically have a key role within our team, from this inception of an idea, through to developing a platform, through to disseminating the intervention on the ground as well. So Bob was talking a little bit about MOIST before. This is a framework that we've been developing, working on, and improving over the past 10 years, really. And it's pretty basic. It's not rocket science. It's basically the integration between online social networking that is designed to promote meaningful and positive relationships, expert support provided by clinicians and vocational workers, peer support provided by young people with lived experience who have been trained to provide peer support online, but also evidence-based psychological interventions and models delivered in really attractive ways. That's what we attempt to do. And we basically choose and pick, I'll come back to that in a moment, the therapeutic models based on the needs and the targets of each population. This is a model that we've been refining and improving over the past 10 years. We developed four versions of it. And I'll show you guys a couple of versions of it, three versions of it today. And the very reason why I jumped into technology and we jumped into technology, and where my heart has been for many, many years, is about long-term recovery, improving lives for good. And this is a quote from Ron Kessler that I really like, as you know, he's one of the most widely cited researchers in mental health in the world. So he said, we spend an enormous amount of effort in research and clinical care on getting people well. And most of the time, that was pretty well, acutely. But we spend almost no effort in keeping people well with enormous losses and costs. And this is certainly the case in young people with psychosis. We can provide with our fantastic early intervention services. I think this is one of the most exciting things that has happened in psychiatry over the past, I would say, 25 years, the development of a specialized early intervention services. But for the most part, we can develop, we can, at least in Australia and in many countries, we can provide support for two to three years of treatment. After that, many young people get referred on to adult mental health services, and we know these are generic mental health services. We have data showing that many young people don't find those services as appropriate to their needs. And many young people don't get any support at all, placing them at risk of relapse and also at risk of losing the benefits of early intervention. So because of this, there's been a number of trials comparing two or three versus five years of specialized care. So we took a slightly different approach, and we thought, can we provide digital support at the point of discharge from these services, which is maintained beyond that time point in order to sustain the clinical improvements and the social improvements of these services? And that's what Horizons was. So this is the first version of Horizons powered by MOS, the second version of MOS. And we were very proud, believe it or not, of this platform. It looks pretty pedestrian, but we call it Horizons Vintage. But this is what it looked like back then, just to give you a bit of flavor. And this is the platform that we tested quite a few years ago now with 20 young people who used the platform for four weeks. And what we found is that they actually really liked it. They engaged very much for four weeks. We found some signals that maybe could improve social connectedness and reduce depression as well. And these improvements appear to be related to the utilization of the system. Of course, a pilot, you cannot really conclude anything beyond safety and acceptability for four weeks. But on the back of that, we managed to get competitive grants to keep on developing MOST. And based on that data, we developed the third version of MOST, which was being iterated from 2014 to 2018. So you can see here what it looks like. So in MOST, or what it used to look like anyway, so in MOST, young people could pick their personal strengths. And once they did that, the system will actually show them how to use their personal strengths in different situations and circumstances. For example, how to use creativity to deal with social anxiety, or to deal with difficult situations in social environments. We put a lot of effort into making therapy as attractive as possible for young people using comics. And we've got a team of two artists at the moment, with novelists and clinical psychologists, other clinicians as well and young people working on developing comics in therapy. You can see that we included even animations in the latest versions of MOST comics, how to breathe in and out, for example, with the movement of the moon. And in the middle one, you've got, we've got the social network that young people could talk to each other, but it will also deliver personalized therapeutic suggestions for young people. And also the problem solving feature, that was something that we call Talk It Out, to the right. And this is something that young people can post problems. And then basically, they enter a problem solving group with other young people and also with clinicians and moderators that help them to solve that problem following the problem solving framework, and the CBT problem solving framework. So that platform has actually been pilot tested in the US with our friends from North Carolina, David Penn and Diana Perkins. And this is something that we tested in a this year, last year, actually, with 26 young people with psychosis, who used the platform for 12 weeks in three different early intervention services from North Carolina. And as you can see, once again, in terms of retention and participation, a strong signal that this is something that young people liked. We found also that active users experience moderate improvements in loneliness, negative symptoms, and depression. And quite encouragingly, we also found significant correlations between indicators of system use, improved wellbeing, reduced loneliness, and depression. Of course, again, a pilot study, we cannot make any conclusions, as I was saying before, beyond basic safety and acceptability and some sort of preliminary thoughts about potential effects on clinical and social variables. But we are now in the midst of doing an implementation project across North Carolina and some early intervention services in psychosis as well, something that we're very excited about. But of course, we need to test the effectiveness of this intervention through controlled trials. And this is what we did in the HORIZONS study. This is an RCT clinical trial that finished last year, a couple of years ago now, actually, about 18 months ago. And what we did here was to basically assess the effectiveness of HORIZONS in maintaining and sustaining the benefits of early intervention services beyond discharge. So we randomized 170 young people with psychosis to either treatment as usual or treatment as usual plus HORIZONS for 18 months at the point of discharge from the EPIC program in Melbourne. And this is actually the first time that I'm showing the results because we basically finished the analysis very, very recently and the paper is in submission now. So what do we find? I mean, first of all, in terms of accessibility and safety, we found that we had no safety incidents or adverse events for five years. So we got a lot of strong indications that doing this with young people is very safe. And also, but in terms of engagement, we found that 80% of young people engage regularly for at least three months, and almost 47%, close to 50% of participants will engage for at least nine months. Just to put this in perspective, it's very unusual that a digital intervention attempts to engage young people for 18 months. This is something that we were attempting to do. And this, in my opinion, highlights the potential of HORIZONS, a digital platform like HORIZONS, to provide sustained acceptable support beyond discharge from early intervention services. But what do we find in terms of clinical and social outcomes? This is the trajectories in terms of social functioning over 18 months. This is comparing HORIZONS and treatment as usual. This was the primary outcome of the study. As you can see here, there were no significant differences between both groups over time. We were expecting and our hypothesis was that the treatment as usual group will experience a decline in psychosocial functioning over time and will maintain psychosocial functioning or social functioning in the HORIZONS group. But as you can see, both groups started quite high, and they remain so over the duration of the study. Just to put this in context, this is a comparable study in DECMA. This is the OPUS trial, and they compared two versus five years of specialized services as well. And at baseline, you can see that the PSP, the same measure of social functioning, was significantly lower than in our study. In other studies, you can find, again, that is a little bit lower. So how can we interpret this? These are some potential explanations. We could have well end up with a higher functioning subgroup of young people because we were recruiting young people in clinical remission. This was for the safety of the social network when we started doing this study about seven years ago now. It could be because of the intensity and the quality of the background treatment as well. EPIC is very well known for the amount of psychosocial support that it provides. We've got a very comprehensive psychosocial program and group program for young people and also intensive vocational support. This could basically lead to higher social functioning at baseline. One thing that has happened as well in our context is that there's been a lot of improvements in post-discharge care, and this is with the headspace services. We've got five headspace services in our catchment area that we manage. They're youth friendly, specialized, and free for young people. And we know that they end up being the discharge point for many young people as well. So it's been an improvement on post-discharge care in our environment. But of course, it could be that we need a different treatment approach, treatment modality, or even intensity to improve social functioning in young people with psychosis. Some explanations there for you. What about other things that was really important for us? This is vocational educational outcomes. So what we found here is that HORIZONS participants were more likely to find employment or enroll in education over the 18 months duration of the study. So specifically, there was a 5.5 times increase in the odds of finding employment or enrolling in education for young people in the HORIZONS group compared to young people in the treatment as usual group. And this is obviously controlling for baseline differences as well. Again, to put this in context, the baseline rate of employment was double the rate of other studies as well. This is the OPUS trial, where you can see that the employment rate at baseline was pretty much half what we had in our study. And even then we were able to pick up on significant differences. And we looked into this further and we found also a dose response effect where young people in the top 25% of logins had a much more significant therapeutic effect on vocational educational recovery compared to young people in the bottom 25% of logins, which reinforces the validity of this finding as well. What else did we find? So we find also evidence that HORIZONS reduces utilization of emergency services. So here it is the hospital admissions due to psychosis over the 18 months follow up of the study. So we found twice the rate of hospital admissions in the treatment as usual group compared to the HORIZONS group. As you can see on the right, this analysis didn't quite reach the level of statistical significance. But just to put this in context, and keep in mind as well that the power of this analysis was quite low, due to low event rates, and the number of needed to treat, the number of young people that we needed to treat with HORIZONS to save or to prevent one hospital admission was seven, which is comparable to the number of needed to treat in specialized first resource psychosis services. But the validity of this finding is also supported by the associated finding that we also had twice the rate of visits to emergency services over the 18 months follow up in the treatment as usual group compared to the HORIZONS group. And this analysis did reach the statistical significance level because the power was also significantly higher. And the number needed to treat, we needed to treat five young people with HORIZONS in order to prevent one visit to emergency services. And you can see here that there were a total of 12 second or third or fourth visits to emergency services from seven different participants and all of which, all of them happened in the treatment as usual group, which once again reinforces the validity of this finding as well. Going a little bit more into exploratory findings. So in our analysis, we also found that there was a decrease in negative symptoms from baseline to 12 months in the HORIZONS group compared to the treatment as usual group. However, this effect was lost at 12 months follow up. So how can we interpret that? So there's been a couple of studies showing that, for example, this is Ashok Mala et al. group, they found that extending the duration of early intervention to five years compared to two years led to improvements in negative symptoms. Eric Chen's team and Chang et al. found the same thing that they found improvements in negative symptoms in three versus two years of specialized care, which were however lost at three years follow up. So our findings are somewhat consistent with these findings and suggest that maybe HORIZONS has a time limited effect on negative symptoms over the first 12 months, which coincides with a higher level of usage of the system. But of course, this could simply be just a chance effect. So we looked into this a little bit further. And this is the work done by one of our fantastic PhD students, Shona O'Sullivan, in our team. And what we've done here is basically try to establish subgroups of different usage patterns in the HORIZONS group, just to see whether different kinds of usage were linked or associated with different patterns of outcomes as well. So the way we did this is by combining the engagement with the social and therapeutic dimensions and the level of use. Just to explain this a little bit further, engaging with the social dimension means basically posting or commenting or reacting to other young people, liking comments, engagement with the therapeutic side of things is doing therapeutic content, scheduling homework, saying I've done this behavioural experiment, and level of engagement was categorised from none to passive. For example, passive will be reading posts and comments by non-necessarily posting or commenting yourself through to active engagement, which will be, for example, in the social dimension, engaging actively with a social network. So combining this information, we found three clusters of use, basically a subgroup with low use, another subgroup with sustained social but decreasing therapeutic use, and another subgroup that has sustained therapy and social use. And then what we did was basically compare each of these subgroups against each other. And what we found here is that while those young people with low use didn't experience any changes in psychopathology, those young people with sustained social but decreasing therapeutic use got worse over time. And the opposite effect was true for those young people with sustained therapy and social engagement where the general psychopathology decreased over time. Just one more thing in this exploratory analysis, we also then compared those young people in the horizons group with high and sustained use on both social and therapeutic dimensions with the treatment as usual group. And what we found here is that those young people with sustained use had improvements in general psychopathology, negative symptoms, but also some dimensions of psychosocial functioning when compared to the treatment as usual group. And this analysis was controlling for DUP, age, gender, and baseline differences. Of course, this is just completely exploratory analysis, non-randomised comparisons, and this might well be non-comparable groups, but still gives us some clues as to what we might be able to do with the intervention to make it more potent as well. So conclusion so far, what can we conclude from the horizons study and our work in psychosis? Well, first, most is a safe and engaging platform for young people with first-person psychosis. And in our view, it's a promising approach to deliver sustained support beyond discharge from specialised services. Then we can say that most in our trial was effective in improving vocational and educational outcomes. This is one of the core aspects of functional and social recovery anyway. And we found a dose response effect on that outcome as well. But also it was effective in reducing utilisation of emergency services in young people with psychosis, which is also one of the aims of specialised early intervention services. We found as well that sustained engagement with therapeutic and social elements might be related to a therapeutic effect. So this is an exploratory analysis and just an hypothesis. And of course, we found that most needs to be refined to better address social functioning, something that we couldn't improve, and other outcomes that we thought maybe we will be able to improve, but we didn't manage to do so. And this is what we've been working on for the past year and a half. So basically, taking into account that research from horizons and other pilot studies that we've done in other populations, and in partnership with young people, we spent about 12 months redesigning MOST and developing a new version of it. And as I was saying, driven by a lot of consultation with young people as well, and the data that we had from our previous trials. So what we set out to do was, let's create a version of MOST that is completely focused on enabling real life recovery. We're not interested in logins, we're not interested in only engagement and safety, that's important. But what we really need to do is to come up with to deliver changes on the ground that are measurable that improve lives. And importantly, for us, this is something that I was mentioning before, we really wanted MOST to enhance face to face care to integrate and to complement services as opposed to replacing them. So I'll show you in a video later on what MOST version four looks like. But just some of the features or the hero features, as we call them of MOST version four, which we launched this year, so has a lot more emphasis on therapy. So we've got guided journeys, guided journeys, journeys that young people can do when they have a significant issue. For example, if a young person has social anxiety or difficulties in social functioning, that would be their journeys on social hacks or social anxiety, respectively. They basically can enter a journey, and it could basically last to two months. And each day they do a different kind of thing. It could be a behavioral experiment, it could be a comic, it could be talking to other young people on a specific topic. And this can be completely tailored by the clinician, but also by AI processes as well, that keep on learning on what helps the young person. In addition to that, we've got tracks. So journeys could last two months, but tracks is things that young people can do in a week, for example, five ways of dealing with a broken heart, or three days on improving your skills in a work environment, whatever that might be. As young people do that, they can collect things in the toolkit, and the toolkit is very powerful. So it includes artificial intelligence as well. And basically what it does is collect things that are really helpful for young people, their personal notes as well, and then suggest those things for young people when they are in moments of need. For example, if something improved your mood in the past, and we pick up on a decrease in mood, we can suggest that thing later on, hey, how about if you use this that it helped you in the past, we put a lot of work making this social network as therapeutic as possible, but also to create a base of wraparound support from online peer workers, clinicians and career consultants, that is fully integrated with face to face clinicians and clinical services. And of course, it's available 24 seven. So some of the things that we're working on is to, we change the therapeutic content to make it more powerful, to focus a lot more on therapeutic alliance, tailoring of interventions by the therapist, but also by the system. And we redesigned the social network to make it more therapeutic as well. So the purpose of the social network has become very clear that is about improving well being above anything else. So this is our research programme, different versions of most and other applications have been applied in different studies. So we've got a focus on relapse prevention, as I was mentioning, social recovery, anxiety, we've got an entire programme of research on family interventions as well, led by my colleague and friend John Gleason from the Australian Catholic University in Melbourne. But also, more recently, we have been working a lot on new models of care for help seeking young people, blended face to face plus online interventions, and also vocational recovery, and so on. So I'm just going to talk about one example. And then I come back to the rollout of most across Victoria. And the example that I want to touch on is social recovery in young people at risk for psychosis, which is related to the topic of the conference, of course, and this is work done, again, with my colleagues and friends, Barnaby Nelson and Alison Jung from Melbourne. So as you know, current treatments for young people at ultra high risk for psychosis are effective in reducing transition rates to psychosis. However, this, like what happens in psychosis as well, these interventions have less of an impact on social functioning deficits, which are pervasive, accrue before psychosis onset and predict transition to psychosis and long term functional outcomes. So for many, for many young people, for many people, basically improving social functioning is one of the next frontier in the field as well. But the thing is, how do we do this? You know, how can we evolve our thinking and social functioning? So we this is something that we researched a lot, we've done longitudinal studies of predictors of social functioning, first of all, psychosis, meta analysis, and so on. But the next thing that we're working on is how can we integrate that knowledge on predictors and drivers of social functioning with theories of social functioning in psychosis to create testable models that inform new therapeutic models. And we thought that that could include cognitive variables such as neurocognition, social cognition, psychological variables, such as if it is beliefs or competence, or motivation. And those variables are likely to influence as well, well being elements that are really important, such as purpose in life, meaning, creating, whether it is upwards or downwards spirals of well being that even drive social functioning in a positive or negative way. So social function is such a complex domain that is probably influenced by multiple variables and ones, and it influences different people in different ways. And the self determination theory, in our view, we've done quite a bit of work with Richard and Ryan ourselves, provides a really useful framework to deliver interventions that target these particular domains. According to this theory, if we're able to target the three core needs of basic psychological needs of self competence, or being able to be effective in the world, relate to having meaningful relationships with others and autonomy, or having the opportunity to control your own destiny, really, that's going to foster engagement with online interventions, but also with life, it's going to increase intrinsic motivation. And that might lead to improve psychosocial functioning as well, through increased performance, and persistence. Another theory that we've been looking into over the years is the Broden and Bell theory from Barbara Fredrickson. And according to this theory, positive emotions have intrinsic value, as well, if we're able to foster those ones, they might broaden an individual repertoire of actions and behaviour and that will develop durable psychosocial resources such as social support, purpose in life and mindfulness that will lead to improve social functioning as well over time. And this is some of our thinking in our evolution of the MERS model into improving social functioning more strongly as well. We've done this before, but we sort of upgraded it as well. So can we target these things very directly? Can we, of course, help young people find their personal strengths and then have them use those personal strengths to cope with the stress to enhance positive emotions to connect with others, and then complement that with theoretically consistent and evidence based models such as mindfulness and self compassion, or even metacognitive and social cognition models that address drivers cognitive as well as social drivers of functioning as well. If we're able to do this, we're likely to generate upwards the spiral of functioning. And if we put all of this into our online social media environment, maybe we can create a new therapeutic environment that is motivating, that targets the drivers of social functioning. And we like to think of it as a transitional social network that young people can use in the path to recovery. And that's exactly what we did in the momentum trial, which is a different iteration of the MERS model, where we integrated strengths based interventions with mindfulness and self compassion, but also with metacognitive and social cognition therapy, as well. We pilot tested this intervention with 13 young people out of high risk for psychosis, that used the system for three months, and we found significant improvements in social functioning, and last satisfaction as well, but also on the therapeutic targets that we're addressing with the intervention, strengths used, mindfulness skills, social support, and we found also significant correlations between using the system and improvements in these targets and outcomes. Of course, pilot study, we cannot conclude anything in terms of effectiveness, let me be clear about that one. So we started this year five year randomized control trial to test effectiveness of momentum in improving social functioning in this population. So just approaching the end of the talk, I just wanted to talk to you guys about our latest sort of work, and this the evolution of MERS into MERS+, which is a blended face to face digital model of care across all phases of treatment. I'm going to try my luck and I'm going to show you a video that hopefully will work. I'm going to apologize in advance for the tone of the video. This is a video just to give you two seconds of context that we put together last year for fundraising. It has that tone of fundraising. This is something that we used to basically fundraise for the digital program in Australia. But it does describe very well our vision in the field. If you just keep that in mind and apologies for a little bit of the tone of the video towards the end in particular, and a little bit dramatic as well, but it does describe our vision very well. I'm just going to take off my headphones and hopefully this will work. We have a national emergency on our hands. Mental illness is the leading cause of death for young Australians. Our kids are dying because we don't have the resources to treat them. Three out of four seriously unwell kids will be turned away from overburdened services. Most young people who do receive services want to discharge before they're ready. The gains made in therapy will start to ebb away in six months. The majority of them will relapse, causing long-term disability. Tragically, some of those young people will go on to take their own lives. Suicide is the biggest killer of young people in Australia, twice the national road toll. It doesn't have to be this way. Imagine a 24-hour online platform, fully integrated into clinical services, and accessed through any smartphone, tablet or computer. A social network, moderated by clinicians and trained peer workers, where young people can connect, problem-solve and hang out safely. With therapy tailored to individual needs, that young people find fun, meaningful, relevant and effective. And career advisors for helping them access work and study. Imagine this technology has passive and active sensing, giving clinicians a better understanding of daily patterns of behaviour and wellbeing, and helping young people learn their triggers and warning signs to prevent relapse. Imagine if families had their own app to learn more about how to help their young people at home, and to connect with professional advice and support from others in similar situations. Imagine if, using all the available research, instead of making social media as addictive as gambling, designed to prioritise likes and advertising, there was a social network scientifically designed to boost wellbeing, combat loneliness and help young people achieve their potential. Imagine safe, meaningful, mindful technology, available 24 hours a day, when they need it, where they need it, for as long as they need it. What if I told you the technology already exists? eOrigin is a technological revolution in mental health care. We use cutting-edge technology and the latest psychological models to relieve the burden on services, increase access for young people, and bring therapy out of the clinic and into the real world. eOrigin has 8 years of research and more than $14 million of R&D behind it. It has a 100% safety record in clinical trials. Mental health treatment can be more effective, more affordable, more engaging, and more accessible for every young person in Australia. We are almost there, but we need your help. Let's not wait any longer. Hopefully that worked. And again, keep in mind that we obviously are a charitable organisation, a not-for-profit, so we always target donors to get funding. So just keep in mind the tone of the video, but it does describe what we are trying to do quite well, in my opinion. So just finishing up the talk, we've been very fortunate that the Victorian government and the Telstra Foundation, this is a big telco from Australia that has been with us for the past 10 years, have invested $7 million to roll out Most across all youth mental health services in Victoria. By the time we're operating at scale, we'll be helping 20,000 young people per year. This will be in year two. And what is the value of a digitally enhanced model of care for young people? Well, it can make therapy continuous for them. It can expand the therapeutic hour. It can provide support between sessions and before and after face-to-face care. It can make therapy social for those young people who want to share their experience with others. It can be very, very personalised and very hands-on, meaning that it can provide support when and where you need it, and it can give you all the tools that you need in one place, including your support or your relationship with your clinician as well. And what is the value for clinicians of enrolling on something like this? Well, it can really increase the therapeutic intensity, continuity and potency. This is something really important for us. We really want to, I suppose, level up the amount of therapy that young people can get access to. So clinicians can get access to a full range of evidence-based effective therapeutic modules that can increase therapeutic alliance. We have evidence that it can increase the likelihood of homework completion. It can make you more creative in therapy as well. I actually use it myself. I still do clinical work at least one day a week. I've been doing that for many years, and I use it with young people, and it can be quite powerful from the perspective of it can really improve your relationship with them as well. It can give you a lot of insights about what works, what doesn't work for them, what they like and what they don't like. So get to know the young person better as well. And it can be very powerful. You can go really deep into the one topic, or you can actually, in the session, address different focuses and then say, how about if offline, online, when we're not seeing each other, you focus on this thing. So you can actually expand the therapeutic focus as well. And it's very useful as a transition out of care, where you know that the young person is going to have this platform when you stop seeing them as well. So just to finish up, what is it that we're trying to do? And we haven't achieved this. This is obviously our dream. I'm not saying that we've got all the solutions or anything like that. Not at all. But this is what we're trying to do, right? We want to move from a youth mental health system, at least in Australia, where limited access to services is the norm, with long wait times, where there's really poor continuity of care. We can only provide in Australia up to 10 sessions of psychological treatment funded by Medicare. And many young people don't, there's not long enough for them. With limited effects on functional recovery, but also with, in our case as well, limited to no relapse prevention support. Not to mention the relapse translation, the research translation failure, the 17 years delay, as you know, between research being done and those findings and innovations reaching the hands of young people. And even then, 85% of findings never make it to clinical practice. So we want to move to a new model where young people can access care, at least digital support, as soon as they access a mental health system. Basically bypassing the entire wait list as well. Then we want to provide blended, continuous, intense, synergistic face-to-face and digital support where the whole is more than the sum of its parts, where it really increases therapeutic intensity. That focuses on both symptoms and recovery and provides continuous support beyond face-to-face interventions. But we also want to move, and I'll finish with that, to a different model of research. And I'm guilty of this, my team is guilty of this as well. You know, we don't want to continue to do five-year clinical trials that cost $2 million, and then by the end of the trial, the intervention is obsolete. And then there's no way of translating that intervention into clinical practice. There's not a clear pathway to do that. These clinical trials are very useful, but they have limitations as well. And on the other hand, there's many other platforms that are being tested in population-based studies. And what happens is that only a very small proportion of people who are potentially eligible to use that intervention use it even if they're well-powered studies. And then when you test those interventions in clinical services, they don't work, they don't integrate well, even if they're evidence-based in those particular studies. So we're thinking, can we do this differently? Can we make youth mental health services digitally enhanced first, and then come up with a new research model powered by large sample sizes where you do iterative, constant, for example, A-B testing? This is something that the tech companies do really well, but with different metrics in mind, rather than capturing attention, can we improve implementation KPIs to make this sustainable, make this engaging but effective, and can we make them effective as well? With improvements that happen in real time being disseminated across the network, the idea is to bypass that sort of like a 17-years delay, but also to address this gap between digital technology and mental health services. Again, we haven't done this, but this is our dream, I suppose. What we really want to develop is a new generation of accessible, engaging, and rapidly evolving youth mental health services so we can help many, many young people in the hundreds of thousands to access effective treatment when they need it, where they need it, for as long as they need it. Just mentioning some of our partners and friends around the world, many in the US, apart from David and Diane that I was basically referring to before. We've been working with Lisa Dixon, Michael Berman, John Kane, and many other friends from New York, and we've been in conversations with our colleagues as well in the US, and we've got collaborations and partners all around the world. So very happy, very collaborative team. I can promise you that if you have any interest in learning more about what we do and collaborating with us, very happy to talk to you guys as well. So I'm going to pause there just to say again, thank you for your attention, for bearing with me for the last hour with my Spanish accent as well, and also, yeah, thank you for giving me the opportunity to present today here. Mario, that was a fantastic presentation. The chat line has been just moving at a tremendous pace. I want to give you a little bit of feedback. When you showed the picture of you and your son, the chat literally exploded for 10 minutes. So I would say that one's a keeper. You're highly engaging, and you're making a good connection with people. That's the first time that I obviously show my son. I don't think he's even four weeks old. So thank you. Thank you, guys, for your kind response to that. Okay. So we have about 10 minutes, and I want to thank the audience, generated just a wealth of really fantastic questions. I'm going to try to prioritize them and get to as many as we can. Mario, one of the first things I want to ask you, in a presentation just before yours, there was a panel on the peer workforce in coordinated specialty care, and it made me think, when you were talking about how young people are embedded in your development team, and you talked about, I was wondering what new roles for young people as recovery specialists that you've discovered in this process, because it might further elaborate the kind of roles that could be envisioned in the United States. I'm sorry. That's a great question. We've been evolving the role of young people into our program. Now we've got quite a few young people, actually. I think it's more than 10 young people employed in our program, because they've got a peer workforce, and they've been basically keeping us on our toes, so to speak. They have one thing that is critical, is to give them full permission to challenge us in any way possible. When they don't think that something is not going in the right direction, they should tell us. Young people now lead the entire peer support workforce, and they actually lead the direction of the social network. That's something that has changed in recent years. What we do is we provide scientific principles in terms of what we think the social network should do. The social network is developed, for example, following the self-determination theory and different specific targets, but then they have total freedom to design and to develop it with our team as well. What I'm trying to say is it's very important to give them a lot of empowerment, but at the same time, to bring them into the evidence-based models. That's something that we've been doing with them, finding that interesting balance where you really empower young people, you really give them a lot of leadership and direction, but you also combine that with rigor and scientific principles. Our experience is that they totally buy into it. They understand it, they understand what we're trying to do, and then buy into that scientific, I suppose, approach. For us, it's very important to keep them as full team members. We've got representatives in each of the leadership teams. We've got in the implementation team, in the clinical team, in the research team, in the ethical team, in the design team. In each of those teams, there's a representative of young people, and then they also lead a lot of co-design sessions as well. More so recently, they're helping us, the champions, we've got champions in each of the services that we're working with, and champions, in many occasions, the champions end up being peer workers from those services as well. They start championing the most model and service in those services. Just a few thoughts. Thank you. That's great. Okay, given that the theme of our conference is touching on issues of diversity, as well as COVID, there was a question, somebody posed the question, artificial intelligence has proven to have biases, much like the humans who have created it. What has Origin done to ensure that the care supported by the artificial intelligence application is fair, equitable, and anti-racist, particularly for marginalized people? Again, an excellent question. We've got a think tank in our team. It's called a think tank slash ethical persuasive sort of team. Basically, what we do is like, we do two things. We, first of all, monitor what the tech companies are doing to persuade people to capture attention. Then we have a look at how ethical it is, what they're doing, and then basically make a judgment as to whether it is ethical to use that for a good purpose. Like, let's say, you know, would it be ethical to do this to convince you to do exercise three times a week, if this is something that you really want to do? For example, is it ethical to use a Strix to do something that you really want to do? So in the think tank, we actually have a look at the ways we're using AI. And to be honest, a lot of the things that we use in AI is basically focused on recommendation systems for therapy. So what it does, basically, there's not a lot in terms of what it will do socially. So I don't think there's very many more risk in terms of what the AI will do to discriminate as a group of people. It's much more around as you post things, as you click on different things, we make an estimation of how likely it is for something to be a problem for you. So for example, if you are clicking a lot on depression, the algorithm starts thinking, well, you're interested in depression content. Is it possible that you have depression? So it makes a bit of an estimation of that. And then what it does is basically matches that with some of the questions that we ask. And then if depression becomes a problem, and we say, yeah, there's depression symptoms for this young person, then we start sort of pushing that content above other content in the social network. Or for example, we'll go to the toolkit, and then we'll go, hey, you're struggling with depression. These three things that you did last year help you and improve your mood. We're going to bring them back to your newsfeed. It's almost advertising therapy. It's advertising things that help you in the past in moments of need. So that's one of the ways we're using now social AI. We're not using AI a lot just yet on the social network, but that's a really good question, just to make sure that when we do it in the social network, as in interactions with each other, but when we do it, we do that in a very equitable way as well. One thing that I should mention, the comics, for example, when we developed them, and I'm not going to say that we fixed this or anything like that, but one thing that we did do is just to really make sure that the comics were completely race and gender neutral. So you cannot really tell whether it is one gender or the other or this background or that background. They're a little bit edgy, so to speak, but the purpose of doing that is that there is no inclination one way or the other. So everyone can identify themselves with the comics, just to give an example. Okay. I think we have time. There were several questions about most and how most is integrated with clinical services. So here are some questions. Is most intended to be used alone or in combination with some in-person mental health services? Do most users tend to bring their digital experience into their in-person therapy sessions? And is it possible to further integrate family caregivers in the approach? I love those three questions. I mean, it is designed to be connected with services and it does it differently in different stages of care. When young people, in our services, we've got about, in high-speed services, we've got about a three-month wait list. So basically we offer most before they see the face-to-face clinician. At that point in time, most is delivered by our online therapists in combination with a digital platform. They're not seeing a face-to-face clinician. When they transition into seeing a face-to-face clinician, basically the clinician can use most as well in the face-to-face therapy. What we do varies. We go from contacting the young person every three weeks to taking more of a, I suppose, less proactive role if they're working with a face-to-face clinician. But then the face-to-face clinician will get an email or a notification of everything that they've done over the past three months, for example, what helped, what didn't, and what we have been working on, and even their personal strengths as well. Then when they're seeing a therapist face-to-face, it can be three scenarios, right? It could be what we call the enthusiast, you know, the therapist, yeah, I want to use the digital platform, I love it, I use it because I know it very well and because I think it helps and young people like that. I'm one of the enthusiasts, of course. But then we've got the light touch clinicians, and they talk about it, but they don't do anything online. They go and say, hey, have you used MOSE? Are you finding this helpful? They can go online, they can see what a young person is doing, they can suggest content, they can tailor the therapy, but they don't have to. And then we've got the sit back and relax clinicians that we call, that they basically, they just don't want to do it, but they're happy for the young person to receive extra support in between sessions. When they finish face-to-face and they transition out of care, that's when we basically step in again to provide a little bit more proactive support as well. So it's coordinated with, I had some slides on that, it was too much detail, but it's basically the face-to-face therapy guides the therapeutic process. They can even tell us what to focus on. And also when they discharge the young person to, when they stop seeing them, there's a little questionnaire that takes like 30 seconds, and they can tell us, I think you should see this person or contact them once a month and focus on this domain and that domain. And then that's what we do, basically. That's a little bit how it works. Families, for sure, like this is my colleague, and as I was mentioning before, I'm a friend, John Gleason has been doing a lot of work for families. There's been most platforms for families as well. And that's one of the things that we really want to work on. And in the future, we would love to integrate them both if possible, because there is evidence showing that when families are integrating care, for example, that increases the adherence to specialized first-resource psychosis services. So we're looking into, is it possible to integrate them both? At the moment, they're separate. So it would be really good to combine them both. Well, I'm already seeing that we're going to have to invite you to come back a few years from now, and you can tell us, give us an update on how your work is progressing. Mario, I want to thank you for a fantastic, thought-provoking and illuminating presentation. It really generated a lot of discussion, a learning community that's already developing around this. And we're going to look forward to hearing more from you. I also want to thank the audience for really generating more, more fantastic questions than I was able to get to. But, you know, hopefully you'll be following Mario's work and that work will, will answer some of these, these questions. Thank you all for joining us and take care, Mario. Thank you so much. Thank you so much for having me. Thank you so much, both for the really kind introduction and for facilitating this as well. And thank you, all of you guys for taking an hour of your time to listen to me. Stay well, my friend. Likewise, my friend.

MOST platform

youth mental health services

online social networking

psychosis

engagement

depression

employment

education enrollment

digital interventions

social functioning

family caregivers