Economic evaluation of an experience sampling method intervention in depression compared with treatment as usual using data from a randomized controlled trial

BACKGROUND

Experience sampling, a method for real-time self-monitoring of affective experiences, holds opportunities for person-tailored treatment. By focussing on dynamic patterns of positive affect, experience sampling method interventions (ESM-I) accommodate strategies to enhance personalized treatment of depression-at potentially low-costs. This study aimed to investigate the cost-effectiveness of an experience sampling method intervention in patients with depression, from a societal perspective.

METHODS

Participants were recruited between January 2010 and February 2012 from out-patient mental health care facilities in or near the Dutch cities of Eindhoven and Maastricht, and through local advertisements. Out-patients diagnosed with major depression (n = 101) receiving pharmacotherapy were randomized into: (i) ESM-I consisting of six weeks of ESM combined with weekly feedback regarding the individual's positive affective experiences, (ii) six weeks of ESM without feedback, or (iii) treatment as usual only. Alongside this randomised controlled trial, an economic evaluation was conducted consisting of a cost-effectiveness and a cost-utility analysis, using Hamilton Depression Rating Scale (HDRS) and quality adjusted life years (QALYs) as outcome, with willingness-to-pay threshold for a QALY set at €50,000 (based on Dutch guidelines for moderate severe to severe illnesses).

RESULTS

The economic evaluation showed that ESM-I is an optimal strategy only when willingness to pay is around €3000 per unit HDRS and around €40,500 per QALY. ESM-I was the least favourable treatment when willingness to pay was lower than €30,000 per QALY. However, at the €50,000 willingness-to-pay threshold, ESM-I was, with a 46% probability, the most favourable treatment (base-case analysis). Sensitivity analyses confirmed the robustness of these results.

CONCLUSIONS

We may tentatively conclude that ESM-I is a cost-effective add-on intervention to pharmacotherapy in outpatients with major depression.

TRIAL REGISTRATION

Netherlands Trial register, NTR1974 .

Constructing a Reward-Related Quality of Life Statistic in Daily Life-a Proof of Concept Study Using Positive Affect

Background: Mental healthcare needs person-tailored interventions. Experience Sampling Method (ESM) can provide daily life monitoring of personal experiences. This study aims to operationalize and test a measure of momentary reward-related Quality of Life (rQoL). Intuitively, quality of life improves by spending more time on rewarding experiences. ESM clinical interventions can use this information to coach patients to find a realistic, optimal balance of positive experiences (maximize reward) in daily life. rQoL combines the frequency of engaging in a relevant context (a 'behavior setting') with concurrent (positive) affect. High rQoL occurs when the most frequent behavior settings are combined with positive affect or infrequent behavior settings co-occur with low positive affect. Methods: Resampling procedures (Monte Carlo experiments) were applied to assess the reliability of rQoL using various behavior setting definitions under different sampling circumstances, for real or virtual subjects with low-, average- and high contextual variability. Furthermore, resampling was used to assess whether rQoL is a distinct concept from positive affect. Virtual ESM beep datasets were extracted from 1,058 valid ESM observations for virtual and real subjects. Results: Behavior settings defined by Who-What contextual information were most informative. Simulations of at least 100 ESM observations are needed for reliable assessment. Virtual ESM beep datasets of a real subject can be defined by Who-What-Where behavior setting combinations. Large sample sizes are necessary for reliable rQoL assessments, except for subjects with low contextual variability. rQoL is distinct from positive affect. Conclusion: rQoL is a feasible concept. Monte Carlo experiments should be used to assess the reliable implementation of an ESM statistic. Future research in ESM should asses the behavior of summary statistics under different sampling situations. This exploration is especially relevant in clinical implementation, where often only small datasets are available.

White noise speech illusion and psychosis expression: An experimental investigation of psychosis liability

Background

An association between white noise speech illusion and psychotic symptoms has been reported in patients and their relatives. This supports the theory that bottom-up and top-down perceptual processes are involved in the mechanisms underlying perceptual abnormalities. However, findings in nonclinical populations have been conflicting.

Objectives

The aim of this study was to examine the association between white noise speech illusion and subclinical expression of psychotic symptoms in a nonclinical sample. Findings were compared to previous results to investigate potential methodology dependent differences.

Methods

In a general population adolescent and young adult twin sample (n = 704), the association between white noise speech illusion and subclinical psychotic experiences, using the Structured Interview for Schizotypy—Revised (SIS-R) and the Community Assessment of Psychic Experiences (CAPE), was analyzed using multilevel logistic regression analyses.

Results

Perception of any white noise speech illusion was not associated with either positive or negative schizotypy in the general population twin sample, using the method by Galdos et al. (2011) (positive: ORadjusted: 0.82, 95% CI: 0.6–1.12, p = 0.217; negative: ORadjusted: 0.75, 95% CI: 0.56–1.02, p = 0.065) and the method by Catalan et al. (2014) (positive: ORadjusted: 1.11, 95% CI: 0.79–1.57, p = 0.557). No association was found between CAPE scores and speech illusion (ORadjusted: 1.25, 95% CI: 0.88–1.79, p = 0.220). For the Catalan et al. (2014) but not the Galdos et al. (2011) method, a negative association was apparent between positive schizotypy and speech illusion with positive or negative affective valence (ORadjusted: 0.44, 95% CI: 0.24–0.81, p = 0.008).

Conclusion

Contrary to findings in clinical populations, white noise speech illusion may not be associated with psychosis proneness in nonclinical populations.

Clinical high risk for psychosis: the association between momentary stress, affective and psychotic symptoms

OBJECTIVE

The aim of this study was to assess associations between momentary stress and both affective and psychotic symptoms in everyday life of individuals at clinical high risk (CHR), compared to chronic psychotic patients and healthy controls, in search for evidence of early stress sensitization. It also assessed whether psychotic experiences were experienced as stressful.

METHOD

The experience sampling method was used to measure affective and psychotic reactivity to everyday stressful activities, events and social situations in 22 CHR patients, 24 patients with a psychotic disorder and 26 healthy controls.

RESULTS

Multilevel models showed significantly larger associations between negative affect (NA) and activity-related stress for CHR patients than for psychotic patients (P = 0.008) and for CHR compared to controls (P < 0.001). Similarly, the association between activity-related stress and psychotic symptoms was larger in CHR than in patients (P = 0.02). Finally, the association between NA and symptoms (P < 0.001) was larger in CHR than in patients.

CONCLUSION

Stress sensitization seems to play a role particularly in the early phase of psychosis development as results suggest that CHR patients are more sensitive to daily life stressors than psychotic patients. In this early phase, psychotic experiences also contributed to the experience of stress.

Evidence That the Impact of Childhood Trauma on IQ Is Substantial in Controls, Moderate in Siblings, and Absent in Patients With Psychotic Disorder

Research suggests that childhood trauma is associated with cognitive alterations, but it is not known whether the cognitive alterations observed in patients with psychotic disorder, and their relatives, is trauma-related. Patients with a schizophrenia-spectrum diagnosis (n = 1119), siblings of patients (n = 1059) and healthy comparison subjects (HCS; n = 586) were interviewed 3 times over a period of 6 years. Repeated measures of IQ were analyzed as a function of childhood trauma and group, controlling for confounders. There were significant differences in the impact of childhood trauma on IQ across the 3 groups. Exposure in HCS was associated with a nearly 5-point reduction in IQ (-4.85; 95% confidence interval [CI]: -7.98 to -1.73, P = .002), a lesser reduction in siblings (-2.58; 95% CI: -4.69 to -0.46, P = .017) and no significant reduction in patients (-0.84; 95% CI: -2.78 to 1.10, P = .398). One-fourth of the sibling-control difference in IQ was reducible to childhood trauma, whereas for patients this was only 5%. Over the 6-year follow-up, those with trauma exposure showed significantly less learning effects with repeated cognitive assessments (b = 1.36, 95% CI: 0.80‒1.92, P < .001) than the nonexposed (b = 2.31, 95% CI: 1.92‒2.71, P < .001; P interaction = .001). Although childhood trauma impacts cognitive ability and learning in non-ill people at low and high genetic risk, its effect on the observed cognitive alterations in psychotic disorder may be minor. Twin and family studies on cognitive alterations in psychotic disorder need to take into account the differential impact of trauma on cognition across ill and non-ill, at risk groups.

Introducing the White Noise task in childhood: associations between speech illusions and psychosis vulnerability

BACKGROUND

Auditory verbal hallucinations (AVH) are common during development and may arise due to dysregulation in top-down processing of sensory input. This study was designed to examine the frequency and correlates of speech illusions measured using the White Noise (WN) task in children from the general population. Associations between speech illusions and putative risk factors for psychotic disorder and negative affect were examined.

METHOD

A total of 1486 children aged 11-12 years of the Copenhagen Child Cohort 2000 were examined with the WN task. Psychotic experiences and negative affect were determined using the Kiddie-SADS-PL. Register data described family history of mental disorders. Exaggerated Theory of Mind functioning (hyper-ToM) was measured by the ToM Storybook Frederik.

RESULTS

A total of 145 (10%) children experienced speech illusions (hearing speech in the absence of speech stimuli), of which 102 (70%) experienced illusions perceived by the child as positive or negative (affectively salient). Experiencing hallucinations during the last month was associated with affectively salient speech illusions in the WN task [general cognitive ability: adjusted odds ratio (aOR) 2.01, 95% confidence interval (CI) 1.03-3.93]. Negative affect, both last month and lifetime, was also associated with affectively salient speech illusions (aOR 2.01, 95% CI 1.05-3.83 and aOR 1.79, 95% CI 1.11-2.89, respectively). Speech illusions were not associated with delusions, hyper-ToM or family history of mental disorders.

CONCLUSIONS

Speech illusions were elicited in typically developing children in a WN-test paradigm, and point to an affective pathway to AVH mediated by dysregulation in top-down processing of sensory input.

Cognitive Performance and Long-Term Social Functioning in Psychotic Disorder: A Three-Year Follow-Up Study

Objective

Studies have linked cognitive functioning to everyday social functioning in psychotic disorders, but the nature of the relationships between cognition, social cognition, symptoms, and social functioning remains unestablished. Modelling the contributions of non-social and social cognitive ability in the prediction of social functioning may help in more clearly defining therapeutic targets to improve functioning.

Method

In a sample of 745 patients with a non-affective psychotic disorder, the associations between cognition and social cognition at baseline on the one hand, and self-reported social functioning three years later on the other, were analysed. First, case-control comparisons were conducted; associations were subsequently further explored in patients, investigating the potential mediating role of symptoms. Analyses were repeated in a subsample of 233 patients with recent-onset psychosis.

Results

Information processing speed and immediate verbal memory were stronger associated with social functioning in patients than in healthy controls. Most cognition variables significantly predicted social functioning at follow-up, whereas social cognition was not associated with social functioning. Symptoms were robustly associated with follow-up social functioning, with negative symptoms fully mediating most associations between cognition and follow-up social functioning. Illness duration did not moderate the strength of the association between cognitive functioning and follow-up social functioning. No associations were found between (social) cognition and follow-up social functioning in patients with recent-onset psychosis.

Conclusions

Although cognitive functioning is associated with later social functioning in psychotic disorder, its role in explaining social functioning outcome above negative symptoms appears only modest. In recent-onset psychosis, cognition may have a negligible role in predicting later social functioning. Moreover, social cognition tasks may not predict self-reported social functioning.

Change in daily life behaviors and depression: Within-person and between-person associations

OBJECTIVE

This study examined associations between daily physical, sedentary, social, and leisure behaviors and depressive symptoms (a) at a macrolevel, over the course of an Experience Sampling (ESM) self-monitoring intervention, and (b) at a microlevel, by examining daily within-person associations. Second, we examined the effects of the ESM self-monitoring intervention on these daily life behaviors.

METHODS

Individuals with a diagnosis of depression (N = 102) receiving pharmacological treatment were randomized to 1 of 2 six-week ESM intervention conditions or a control condition. Physical, sedentary, social, and leisure behaviors as well as depressive symptoms were assessed prospectively in every-day life at baseline, postintervention, and during the ESM interventions.

RESULTS

Change in physical activity and talking from baseline to postintervention was associated with change in depressive symptoms from baseline to postintervention. Within-person daily fluctuations in talking, physical activity, doing nothing/resting, and being alone predicted end-of-day depressive symptoms over and above depressive symptoms at the previous day. The ESM interventions contributed to change in talking, doing nothing/resting, and being alone over time in comparison with the control group. The analyses revealed individual differences in the amount of behavioral change over time and in the within-subject associations between daily behaviors and depressive symptoms.

CONCLUSIONS

The findings suggest that physical, sedentary, and social behaviors have affective implications for daily mental health of individuals with depression. Self-monitoring using ESM may be a useful add-on tool to achieve behavioral change and to gain personalized insight in behaviors that improve daily depressive symptoms.

Data Gathering Bias: Trait Vulnerability to Psychotic Symptoms?

Background

Jumping to conclusions (JTC) is associated with psychotic disorder and psychotic symptoms. If JTC represents a trait, the rate should be (i) increased in people with elevated levels of psychosis proneness such as individuals diagnosed with borderline personality disorder (BPD), and (ii) show a degree of stability over time.

Methods

The JTC rate was examined in 3 groups: patients with first episode psychosis (FEP), BPD patients and controls, using the Beads Task. PANSS, SIS-R and CAPE scales were used to assess positive psychotic symptoms. Four WAIS III subtests were used to assess IQ.

Results

A total of 61 FEP, 26 BPD and 150 controls were evaluated. 29 FEP were revaluated after one year. 44% of FEP (OR = 8.4, 95% CI: 3.9–17.9) displayed a JTC reasoning bias versus 19% of BPD (OR = 2.5, 95% CI: 0.8–7.8) and 9% of controls. JTC was not associated with level of psychotic symptoms or specifically delusionality across the different groups. Differences between FEP and controls were independent of sex, educational level, cannabis use and IQ. After one year, 47.8% of FEP with JTC at baseline again displayed JTC.

Conclusions

JTC in part reflects trait vulnerability to develop disorders with expression of psychotic symptoms.

Experience sampling-based personalized feedback and positive affect: a randomized controlled trial in depressed patients

OBJECTIVES

Positive affect (PA) plays a crucial role in the development, course, and recovery of depression. Recently, we showed that a therapeutic application of the experience sampling method (ESM), consisting of feedback focusing on PA in daily life, was associated with a decrease in depressive symptoms. The present study investigated whether the experience of PA increased during the course of this intervention.

DESIGN

Multicentre parallel randomized controlled trial. An electronic random sequence generator was used to allocate treatments.

SETTINGS

University, two local mental health care institutions, one local hospital.

PARTICIPANTS

102 pharmacologically treated outpatients with a DSM-IV diagnosis of major depressive disorder, randomized over three treatment arms.

INTERVENTION

Six weeks of ESM self-monitoring combined with weekly PA-focused feedback sessions (experimental group); six weeks of ESM self-monitoring combined with six weekly sessions without feedback (pseudo-experimental group); or treatment as usual (control group).

MAIN OUTCOME

The interaction between treatment allocation and time in predicting positive and negative affect (NA) was investigated in multilevel regression models.

RESULTS

102 patients were randomized (mean age 48.0, SD 10.2) of which 81 finished the entire study protocol. All 102 patients were included in the analyses. The experimental group did not show a significant larger increase in momentary PA during or shortly after the intervention compared to the pseudo-experimental or control groups (χ2(2) = 0.33, p = .846). The pseudo-experimental group showed a larger decrease in NA compared to the control group (χ2(1) = 6.29, p =.012).

CONCLUSION

PA-focused feedback did not significantly impact daily life PA during or shortly after the intervention. As the previously reported reduction in depressive symptoms associated with the feedback unveiled itself only after weeks, it is conceivable that the effects on daily life PA also evolve slowly and therefore were not captured by the experience sampling procedure immediately after treatment.

TRIAL REGISTRATION

Trialregister.nl/trialreg/index.asp. NTR1974.

Theory of Mind and attachment styles in people with psychotic disorders, their siblings, and controls

OBJECTIVE

Impaired Theory of Mind (ToM) and insecure (adult) attachment styles have been found in persons with schizophrenia as well as in their healthy siblings. ToM refers to the ability to infer mental states of self and others including beliefs and emotions. Insecure attachment is proposed to underlie impaired ToM, and comprises avoidant (discomfort with close relationships, high value of autonomy) and anxious (separation anxiety, dependency on others) attachment. Insight into the association between attachment style and ToM is clinically relevant, as it enhances our understanding and clinical approach to social dysfunction in schizophrenia. Therefore, we studied the association between insecure attachment styles and ToM in patients with schizophrenia, their siblings, and healthy controls.

METHODS

A total of 111 patients with a diagnosis in the schizophrenia spectrum, 106 non-affected siblings and 63 controls completed the Psychosis Attachment Measure, the Conflicting Beliefs and Emotions, a subsection of the Wechsler Adult Intelligence Scale, and the Childhood Trauma Questionnaire-Short Form. Severity of symptoms was assessed with the Community Assessment of Psychic Experiences and the Positive and Negative Syndrome Scale.

RESULTS

After controlling for sex, intelligence, history of trauma and symptom severity, avoidant attachment was significantly associated with cognitive as well as with affective ToM, showing U-shaped associations, indicating better ToM performance for patients with lower or higher levels of avoidant attachment compared to medium levels. Anxious attachment in patients was associated with more problems in cognitive ToM.

CONCLUSION

The results from this study support the idea that an anxious attachment style is associated with worse ToM performance in patients. Results also suggested a potential protective role of higher levels of avoidant attachment on ToM. These findings bear clinical relevance, as activation of (insecure) attachment mechanisms may affect interpersonal relations, as well as therapeutic working alliance. Further clarification is needed, especially on associations between ToM and avoidant attachment.

Novel evidence that attributing affectively salient signal to random noise is associated with psychosis

We wished to replicate evidence that an experimental paradigm of speech illusions is associated with psychotic experiences. Fifty-four patients with a first episode of psychosis (FEP) and 150 healthy subjects were examined in an experimental paradigm assessing the presence of speech illusion in neutral white noise. Socio-demographic, cognitive function and family history data were collected. The Positive and Negative Syndrome Scale (PANSS) was administered in the patient group and the Structured Interview for Schizotypy-Revised (SIS-R), and the Community Assessment of Psychic Experiences (CAPE) in the control group. Patients had a much higher rate of speech illusions (33.3% versus 8.7%, OR_adjusted: 5.1, 95% CI: 2.3–11.5), which was only partly explained by differences in IQ (OR_adjusted: 3.4, 95% CI: 1.4–8.3). Differences were particularly marked for signals in random noise that were perceived as affectively salient (OR_adjusted: 9.7, 95% CI: 1.8–53.9). Speech illusion tended to be associated with positive symptoms in patients (OR_adjusted: 3.3, 95% CI: 0.9–11.6), particularly affectively salient illusions (OR_adjusted: 8.3, 95% CI: 0.7–100.3). In controls, speech illusions were not associated with positive schizotypy (OR_adjusted: 1.1, 95% CI: 0.3–3.4) or self-reported psychotic experiences (OR_adjusted: 1.4, 95% CI: 0.4–4.6). Experimental paradigms indexing the tendency to detect affectively salient signals in noise may be used to identify liability to psychosis.

The serotonin transporter 5-HTTLPR polymorphism in the association between sleep quality and affect

A link between sleep and affect is well-known. Serotonin (5-HT) is associated with the regulation of affective as well as sleep-related processes. A functional polymorphism in the serotonin transporter gene (5-HTTLPR) has been associated with serotonergic functioning. The present study investigated whether allelic variation of this gene moderates the association between nighttime subjective sleep quality and affect the following day. A population-based sample of 361 ethnically homogenous adult female twins underwent a five day protocol based on the experience sampling method (ESM), assessing momentary negative affect, positive affect, and subjective sleep quality repeatedly and prospectively. There was a significant interaction between sleep quality and genotype in predicting positive affect the next day: carriers of one (n=167) or two S-alleles (n=78) had a significantly steeper slope compared to LL carriers (n=116) (χ(2)=4.16, p=.042 and χ(2)=3.90, p=.048 respectively). The association between subjective sleep quality and positive affect the next day varied as a function of 5-HTTLPR: it was stronger in carriers of at least one copy of the S-allele compared to homozygous L-carriers, supporting a link between sleep and affect regulation, in which serotonin may play a role. However, these results are preliminary and require replication.

Time-lagged moment-to-moment interplay between negative affect and paranoia: new insights in the affective pathway to psychosis

Evidence suggests that affect plays a role in the development of psychosis but the underlying mechanism requires further investigation. This study examines the moment-to-moment dynamics between negative affect (NA) and paranoia prospectively in daily life. A female general population sample (n = 515) participated in an experience sampling study. Time-lagged analyses between increases in momentary NA and subsequent momentary paranoia were examined. The impact of childhood adversity, stress sensitivity (impact of momentary stress on momentary NA), and depressive symptoms on these time-lagged associations, as well as associations with follow-up self-reported psychotic symptoms (Community Assessment of Psychic Experiences and the Symptom Checklist-90-Revised) were investigated. Moments of NA increase resulted in a significant increase in paranoia over 180 subsequent minutes. Both stress sensitivity and depressive symptoms impacted on the transfer of NA to paranoia. Stress sensitivity moderated the level of increase in paranoia during the initial NA increase, while depressive symptoms increased persistence of paranoid feelings from moment to moment. Momentary paranoia responses to NA increases were associated with follow-up psychotic symptoms. Examination of microlevel momentary experience may thus yield new insights into the mechanism underlying co-occurrence of altered mood states and psychosis. Knowledge of the underlying mechanism is required in order to determine source and place where remediation should occur.

Intermediate phenotype analysis of patients, unaffected siblings, and healthy controls identifies VMAT2 as a candidate gene for psychotic disorder and neurocognition

Psychotic disorders are associated with neurocognitive alterations that aggregate in unaffected family members, suggesting that genetic vulnerability to psychotic disorder impacts neurocognition. The aim of the present study was to investigate whether selected schizophrenia candidate single nucleotide polymorphisms (SNPs) are associated with (1) neurocognitive functioning across populations at different genetic risk for psychosis (2) and psychotic disorder. The association between 152 SNPs in 43 candidate genes and a composite measure of neurocognitive functioning was examined in 718 patients with psychotic disorder. Follow-up analyses were carried out in 750 unaffected siblings and 389 healthy comparison subjects. In the patients, 13 associations between SNPs and cognitive functioning were significant at P < .05, situated in DRD1, DRD3, SLC6A3, BDNF, FGF2, SLC18A2, FKBP5, and DNMT3B. Follow-up of these SNPs revealed a significant and directionally similar association for SLC18A2 (alternatively VMAT2) rs363227 in siblings (B = -0.13, P = .04) and a trend association in control subjects (B = -0.10, P = .12). This association was accompanied by a significantly increased risk for psychotic disorder associated with the T allele (linear OR = 1.51, 95% CI 1.10-2.07, P = .01), which was reduced when covarying for cognitive performance (OR = 1.29, 95% CI 0.92-1.81, P = .14), suggesting mediation. Genetic variation in VMAT2 may be linked to alterations in cognitive functioning underlying psychotic disorder, possibly through altered transport of monoamines into synaptic vesicles.

Day-to-day associations between subjective sleep and affect in regard to future depression in a female population-based sample

BACKGROUND

Poor sleep is a risk factor for depression, but little is known about the underlying mechanisms.

AIMS

Disentangling potential mechanisms by which sleep may be related to depression by zooming down to the 'micro-level' of within-person daily life patterns of subjective sleep and affect using the experience sampling method (ESM).

METHOD

A population-based twin sample consisting of 553 women underwent a 5-day baseline ESM protocol assessing subjective sleep and affect together with four follow-up assessments of depression.

RESULTS

Sleep was associated with affect during the next day, especially positive affect. Daytime negative affect was not associated with subsequent night-time sleep. Baseline sleep predicted depressive symptoms across the follow-up period.

CONCLUSIONS

The subtle, repetitive impact of sleep on affect on a daily basis, rather than the subtle repetitive impact of affect on sleep, may be one of the factors on the pathway to depression in women.

Emotion recognition in psychosis: no evidence for an association with real world social functioning

BACKGROUND

Patients with psychotic disorders show impairments in the recognition of emotions in other people. These impairments have been associated with poor social functioning as measured by self-report questionnaires, clinical interviews and laboratory-based tests of social skills. The ecological validity of these tests, however, is low. Associations were examined between emotion recognition and daily life social interactions in 50 patients diagnosed with a non-affective psychotic disorder and 67 healthy controls.

METHODS

All participants were assessed with the Degraded Facial Affect Recognition Task (DFAR), a computer test measuring the recognition of emotional facial expressions. Social functioning in daily life was assessed using the Experience Sampling Method (a random time sampling technique) with focus on measures of social context and appraisal of the social situation.

RESULTS

Groups differed significantly in the recognition of angry faces, whereas no differences existed for other emotions. There were no associations between emotion recognition and social functioning in daily life and there was no evidence for differential associations in patients as compared to controls.

DISCUSSION

Social functioning, when assessed in an ecologically valid fashion, is not sensitive to variation in the traditional experimental assessment of emotion recognition. Real life measures of functioning should guide research linking the handicaps associated with psychosis to underlying cognitive and emotional dysregulation.

Genetic Risk and Outcome of Psychosis (GROUP), a multi-site longitudinal cohort study focused on gene-environment interaction: objectives, sample characteristics, recruitment and assessment methods

OBJECTIVE

A longitudinal focus on gene-environment vulnerability and resilience in both patients, their unaffected family members and non-related controls offers the opportunity to elucidate etiological and pathogenetic factors influencing the onset and course of psychotic disorders. The current paper delineates the objectives, sample characteristics, recruitment and assessment procedures of the Genetic Risk and Outcome of Psychoses (GROUP) study.

METHODS

A naturalistic longitudinal cohort study with assessments at baseline, after three and six years of follow-up. The study is conducted by a consortium of four university psychiatric centres, with their affiliated mental health care institutions in the Netherlands covering more than 7.5 million inhabitants. Extensive assessment of genetic factors, environmental factors, (endo)phenotypes, and outcome.

RESULTS

At baseline, 1120 patients, 1057 siblings, 919 parents and 590 healthy controls were included.

CONCLUSION

The GROUP study will contribute to insight in risk and protective factors in the aetiology of non-affective psychotic disorders, and in the variation in their course and outcome.

Evidence that genes for depression impact on the pathway from trauma to psychotic-like symptoms by occasioning emotional dysregulation

BACKGROUND

Genes for depression may act by making individuals more sensitive to childhood trauma. Given that childhood adversity is a risk factor for adult psychosis and symptoms of depression and psychosis tend to cluster within individuals and families, the aim was to examine whether the association between childhood adversity and psychotic-like symptoms is moderated by genetic liability for depression. A secondary aim was to determine to what degree a depression-related increase in stress sensitivity or depressive symptoms themselves occasioned the moderating effect.

METHOD

Female twins (n=508) completed both prospective and retrospective questionnaires regarding childhood adversity [the Symptom Checklist-90 - Revised (SCL-90-R) and SCID-I (psychotic symptoms)] and psychotic trait liability [the Community Assessment of Psychic Experiences (CAPE)]. Stress sensitivity was indexed by appraisals of event-related stress and negative affect (NA) in the flow of daily life, assessed with momentary assessment technology for five consecutive days. Multilevel regression analyses were used to examine moderation of childhood adversity by genetic liability for depression in the prediction of follow-up psychotic experiences.

RESULTS

The effect of childhood adversity was significantly moderated by genetic vulnerability for depression in the model of both follow-up psychotic experiences (SCL-90-R) and follow-up psychotic trait liability (CAPE). The moderation by genetic liability was mediated by depressive experience but not by stress sensitivity.

CONCLUSIONS

Genetic liability for depression may potentiate the pathway from childhood adversity to psychotic-like symptoms through dysfunctional emotional processing of anomalous experiences associated with childhood trauma.

Cognitive alterations in patients with non-affective psychotic disorder and their unaffected siblings and parents

OBJECTIVE

The purpose of this study was to examine a range of cognitive measures as candidate phenotypic liability markers for psychosis in a uniquely large sample of patients with psychosis, their unaffected relatives and control subjects.

METHOD

Patients with non-affective psychosis (n = 1093), their unaffected siblings (n = 1044), parents (n = 911), and controls (n = 587) completed a comprehensive cognitive test battery. Cognitive functioning was compared using tests of verbal learning and memory, attention/vigilance, working memory, processing speed, reasoning and problem solving, acquired knowledge, and social cognition. Age- and gender-adjusted z-scores were compared between groups using mixed-model analyses of covariance. Clinically relevant impairment (-1 and -2 SD from control mean) was compared between subject groups.

RESULTS

Patients performed significantly worse than controls in all cognitive domains (z-range -0.26 to -1.34). Siblings and parents showed alterations for immediate verbal learning, processing speed, reasoning and problem solving, acquired knowledge, and working memory (z-range -0.22 to -0.98). Parents showed additional alterations for social cognition. Prevalence of clinically relevant impairment in relatives ranged from 50% (-1 SD criterion) to 10% (-2 SD criterion).

CONCLUSION

Cognitive functioning is a candidate intermediate phenotype given significant small to large alterations in patients and intermediate alterations in first-degree relatives.

Momentary assessment technology as a tool to help patients with depression help themselves

OBJECTIVE

Given high relapse rates and residual symptoms in depression, new strategies to increase treatment effectiveness are required. A promising avenue is to investigate how electronic momentary assessment technology may contribute to clinical assessment and interventions in depression.

METHOD

A literature search was conducted focusing on the potential contribution of momentary assessments to clinical applications in depression.

RESULTS

Momentary assessments are able to reveal subtle, small but repetitive and relevant patterns of emotional expression that predict future course of depression. A momentary assessment tool may expose manageable pieces of daily life behaviour contributing to the depressive experience that patients can influence. The use of this explicit knowledge of daily life experience is understudied with regard to its contribution to diagnostic assessment, monitoring of treatment effects and feedback interventions in depressed patients. The clinical application of momentary assessments may stimulate a shift from passive consumption of treatment to an active role for patients in their recovery and increased patient ownership.

CONCLUSION

The precise, prospective and fine-grained information that momentary assessment technology provides may contribute to clinical practice in various ways. Future studies should examine the clinical impact of its use and the feasibility of its implementation in mental health care.

The dynamic interplay between negative and positive emotions in daily life predicts response to treatment in depression: a momentary assessment study

OBJECTIVES

Although the treatment of depressive illness aims to restore the imbalance between an excess of negative affect (NA) and a shortage of positive affect (PA), no study has examined how NA and PA may influence each other in depression. This study examines how NA and PA dynamically influence each other in depression and how this may impact on treatment response.

DESIGN

Depressed help-seeking individuals participated in the Experience Sampling Method (ESM), which enables visualization of subtle dynamic alterations of momentary affective states over time. Thereafter, participants received a combination of antidepressant treatment and psychotherapy, and were followed up each month.

METHODS

NA and PA were assessed during ESM at 10 random moments per day for 6 days. Depressive symptoms were assessed at baseline and at monthly intervals during treatment.

RESULTS

Future response to treatment was associated with altered baseline NA-PA dynamics in individuals with previous depressive episodes. Their daily life boosts of PA were followed by a stronger suppression of NA over subsequent hours than in other depressed groups or controls.

CONCLUSIONS

Subtle individual differences in daily life emotional dynamics predict future treatment outcome in depression.

Unveiling patterns of affective responses in daily life may improve outcome prediction in depression: a momentary assessment study

OBJECTIVE

Daily life affective responses are closely linked to vulnerability and resilience in depression. Prediction of future clinical course may be improved if information on daily life emotional response patterns is taken into account.

METHOD

Female subjects with a history of major depression (n=83), recruited from a population twin register, participated in a longitudinal study using momentary assessment technology with 4 follow-up measurements. The effect of baseline daily life emotional response patterns (affect variability, stress-sensitivity and reward experience) on follow-up depressive symptomatology was examined.

RESULTS

Both reward experience (B=-0.30, p=0.001) and negative affect variability (B=0.46, p=0.001) predicted future negative affective symptoms independent of all other dynamic emotional patterns and conventional predictors.

CONCLUSION

Daily life information on dynamic emotional patterns adds to the prediction of future clinical course, independent of severity of symptoms and neuroticism score. Better prediction of course may improve decision-making regarding quantitative and qualitative aspects of treatment.