Smartphone Social Behavior and Relapse in Schizophrenia


Changes in social behavior on a mobile device may indicate relapse risk that could be assessed in the clinical setting.




Dr Miller is Associate Professor of Psychiatry, Department of Psychiatry and Health Behavior, Augusta University, Augusta, Georgia. He is the Schizophrenia Section Editor for Psychiatric Times.

Schizophrenia is associated with significant impairments in social functioning. Even after controlling for psychopathology, social support predicts quality of life in patients with schizophrenia.1

Social behavior may play a role in identifying periods of symptomatic exacerbation. Smartphones and other mobile technologies offer opportunities to objectively and continuously capture digital indices of social behavior. Ben-Zeev and colleagues2 developed CrossCheck, a multimodal continuous data collection system that allows remote monitoring of patients with schizophrenia.

Buck and colleagues3 used the CrossCheck system to evaluate whether smartphone-collected measures of social behavior can serve as an early indicator of relapse in patients with schizophrenia. They examined digital indicators of social function in the 30-day periods that preceded illness relapse.

The authors collected data as part of a year-long smartphone-assisted relapse prevention trial in patients with schizophrenia-spectrum disorders.4 Outpatient subjects aged 18 years or older with a diagnosis of schizophrenia, schizoaffective disorder, or psychosis not otherwise specified, and a significant psychiatric event in the past 12 months were included.

Subjects were excluded if they had less than a sixth-grade reading level, or hearing, vision, or motor impairment that prevented engagement with a mobile device. All participants were given a Samsung Galaxy S5 Android smartphone with an unlimited data/call/text plan for one year. Subjects were asked to carry the device with them and charge it nightly.

CrossCheck logged the number (only) of incoming and outgoing text messages and phone calls. The software also activated the smartphone microphones every 3 minutes to identify and log the presence of human speech. These data were used to calculate speech duration and frequency. Subjects had in-person assessments and review of electronic health record data at baseline and at 3-month intervals throughout the year.

Relapse was defined as psychiatric hospitalization, a significant increase in the level of psychiatric care coupled with either a 25% increase from baseline on the Brief Psychiatric Rating Scale (BPRS) total score, clinically significant suicidal or homicidal ideation, deliberate self-injury, or violent behavior damaging another person or property. Data on digital indicators were averaged across the 30-day period preceding a relapse event and were compared with 30-day periods that did not precede relapse.

A total of 61 subjects were included in the study. Mean age was 37, and 59% of the sample was male. Of the participants, 43% had a diagnosis of schizophrenia and 43% had a diagnosis of schizoaffective disorder. During the study period, 20 subjects relapsed, with a total of 27 relapse events.

Most relapses (88%) involved psychiatric hospitalizations. Entire day averages were significantly lower in 30-day blocks preceding relapses for: (1) outgoing call duration, (2) incoming text messages, and (3) outgoing text messages. Incoming call duration or number did not relate to relapse. Speech frequency or duration was also not associated with relapse.

This exploratory analysis found that smartphone-collected digital indicators of social functioning differed from their typical patterns in the 30-day period that preceded illness relapse in patients with schizophrenia and related disorders.

Individuals who relapsed made fewer and shorter outgoing phone calls, and sent and received fewer text messages during the period that preceded relapse. These findings suggest that a stress-avoidance cycle may be identified in passively detected information from a mobile device.

The bottom line

Changes in smartphone social behavior may indicate relapse risk that could be assessed in the clinical setting. This approach may identify novel avenues for early relapse prevention in patients with schizophrenia.


The author reports that he receives research support from Augusta University, the National Institute of Mental Health, the Brain and Behavior Research Foundation, and the Stanley Medical Research Institute.


1. Eack SM, Bahorik AL, Newhill CE, et al. Interviewer perceived honesty as a mediator of racial disparities in the diagnosis of schizophrenia. Psychiatr Serv. 2012; 63: 875-880.

2. Ben-Zeev D, Scherer EA, Wang R, Xie H. Next-generation psychiatric assessment: using smartphone sensors to monitor behavior and mental health. Psychiatr Rehabil J. 2015;38:218-226.

3. Buck B, Scherer E, Brian R, et al. Relationships between smartphone social behavior and relapse in schizophrenia: a preliminary report. Schizophr Res. 2019 Mar 30. pii: S0920-9964(19)30108-2. doi: 10.1016/j.schres.2019.03.014. [Epub ahead of print]

4. Ben-Zeev D, Brian R, Wang R, et al. CrossCheck: integrating self-report, behavioral sensing, and smartphone use to identify digital indicators of psychotic relapse. Psychiatr Rehabil J. 2017;40:266-275.

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