A web-based, peer-supported self-management intervention to reduce distress in relatives of people with psychosis or bipolar disorder: the REACT RCT
Authors: Lobban Fiona , Akers Nadia , Appelbe Duncan , Iraci Capuccinello Rossella , Chapman Lesley , Collinge Lizzi , Dodd Susanna , Flowers Sue , Hollingsworth Bruce , Honary Mahsa , Johnson Sonia , Jones Steven H , Mateus Ceu , Mezes Barbara , Murray Elizabeth , Panagaki Katerina , Rainford Naomi , Robinson Heather , Rosala-Hallas Anna , Sellwood William , Walker Andrew , Williamson Paula R 
Published: July 2020

Background
Relatives caring for people with severe mental health problems find information and emotional support hard to access. Online support for self-management offers a potential solution.

Objective
The objective was to determine the clinical effectiveness and cost-effectiveness of an online supported self-management tool for relatives: the Relatives’ Education And Coping Toolkit (REACT).

Design and setting
This was a primarily online (UK), single-blind, randomised controlled trial, comparing REACT plus a resource directory and treatment as usual with the resource directory and treatment as usual only, by measuring user distress and other well-being measures at baseline and at 12 and 24 weeks.

Participants
A total of 800 relatives of people with severe mental health problems across the UK took part; relatives who were aged ≥ 16 years, were experiencing high levels of distress, had access to the internet and were actively seeking help were recruited.

Intervention
REACT comprised 12 psychoeducation modules, peer support through a group forum, confidential messaging and a comprehensive resource directory of national support. Trained relatives moderated the forum and responded to messages.

Main outcome measure
The main outcome was the level of participants’ distress, as measured by the General Health Questionnaire-28 items.

Results
Various online and offline strategies, including social media, directed potential participants to the website. Participants were randomised to one of two arms: REACT plus the resource directory (n = 399) or the resource directory only (n = 401). Retention at 24 weeks was 75% (REACT arm, n = 292; resource directory-only arm, n = 307). The mean scores for the General Health Questionnaire-28 items reduced substantially across both arms over 24 weeks, from 40.2 (standard deviation 14.3) to 30.5 (standard deviation 15.6), with no significant difference between arms (mean difference –1.39, 95% confidence interval –3.60 to 0.83; p = 0.22). At 12 weeks, the General Health Questionnaire-28 items scores were lower in the REACT arm than in the resource directory-only arm (–2.08, 95% confidence interval –4.14 to –0.03; p = 0.027), but this finding is likely to be of limited clinical significance. Accounting for missing data, which were associated with higher distress in the REACT arm (0.33, 95% confidence interval –0.27 to 0.93; p = 0.279), in a longitudinal model, there was no significant difference between arms over 24 weeks (–0.56, 95% confidence interval –2.34 to 1.22; p = 0.51). REACT cost £142.95 per participant to design and deliver (£62.27 for delivery only), compared with £0.84 for the resource directory only. A health economic analysis of NHS, health and Personal Social Services outcomes found that REACT has higher costs (£286.77), slightly better General Health Questionnaire-28 items scores (incremental General Health Questionnaire-28 items score adjusted for baseline, age and gender: –1.152, 95% confidence interval –3.370 to 1.065) and slightly lower quality-adjusted life-year gains than the resource directory only; none of these differences was statistically significant. The median time spent online was 50.8 minutes (interquartile range 12.4–172.1 minutes) for REACT, with no significant association with outcome. Participants reported finding REACT a safe, confidential environment (96%) and reported feeling supported by the forum (89%) and the REACT supporters (86%). No serious adverse events were reported.

Limitations
The sample comprised predominantly white British females, 25% of participants were lost to follow-up and dropout in the REACT arm was not random.

Conclusions
An online self-management support toolkit with a moderated group forum is acceptable to relatives and, compared with face-to-face programmes, offers inexpensive, safe delivery of National Institute for Health and Care Excellence-recommended support to engage relatives as peers in care delivery. However, currently, REACT plus the resource directory is no more effective at reducing relatives’ distress than the resource directory only.

Future work
Further research in improving the effectiveness of online carer support interventions is required.

Trial registration
Current Controlled Trials ISRCTN72019945.

Funding
This project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 24, No. 32. See the NIHR Journals Library website for further project information.