The experience sampling method as an mHealth tool to support self-monitoring, self-insight, and personalized health care in clinical practice

Three-Year Follow-up of PositiveLinks: Higher Use of mHealth Platform Associated with Sustained HIV Suppression

PositiveLinks (PL) is a mHealth platform to support care engagement by people with HIV (PWH). Daily reminders prompt the user to report medication adherence, mood, and daily stress. Higher response rate to PL check-ins has been associated with better suppression of viral load over 6-18 months. We conducted a retrospective chart review for a three-year period collecting demographic information, average mood and stress scores, and all viral loads obtained in usual patient care. We performed multivariable logistic regression modeling to identify factors associated with loss of viral load suppression and a time-to-event survival analysis until first unsuppressed viral load stratified by PL usage. Of the 513 PWH included, 103 had at least one episode of viral non-suppression. Low users of PL were more likely to have an unsuppressed viral load with an adjusted Odds Ratio (aOR) of 5.8 (95% CI 3.0-11.5, p < 0.001). Protective factors included older age (aOR 0.96; 95% CI 0.93-0.98, p = 0.003) and income above the federal poverty level (FPL) (aOR 0.996; 95% CI 0.995-0.998, p < 0.001). High PL use was also associated with better viral load suppression (VLS) over time (p < 0.0001 ((aHR) of 0.437 (95% CI 0.290-0.658, p < 0.001)) after adjusting for age and FPL. High stress scores were related to subsequent loss of viral suppression in an exploratory analysis. High check-in response rate on the PL app, older age, and higher income are associated with sustained VLS over time. Conversely, lack of response to check-ins or increased reported stress may signal a need for additional support.

What is in a Day? Investigating the Relationship Between Sleep Quality and Quality of Life Among Caregivers of Children With Autism

OBJECTIVE

The purpose of this study was to investigate the relationship between sleep quality and quality of life (QOL), or overall level of well-being, in caregivers of children with autism spectrum disorder (ASD) on the daily level.

METHOD

This study utilizes mobile ecological momentary assessment (mEMA) to capture daily experiences of caregivers of children with ASD over a period of 14 days. Utilizing mEMA, this study examines relations between sleep quality and QOL and the role of mood and physical health as mediators on the daily level, specifically for caregivers of children with ASD (n = 51). The data were analyzed using multilevel modeling by MLMed macro.

RESULTS

The results suggest that there is a significant positive relation between sleep quality and QOL across individuals. Surprisingly, there was a negative relation between sleep quality and QOL within individuals. The positive relationship between sleep quality and QOL across participants was explained through positive mood across individuals. Furthermore, this relationship also occurred through better physical health across and within individuals.

CONCLUSION

For caregivers of children with ASD, daily positive mood and better physical health explain the relationship between daily sleep quality and QOL. Understanding daily experiences of caregivers of children with ASD may inform interventions and practices aimed at improving sleep and its associated outcomes to ultimately improve caregiver well-being.

Resilience in the Face of Cancer: On the Importance of Defining and Studying Resilience as a Dynamic Process of Adaptation

Resilience is defined as the maintenance or relatively quick recovery of mental health during and after adversity. Rather than focusing on psychopathology and its causes, resilience research aims to understand what protective mechanisms shield individuals against developing such disorders and translate these insights to improve psychosocial care. This resilience approach seems especially promising for the field of oncology because patients face stressor after stressor from diagnosis to survivorship. Helping patients to learn how they can best use the resources and abilities available to them can empower patients to handle subsequent stressors. In the past few decades, resilience has increasingly been considered as a dynamic process of adaptation. While researchers use this definition, resilience has not yet been studied as a dynamic process in the field of oncology. As a result, the potential of resilience research to gain insight into what helps protect cancer patients from developing psychopathology is limited. We discuss conceptual and methodological proposals to advance resilience research in oncology. Most importantly, we propose applying prospective longitudinal designs to capture the dynamic resilience process. By gaining insight in how cancer patients engage in protective factors, resilience research can come to its full potential and help prevent psychopathology.

Use of the experience sampling method in adolescents with Duchenne muscular dystrophy: a feasibility study

Experience sampling methods (ESM) using mobile health (mHealth) technology with a smartphone application are increasingly used in clinical practice and research. Still, recommendations are limited in young people, and adaptations may be necessary. Patients with Duchenne muscular dystrophy (DMD) are chronically treated with steroids from a young age. However, the impact of intermittent treatment schedules on fluctuations in somatic, cognitive and behavioural symptoms is poorly investigated. Existing studies are often cross-sectional and occur in controlled clinical settings, which do not provide sufficiently detailed insights into possible correlations. ESM might alleviate these problems. ESM innovates data collection with a smartphone application, which repeatedly assesses specific symptoms and contextual factors at random moments in daily life. We aimed to evaluate its feasibility in adolescents with DMD. In three (without/with/without steroids) 4-day periods of ESM, that were nested in 10/10 or 11/9 day on/off-medication periods, we evaluated its user-friendliness and compliance, and explored its ability to objectify fluctuations in somatic, cognitive and behavioural symptom severity and their relationship with contextual factors in seven DMD patients (age range 12-18 years) using intermittent corticosteroid treatment (dosage range 0.3-0.6 mg/kg/day). Patients reported that ESM was convenient and user-friendly. We were able to capture extensive intra-individual symptom fluctuations during intermittent corticosteroid treatment that were not revealed by routine clinical assessment. Implementing ESM to evaluate symptom fluctuation patterns in relation to treatment effects shows promise in adolescents with DMD. Optimization in further research is needed.

Strategies, processes, outcomes, and costs of implementing experience sampling-based monitoring in routine mental health care in four European countries: study protocol for the IMMERSE effectiveness-implementation study

BACKGROUND

Recent years have seen a growing interest in the use of digital tools for delivering person-centred mental health care. Experience Sampling Methodology (ESM), a structured diary technique for capturing moment-to-moment variation in experience and behaviour in service users' daily life, reflects a particularly promising avenue for implementing a person-centred approach. While there is evidence on the effectiveness of ESM-based monitoring, uptake in routine mental health care remains limited. The overarching aim of this hybrid effectiveness-implementation study is to investigate, in detail, reach, effectiveness, adoption, implementation, and maintenance as well as contextual factors, processes, and costs of implementing ESM-based monitoring, reporting, and feedback into routine mental health care in four European countries (i.e., Belgium, Germany, Scotland, Slovakia).

METHODS

In this hybrid effectiveness-implementation study, a parallel-group, assessor-blind, multi-centre cluster randomized controlled trial (cRCT) will be conducted, combined with a process and economic evaluation. In the cRCT, 24 clinical units (as the cluster and unit of randomization) at eight sites in four European countries will be randomly allocated using an unbalanced 2:1 ratio to one of two conditions: (a) the experimental condition, in which participants receive a Digital Mobile Mental Health intervention (DMMH) and other implementation strategies in addition to treatment as usual (TAU) or (b) the control condition, in which service users are provided with TAU. Outcome data in service users and clinicians will be collected at four time points: at baseline (t0), 2-month post-baseline (t1), 6-month post-baseline (t2), and 12-month post-baseline (t3). The primary outcome will be patient-reported service engagement assessed with the service attachment questionnaire at 2-month post-baseline. The process and economic evaluation will provide in-depth insights into in-vivo context-mechanism-outcome configurations and economic costs of the DMMH and other implementation strategies in routine care, respectively.

DISCUSSION

If this trial provides evidence on reach, effectiveness, adoption, implementation and maintenance of implementing ESM-based monitoring, reporting, and feedback, it will form the basis for establishing its public health impact and has significant potential to bridge the research-to-practice gap and contribute to swifter ecological translation of digital innovations to real-world delivery in routine mental health care.

TRIAL REGISTRATION

ISRCTN15109760 (ISRCTN registry, date: 03/08/2022).

A randomized controlled trial of brief behavioral activation plus savoring for positive affect dysregulation in university students

Rising rates of depression on university campuses accentuate the need for specific intervention. Interventions targeting disturbances in positive affect, in particular, remain sparse, yet such deficits interfere substantially with functioning and further exacerbate or maintain negative symptoms. The current study aimed to evaluate the impact of a virtual, two-session Behavioral Activation augmented with Savoring (BA + S) intervention compared to an Emotional Awareness (EA) control group in increasing positive affect. Sixty university students with low positive affect were randomized to BA + S or EA and completed 21 days of experience-sampling of positive affect. Weekly measures of positive and negative valence symptoms were assessed at baseline, sessions one and two, and at one-week follow-up. Through a prori analyses utilizing multilevel and multivariate multilevel models, our results demonstrate that daily positive affect measured via experience-sampling significantly improved in BA + S, whereas positive affect did not change for those receiving EA, though the interaction of condition and time was not significant. Furthermore, interactions in weekly variables were significant. Increases in positive valence symptoms (affect, anhedonia, etc.) were only reported for students receiving BA + S but not EA. Negative valence symptoms (affect, depression, general distress) improved in both conditions but with superior improvements in BA + S compared to EA. BA + S shows promise for a scalable and accessible intervention to university students with clinical levels of positive and negative affect. ClinicalTrials ID: NCT05234476.

Feasibility of a novel blended-care intervention for fatigue after acquired brain injury: a pilot study of the Tied by Tiredness intervention

PURPOSE

Evidence-based treatments for fatigue after brain injury are scarce and often not personalized. An approach to foster personalization is Experience Sampling Methodology (ESM), consisting of repeated daily measurements of fatigue and related factors in daily life. We investigated the feasibility and usability of a novel six-week ESM-based intervention for fatigue after brain injury.

MATERIALS AND METHODS

Ten individuals with acquired brain injury (six men; four women) aged between 36-70 years (M = 53.3, SD = 12.9) used a mHealth application for three days each week during six-weeks; seven completed the intervention. Momentary fatigue, activities, mood, worrying, and social context were assessed with ESM and participants received weekly personalized feedback by a therapist..

RESULTS

56% of ESM-questionnaires (568/1008) were completed, providing detailed insights into individual fatigue patterns. No statistically significant decrease in response rate was found over the course of treatment. Qualitative feedback from participants revealed increased insight into factors underlying fatigue, and no problems with treatment duration or difficulties using the app. Five participants showed a decline in fatigue level during treatment.

CONCLUSIONS

This pilot study provides initial support for the feasibility and usability of this novel blended-care intervention, aimed at alleviating fatigue through personalized feedback and treatment strategies.

Environmental stress and emotional reactivity: an exploratory experience sampling method study

Background

Previous studies have shown a relationship between environments and mental health. However, limited studies have investigated the impact of environment stress (ES) on emotional reactivity. Our study aimed to fill this gap by examining how daily ES affects momentary emotional reactivity using experience sampling method (ESM).

Methods

Participants were randomly recruited from a prospective cohort study in Hong Kong to participate in a 7-day ESM study. The participants received eight electronic signals daily assessing their ES, positive affect (PA) and negative affect (NA). Participants were categorized into depressed group or control group based on Revised Clinical Interview Schedule. Psychometric properties of the ESM assessment were evaluated. Multilevel linear regression analyzes were conducted to examine the association of ES with PA, NA and the group status of the participants (cases versus controls).

Results

A total of 15 participants with depression and 15 healthy controls were recruited, and 1307 momentary assessments were completed with a compliance rate of 77.8%. The depressed group demonstrated a significant increase in NA in response to ES, while the control group showed a decrease in PA. In addition, the depressed group reported a lower perception of control and interaction with their environment compared to the control group.

Conclusion

Using ESM, a valid, reliable, and easy-to-use self-reporting tool, our findings provided valuable insights on the potential mechanisms underlying emotional responses to stressful environments.

Feasibility and Acceptability of a Mobile App for Prolonged Grief Disorder Symptoms

Background

Mobile apps provide a unique platform for mental health assessment and monitoring. They can provide real time, accessible data on symptoms of mental disorders that may yield rich data for detailed clinical assessment and help individuals gain insight into their current mental state. We developed one of the first apps for tracking symptoms of prolonged grief disorder.

Method

In this pilot feasibility study, we assess the feasibility and acceptability of a new mobile app mGAGE for use once a day for 3 weeks. 27 participants completed mental health assessments at t1 and t2.

Results

Adherence to the app protocol was very high with 100% for the first two weeks of use. A surprising finding was the improvement of grief symptoms at t2. Debriefing interviews revealed general qualitative categories including positive feedback, negative feedback and specific recommendations. Overall, the app was found to be feasible for use for the first two weeks and acceptable for bereaved individuals.

Conclusions

This app could provide valuable data for in depth clinical assessment, may support individuals to gain greater insight into their symptoms and may have a therapeutic effect in terms of improved grief symptoms. Implications for future studies including use in larger intervention studies are discussed.

Applications of the experience sampling method (ESM) in paediatric healthcare: a systematic review

BACKGROUND

With the Experience Sampling Method (ESM) participants are asked to provide self-reports of their symptoms, feelings, thoughts and behaviours in daily life. This preregistered systematic review assessed how ESM is being used to monitor emotional well-being, somatic health, fatigue and pain in children and adolescents with a chronic somatic illness.

METHODS

Databases were searched from inception. Studies were selected if they included children or adolescents aged 0-25 years with a chronic somatic illness and used ESM focussing on mental health or psychosocial wellbeing, biopsychosocial factors and/or somatic health. Two reviewers extracted data of the final 47 papers, describing 48 studies.

RESULTS

Most studies evaluated what factors influence medical or psychological symptoms and how symptoms influence each other. Another common purpose was to study the feasibility of ESM or ESM as part of an app or intervention. Study methods were heterogeneous and most studies lack adequate reporting of ESM applications and results.

CONCLUSIONS

While ESM holds great potential for providing results and feedback to patients and caregivers, little use is being made of this option. Future studies should consider what they report in their studies, conduct a priori power analyses and how ESM can be embedded in clinical practice.

IMPACT

While ESM has many clinical applications, it is currently mostly used for research purposes. Current studies using ESM are heterogeneous and lack consistent, high-quality reporting. There is great potential in ESM for providing patients and parents with personalised feedback.

Affect dimensions and variability during major depressive episodes: Ecological momentary assessment of unipolar, bipolar, and borderline patients and healthy controls

Differentiating major depressive episodes (MDEs) of major depressive disorder (MDD), bipolar disorder (MDE/BD) and the MDEs comorbid with borderline personality disorder (MDE/BPD) is crucial for appropriate treatment, and knowledge of phenomenological differences may aid this. However, studies comparing affect experiences of these three patient groups and healthy subjects are scarce. In our study, participants (N = 114), including patients with MDD (n = 34), MDE/BD (n = 27), and MDE/BPD (n = 24), and healthy controls (HC, n = 29) responded to ecological momentary assessment (EMA) with ten circumplex model affect items ten times daily for seven days (7709 recordings). Explorative factor analysis resulted in two affect dimensions. The positive dimension included active, excited, cheerful (high arousal), and content (low arousal) affects, and the negative dimension irritated, angry, and nervous (high arousal) affects. Relative to HC, patients reported 3.5-fold negative affects (mean MDD 1.36 (SD 0.92), MDE/BD 1.43 (0.76), MDE/BPD 1.81 (0.95) vs. HC 0.44 (0.49) (p < 0.01)) but 0.5-fold positive affects (2.01 (0.90), 1.95 (0.89), 2.24 (1.03), vs. 3.2 (0.95), respectively (p < 0.01)). We used multilevel modelling. Negative-affect within-individual stability was lowest in MDE/BPD and highest in MDD. Negative affect predicted concurrent positive affect more in MDE/BPD than in MDD. Moderate size of subcohorts and no inpatients were limitations. Despite apparently similar MDEs, affective experiences may differ between BPD, BD, and MDD patients. Clinical subgroups of patients with depression may vary in affective instability and concurrent presence of negative and positive affects during depression.

Personalized exposure and experience sampling method feedback versus exposure as usual for obsessive-compulsive disorder: a study protocol for a randomized controlled trial

BACKGROUND

Patients with obsessive-compulsive disorder (OCD) suffer from repetitive fearful intrusions which they try to neutralize by performing compulsions. OCD is considered to be the most resistant anxiety disorder with a remission rate of only 53% after a year of an evidence-based treatment. Therefore, it remains an obligation to develop and investigate more effective treatment interventions. This study aims to compare personalized exposure with response prevention (ERP) using experience sampling methodology-based feedback to ERP as usual in patients with OCD. Personalized exposure will be provided screen-to-screen in an ecologically valid (real time and real place) context by means of a smartphone application. This app will also be used to collect both objective and subjective data by means of experience sampling methodology (ESM). This ESM data will be used to identify triggers and protective factors for symptom severity, provide personalized feedback and optimize the effect of ERP. The primary goal of this RCT is to compare the effectiveness of personalized ERP to ERP as usual in the traditional context of a therapist's room in patients with OCD in OCD symptom severity, as well as differences in quality of life, depressive symptoms and anxiety states. Since both self-efficacy and experiential avoidance are known to influence symptom severity in OCS, a secondary goal is to examine if a possible treatment effect is mediated by self-efficacy or experiential avoidance.

METHODS

This study involves a randomized controlled trial with 20 weekly sessions by 2 groups (ERP as usual versus personalized ERP), repeated measurements at baseline (T0), 5 weeks of treatment (T1), 10 weeks of treatment (T2), 15 weeks of treatment (T3), posttest at 20 weeks (T4), 6 weeks follow-up (T5), 3 months follow-up (T6), 6 months follow-up (T7) and a year follow-up (T8). A hundred and sixty patients with an OCD diagnosis according to DSM-5 criteria will participate. Half of the group will receive exposure with response prevention as usual, the other half will receive personalized exposure with response prevention with a smartphone application and personalized feedback sessions based on experience sampling data. Multilevel mixed modelling analysis will be used to investigate differences in treatment effect, as well as differences in quality of life, depressive symptoms and anxiety states. We will use the macro of Preacher and Hayes and apply bootstrapping methods to assess the possible mediating effect of changes in self-efficacy and experiential avoidance on subsequent treatment effects.

DISCUSSION

This randomized controlled trial is the first to assess the influence of delivering ERP through video-calling and the use of an ESM intervention on the symptom severity of OCD. Since the global pandemic COVID-19, the use of video-calling to deliver psychological treatments has become more common, increasing the relevance of this study.

TRIAL REGISTRATION

ICTRP Trial NL8254. Registered on 2019-12-24.

Usability of the Experience Sampling Method in Specialized Mental Health Care: Pilot Evaluation Study

BACKGROUND

Mental health problems occur in interactions in daily life. Yet, it is challenging to bring contextual information into the therapy room. The experience sampling method (ESM) may facilitate this by assessing clients' thoughts, feelings, symptoms, and behaviors as they are experienced in everyday life. However, the ESM is still primarily used in research settings, with little uptake in clinical practice. One aspect that may facilitate clinical implementation concerns the use of ESM protocols, which involves providing practitioners with ready-to-use ESM questionnaires, sampling schemes, visualizations, and training.

OBJECTIVE

This pilot study's objective was to evaluate the usability of an ESM protocol for using the ESM in a specialized mental health care setting.

METHODS

We created the ESM protocol using the m-Path software platform and tested its usability in clinical practice. The ESM protocol consists of a dashboard for practitioners (ie, including the setup of the template and data visualizations) and an app for clients (ie, for completing the ESM questionnaires). A total of 8 practitioners and 17 clients used the ESM in practice between December 1, 2020, and July 31, 2021. Usability was assessed using questionnaires, ESM compliance rates, and semistructured interviews.

RESULTS

The usability was overall rated reasonable to good by practitioners (mean scores of usability items ranging from 5.33, SD 0.91, to 6.06, SD 0.73, on a scale ranging from 1 to 7). However, practitioners expressed difficulty in personalizing the template and reported insufficient guidelines on how to use the ESM in clinical practice. On average, clients completed 55% (SD 25%) of the ESM questionnaires. They rated the usability as reasonable to good, but their scores were slightly lower and more variable than those of the practitioners (mean scores of usability items ranging from 4.18, SD 1.70, to 5.94, SD 1.50 on a scale ranging from 1 to 7). Clients also voiced several concerns over the piloted ESM template, with some indicating no interest in the continued use of the ESM.

CONCLUSIONS

The findings suggest that using an ESM protocol may facilitate the implementation of the ESM as a mobile health assessment tool in psychiatry. However, additional adaptions should be made before further implementation. Adaptions include providing training on personalizing questionnaires, adding additional sampling scheme formats as well as an open-text field, and creating a dynamic data visualization interface. Future studies should also identify factors determining the suitability of the ESM for specific treatment goals among different client populations.

Time Effect on Acute Postoperative Pain After Total Knee Replacement Surgery: An Exploratory Study Using the Experience Sampling Method

OBJECTIVES

Acute postoperative pain (APP) is the main cause of postoperative dissatisfaction; however, traditional methods of pain assessment provide limited insights into the dynamics and development of APP. This study used the experience sampling method to understand the dynamics of APP over time in relation to various patient factors.

MATERIALS AND METHODS

Forty patients scheduled to undergo total knee replacement surgery were recruited in this study. Following an initial assessment, a short report questionnaire was sent to the patients through 10 digital alerts per day to assess the pain levels during 2 preoperative and the first 6 postoperative days. The data were analyzed using multilevel regression, including random intercept and slope.

RESULTS

Thirty-two patients submitted the prespecified minimum of 30% of their short reports, yielding 1217 records. The analysis revealed significant ( P <0.001) linear and quadratic decreases in APP and a quadratic time effect. The lowest between-day and within-day pain levels were observed on postoperative day 4.8 and during the time slot 3.8 or ~19:15, respectively. Significant random intercepts and slopes were noted, indicating variations in the mean pain level between patients and a decrease in pain. None of the 10 patient factors had any confounding effect.

DISCUSSION

Using the experience sampling method data combined with multilevel analysis, we were able to evaluate the postoperative pain course while considering inter-individual differences in the baseline pain level and nonlinear pain course over time. The findings of this study could aid clinicians in personalizing the treatment for APP.

Mental Health Self-Tracking Preferences of Young Adults With Depression and Anxiety Not Engaged in Treatment: Qualitative Analysis

BACKGROUND

Despite the high prevalence of anxiety and depression among young adults, many do not seek formal treatment. Some may turn to digital mental health tools for support instead, including to self-track moods, behaviors, and other variables related to mental health. Researchers have sought to understand processes and motivations involved in self-tracking, but few have considered the specific needs and preferences of young adults who are not engaged in treatment and who seek to use self-tracking to support mental health.

OBJECTIVE

This study seeks to assess the types of experiences young adults not engaged in treatment have had with digital self-tracking for mood and other mental health data and to assess how young adults not seeking treatment want to engage in self-tracking to support their mental health.

METHODS

We conducted 2 online asynchronous discussion groups with 50 young adults aged 18 years to 25 years who were not engaged in treatment. Participants were recruited after indicating moderate to severe symptoms of depression or anxiety on screening surveys hosted on the website of Mental Health America. Participants who enrolled in the study responded anonymously to discussion prompts on a message board, as well as to each other's responses, and 3 coders performed a thematic analysis of their responses.

RESULTS

Participants had mixed experiences with self-tracking in the past, including disliking when tracking highlighted unwanted behaviors and discontinuing tracking for a variety of reasons. They had more positive past experiences tracking behaviors and tasks they wanted to increase, using open-ended journaling, and with gamified elements to increase motivation. Participants highlighted several design considerations they wanted self-tracking tools to address, including building self-understanding; organization, reminders, and structure; and simplifying the self-tracking experience. Participants wanted self-tracking to help them identify their feelings and how their feelings related to other variables like sleep, exercise, and events in their lives. Participants also highlighted self-tracking as useful for motivating and supporting basic activities and tasks of daily living during periods of feeling overwhelmed or low mood and providing a sense of accomplishment and stability. Although self-tracking can be burdensome, participants were interested and provided suggestions for simplifying the process.

CONCLUSIONS

These young adults not engaged in treatment reported interest in using self-tracking to build self-understanding as a goal in and of itself or as a first step in contemplating and preparing for behavior change or treatment-seeking. Alexithymia, amotivation, and feeling overwhelmed may serve both as barriers to self-tracking and opportunities for self-tracking to help.

Patient-reported outcome measures in functional dyspepsia: a systematic review and COSMIN analysis

BACKGROUND

Functional dyspepsia (FD) as a type of disorders of brain-gut interaction (DBGI), patient self-reporting of its symptoms becomes an important component of clinical outcome assessment. We performed a systematic review using Consensus Based Standards for the Selection of Health Measurement Instruments (COSMIN) guidelines to identify the best available patient-reported outcome measure (PROM) of FD.

METHODS

The study was conducted according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA). We searched four databases with no date limit, looking for previously confirmed PROMs for evaluating FD symptoms. An overall rating was then assigned based upon COSMIN guidelines, and the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) approach was used to assess the level of evidence for psychometric properties of included PROMs.

RESULTS

Thirty articles covering outcome indicators of 24 patient reports were included. The Leuven Postprandial Distress Scale (LPDS) showed adequate content validity and moderate quality evidence of adequate internal consistency to generate an A recommendation.

CONCLUSION

LPDS is currently the most recommended PROM for patient self-reported FD symptoms. However, it fails to assess two important areas of cross-cultural validity/ measurement invariance and measurement error. Future research can be continuously improved on this basis.

Ecological momentary assessment (EMA) combined with unsupervised machine learning shows sensitivity to identify individuals in potential need for psychiatric assessment

Ecological momentary assessment (EMA), a structured diary assessment technique, has shown feasibility to capture psychotic(-like) symptoms across different study groups. We investigated whether EMA combined with unsupervised machine learning can distinguish groups on the continuum of genetic risk toward psychotic illness and identify individuals with need for extended healthcare. Individuals with psychotic disorder (PD, N = 55), healthy individuals (HC, N = 25) and HC with first-degree relatives with psychosis (RE, N = 20) were assessed at two sites over 7 days using EMA. Cluster analysis determined subgroups based on similarities in longitudinal trajectories of psychotic symptom ratings in EMA, agnostic of study group assignment. Psychotic symptom ratings were calculated as average of items related to hallucinations and paranoid ideas. Prior to EMA we assessed symptoms using the Positive and Negative Syndrome Scale (PANSS) and the Community Assessment of Psychic Experience (CAPE) to characterize the EMA subgroups. We identified two clusters with distinct longitudinal EMA characteristics. Cluster 1 (NPD = 12, NRE = 1, NHC = 2) showed higher mean EMA symptom ratings as compared to cluster 2 (NPD = 43, NRE = 19, NHC = 23) (p < 0.001). Cluster 1 showed a higher burden on negative (p < 0.05) and positive (p < 0.05) psychotic symptoms in cross-sectional PANSS and CAPE ratings than cluster 2. Findings indicate a separation of PD with high symptom burden (cluster 1) from PD with healthy-like rating patterns grouping together with HC and RE (cluster 2). Individuals in cluster 1 might particularly profit from exchange with a clinician underlining the idea of EMA as clinical monitoring tool.

Feedback based on experience sampling data: Examples of current approaches and considerations for future research

Methodologies such as the Experience Sampling Method (ESM) or Ecological Momentary Assessment allow the gathering of fine-graded, dynamic, personal data within a patient's daily life. Currently, it is studied whether feedback based on experience sampling data (ESM-based feedback) can be used as a clinical tool to inform shared decision-making in clinical practice. Although the potential of feedback is recognized, little is known on how to generate, use, and implement it. This article (i) presents n = 15 ongoing ESM projects within the Belgian-Dutch network for ESM research wherein ESM-based feedback is provided to various patient populations, and (ii) summarizes qualitative data on experiences with ESM-based feedback of researchers (n = 8) with extensive expertise with ESM (average of 10 years) involved in these ongoing studies. The following aspects appear to be of relevance when providing ESM-based feedback: training for healthcare professionals and researchers, the use of online interfaces and graphical visualizations to present data, and interacting with patients in a face-to-face setting when discussing the contextual relevance and potential implications. Prospectively, research may build on these aspects and create coherent consensus-based guidelines for the use of ESM-based feedback.

Tracking variations in daily questionable health behaviors and their psychological roots: a preregistered experience sampling study

People resort to various questionable health practices to preserve or regain health - they intentionally do not adhere to medical recommendations (e.g. self-medicate or modify the prescribed therapies; iNAR), or use traditional/complementary/alternative (TCAM) medicine. As retrospective reports overestimate adherence and suffer from recall and desirability bias, we tracked the variations in daily questionable health behaviors and compared them to their retrospectively reported lifetime use. We also preregistered and explored their relations to a wide set of psychological predictors - distal (personality traits and basic thinking dispositions) and proximal (different unfounded beliefs and biases grouped under the term irrational mindset). A community sample (N = 224) tracked daily engagement in iNAR and TCAM use for 14 days, resulting in 3136 data points. We observed a high rate of questionable health practices over the 14 days; daily engagement rates roughly corresponded to lifetime ones. Both iNAR and TCAM were weakly, but robustly positively related. Independent of the assessment method, an irrational mindset was the most important predictor of TCAM use. For iNAR, however, psychological predictors emerged as relevant only when assessed retrospectively. Our study offers insight into questionable health behaviors from both a within and between-person perspective and highlights the importance of their psychological roots.

Prospectively predicting naturalistic exposure to fitspiration and thinspiration in young women with disordered eating by leveraging an ecological momentary assessment design

OBJECTIVE

Although a growing body of research has examined the impacts of ED-salient content, such as fitspiration and thinspiration, on eating disorder (ED) symptoms, there is less known about the characteristics of who may be at risk for accessing this content on Instagram. Current research is limited by cross-sectional and retrospective designs. This prospective study used ecological momentary assessment (EMA) to predict naturalistic exposure to ED-salient content on Instagram.

METHODS

Female university students with disordered eating (N = 171, Mage = 20.23, SD = 1.71, range = 18-25) completed a baseline session, followed by a seven-day EMA protocol, in which they reported on Instagram use and exposure to fitspiration and thinspiration. Mixed-effects logistical regressions were used to predict exposure to ED-salient content on Instagram from four principal components (e.g., behavioral ED symptoms and trait social comparison) controlling for duration of Instagram use (i.e., dose) and day of study.

RESULTS

Duration of use was positively associated with all types of exposure. Purging/cognitive restraint and excessive exercise/muscle building prospectively predicted access to any ED-salient content and fitspiration only. Restricting positively predicted thinspiration only access. Purging/cognitive restraint positively predicted accessing fitspiration and thinspiration (dual exposure). Day of study was negatively associated with any exposure, fitspiration only, and dual exposure.

CONCLUSIONS

Baseline ED behaviors were differentially associated with exposure to ED-salient Instagram content; however, duration of use was also a significant predictor. Limiting use of Instagram may be important for young women with disordered eating to reduce probability of encountering ED-salient content.

Using Experience Sampling Methods to support clinical management of psychosis: The perspective of people with lived experience

The Experience sampling method (ESM) has the potential to support person-centered care of psychotic disorders. However, clinical implementation is hampered by a lack of user involvement in the design of ESM tools. This qualitative study explored the perspective of nine people with lived experiences of psychosis. Participants reported a need to monitor a diverse range of daily-life experiences and indicated that ESM should allow for personalization to be clinically useful. While participants recognized the potential of ESM to increase awareness and control over their mental health, concerns were voiced about the validity and burden of monitoring one's own mental health.

Real-time Symptom Assessment in Patients With Endometriosis: Psychometric Evaluation of an Electronic Patient-Reported Outcome Measure, Based on the Experience Sampling Method

BACKGROUND

The experience sampling method (ESM) holds advantages over traditional retrospective questionnaires including a high ecological validity, no recall bias, the ability to assess fluctuation of symptoms, and the ability to analyze the temporal relationship between variables.

OBJECTIVE

This study aimed to evaluate the psychometric properties of an endometriosis-specific ESM tool.

METHODS

This is a short-term follow-up prospective study, including patients with premenopausal endometriosis aged ≥18 years who reported dysmenorrhea, chronic pelvic pain, or dyspareunia between December 2019 and November 2020. An ESM-based questionnaire was sent out by a smartphone application 10 times a day during 1 week on randomly chosen moments. Additionally, patients completed questionnaires concerning demographics, end-of-day pain scores, and end-of-week symptom scores. The psychometric evaluation included compliance, concurrent validity, and internal consistency.

RESULTS

Twenty-eight patients with endometriosis completed the study. Compliance for answering the ESM questions was as high as 52%. End-of-week pain scores were higher than ESM mean scores and showed peak reporting. ESM scores showed strong concurrent validity when compared with symptoms scored by the Gastrointestinal Symptom Rating Scale-Irritable Bowel Syndrome, 7-item Generalized Anxiety Disorders Scale, 9-question Patient Health Questionnaire, and the majority of questions of the 30-item Endometriosis Health Profile. Cronbach α coefficients demonstrated a good internal consistency for abdominal symptoms, general somatic symptoms, and positive affect, and an excellent internal consistency for negative affect.

CONCLUSIONS

This study supports the validity and reliability of a newly developed electronic instrument for the measurement of symptoms in women with endometriosis, based on momentary assessments. This ESM patient-reported outcome measure has the advantage of providing a more detailed view on individual symptom patterns and offers the possibility for patients to have insight in their symptomatology, leading to more individualized treatment strategies that can improve the quality of life of women with endometriosis.

Integrating personalized experience sampling in psychotherapy: A case illustration of the Therap-i module

Background

The experience sampling methodology (ESM) is increasingly being suggested as a clinical tool in mental health care, as it offers ecologically valid, microlevel information on psychopathological processes. Patients and clinicians have recommended that applications of ESM should be personalized and integrated into the existing clinical process, but there is still much uncertainty about how implementation may look like.

Objective

To provide an example of personalized ESM assessment and feedback being integrated into psychotherapy for depression, specifically looking at the collaborative use of ESM in case conceptualization.

Methods

George, a 27-year-old man diagnosed with depression, and his therapist participated in the Therap-i randomized controlled trial, which investigates the efficacy of a personalized ESM module added to psychotherapy. Together, they created a personalized ESM questionnaire, aiming to capture their hypotheses and questions regarding George's case conceptualization. George then filled out his ESM questionnaire five times per day, for 8 weeks. During this period, ESM data were discussed and interpreted by George, his therapist, and a researcher, in three feedback sessions. In these sessions, data were visualized in a flexible feedback interface that allowed for collaborative exploration of George's data. Both patient and therapist evaluated the module through questionnaires and George also participated in a semi-structured evaluation interview.

Results

George's ESM questionnaire included personalized items on the topics of self-esteem and open versus withdrawn behavior. He completed 241 (89.3%) assessments. Discussions during the feedback sessions focused on two core themes: First, George's low energy level, which was further explored with regard to his sleep, medication, and activity patterns. Second, his low sense of self-esteem, which led to an in-depth exploration of his thinking patterns and social interactions. The ESM module was seen as useful and insightful by both George and therapist.

Conclusions

This case shows how ESM and ESM-based feedback can stimulate the collaborative exploration of the patient's complaints, and how it can provide useful insights for treatment. We discuss how our personalized ESM module relates to current clinical principles and practices, and make suggestions for further implementation.

Staff and ward factors associated with aggression development on an acute closed psychiatric ward: an experience sampling method study

Aggression on psychiatric wards develops under influence of patient, staff and ward factors. Assessment of naturalistic derived staff and ward factors might increase better understanding of how aggressive incidents develop on psychiatric wards.

OBJECTIVE

Studying staff and ward factors including interactions between patients and nurses prior and after development of aggression, within a naturalistic closed ward setting.

DESIGN

A prospective naturalistic experience sampling method (ESM) study.

SETTING AND PARTICIPANTS

A high intensive care unit of a mental health institution in The Netherlands where 29 nurses answered beeps generated by an app during approximately 7 consecutive days with questions regarding their subjective feelings, ward atmosphere, location, interaction they had with patients and their colleagues and whether an incident took place.

MAIN OUTCOME MEASURES

Associations were established between different staff and ward factors and the occurrence of aggressive incidents on the ward.

RESULTS

Risk for aggression was associated with the nurse being with a patient (OR=2.26, 95% CI 0.99 to 5.15, p=0.05). No significant association was found between discussing with the patient and setting a limit or physical absence of the nurse on the one hand and aggression on the other. More experienced nurses encountered more aggression (OR=3.5, 95% CI 1.32 to 8.26, p=0.01). Age and gender of the nurse were not associated with aggression development. Exceeding the maximum bed capacity was associated with a greater risk for aggression (OR=5.36, 95% CI 1.69 to 16.99, p=0.004). There was no significant association when analysing a more positive atmosphere on the ward or positive affect of the nurse, but negative affect of the nurses showed a trend for an association with less aggression.

CONCLUSION

Aggression is a problem that should be managed from a multidimensional perspective. The quality of interaction between nurses and patients is crucial. Exceeding the maximum bed capacity is likely associated with more aggression.

Combining actigraphy and experience sampling to assess physical activity and sleep in patients with psychosis: A feasibility study

BACKGROUND

Sleep disorders and reduced physical activity are common in patients with psychosis and can be related to health-related outcomes such as symptomatology and functioning. Mobile health technologies and wearable sensor methods enable continuous and simultaneous monitoring of physical activity, sleep, and symptoms in one's day-to-day environment. Only a few studies have applied simultaneous assessment of these parameters. Therefore, we aimed to examine the feasibility of the simultaneous monitoring of physical activity, sleep, and symptoms and functioning in psychosis.

METHODS

Thirty three outpatients diagnosed with a schizophrenia or other psychotic disorder used an actigraphy watch and experience sampling method (ESM) smartphone app for 7 consecutive days to monitor physical activity, sleep, symptoms, and functioning. Participants wore the actigraphy watch during day and night and completed multiple short questionnaires (eight daily, one morning, and one evening) on their phone. Hereafter they completed evaluation questionnaires.

RESULTS

Of the 33 patients (25 male), 32 (97.0%) used the ESM and actigraphy during the instructed timeframe. ESM response was good: 64.0% for the daily, 90.6% for morning, and 82.6% for evening questionnaire(s). Participants were positive about the use of actigraphy and ESM.

CONCLUSION

The combination of wrist-worn actigraphy and smartphone-based ESM is feasible and acceptable in outpatients with psychosis. These novel methods can help both clinical practice and future research to gain more valid insight into physical activity and sleep as biobehavioral markers linked to psychopathological symptoms and functioning in psychosis. This can be used to investigate relationships between these outcomes and thereby improve individualized treatment and prediction.

Are Ecological Momentary Assessments of Pain Valid and Reliable? A Systematic Review and Meta-analysis

OBJECTIVES

This systematic review and meta-analysis aimed to determine the level of evidence for the psychometric properties of Ecological Momentary Assessment (EMA) in populations with persistent pain.

MATERIALS AND METHODS

Five databases were searched from 1980 to December 2021. Two reviewers independently screened the titles, abstracts, and full text, extracted data, and assessed adherence to reporting standards and methodological rigor before evaluating the quality of evidence. A meta-analysis, including the pooling of correlations for the relevant EMA pain outcomes, was completed.

RESULTS

Overall, 3270 studies were identified, with 14 studies meeting inclusion criteria. Meta-analyses confirmed good to excellent relationships demonstrated between EMA and recalled pain intensity and interference across different timeframes. Many of the included studies did not fully adhere to recommended reporting standards, and the quality of included studies was either doubtful or inadequate due to methodological flaws. The level of evidence for measurement properties of pain outcomes was low for the criterion validity of pain intensity and interference and very low for reliability and construct validity of pain intensity and interference.

DISCUSSION

Ecological momentary assessment of pain experience appears both valid and reliable. Although the levels of evidence were low or very low, these findings provide preliminary support for the use of EMA in clinical practice and research settings. Potential strengths of EMA include providing measures with greater ecological validity while also reducing recall bias, both pertinent in pain outcome measurement. More research, including higher-quality studies, is needed to demonstrate further support for EMA, including the need for establishing other types of validity.

Impact of smartphone overuse on 1-year severe depressive symptoms and momentary negative affect: Longitudinal and experience sampling findings from a representative epidemiological youth sample in Hong Kong

Smartphone overuse can have detrimental impacts on youth mental health. How it may be longitudinally associated with depressive symptoms and functioning, and with daily momentary affect, remains to be investigated. A total of 3,033 young people were consecutively recruited from a large-scale epidemiological youth mental health study in Hong Kong. A subsample (n = 936) was followed-up after 1 year, with experience sampling data collected from 177 participants. Separate multivariable logistic regression models were applied to examine the prospective associations between smartphone overuse and depressive symptoms, with multilevel models fitted to examine its associations with momentary affect. The prevalence of smartphone overuse in the Hong Kong youth population was 29.3%. Smartphone overuse was significantly associated with more depressive symptoms and functional impairments both cross-sectionally and longitudinally. The associations between smartphone overuse and 1-year depressive symptoms were significant, even when accounting for baseline symptoms, social media use, and other risk and protective factors. Baseline depressive symptoms, in contrast, were not associated with 1-year smartphone overuse after adjusting for baseline smartphone overuse. Smartphone overuse was also significantly associated with higher levels of momentary negative affect, even when accounting for depressive symptoms. Strategies to mitigate the impact of smartphone overuse can have important long-term implications.

Promoting Daily Well-being in Adolescents using mHealth

Adolescents are at increased risk for developing mental health problems. The Grow It! app is an mHealth intervention aimed at preventing mental health problems through improving coping by cognitive behavioral therapy (CBT)-inspired challenges as well as self-monitoring of emotions through Experience Sampling Methods (ESM). Yet, little is known about daily changes in well-being and coping during a stressful period, like the COVID-19 pandemic. The current study aimed to elucidate daily changes in positive and negative affect, and adaptive coping, and to better understand the within-person's mechanisms of the Grow It! app. The sample consisted of 12-25-year old Dutch adolescents in two independent cohorts (cohort 1: N = 476, Mage = 16.24, 76.1% female, 88.7% Dutch; cohort 2: N = 814, Mage = 18.45, 82.8% female, 97.2% Dutch). ESM were used to measure daily positive and negative affect and coping (cohort 1: 42 days, 210 assessments per person; cohort 2: 21 days, 105 assessments). The results showed that, on average, adolescents decreased in daily positive affect and adaptive coping, and increased in their experienced negative affect. A positive relation between adaptive coping and positive affect was found, although independent of the CBT-based challenges. Latent class analysis identified two heterogeneous trajectories for both positive and negative affect, indicating that the majority of participants with low to moderate-risk on developing mental health problems were likely to benefit from the Grow It! app.

Is it acceptable and feasible to measure prolonged grief disorder symptoms in daily life using experience sampling methodology?

INTRODUCTION

Current grief research is dominated by cross-sectional studies assessing prolonged grief disorder (PGD) symptoms retrospectively. Examining grief in daily life, using Experience Sampling Methodology (ESM), may advance the field. Because of the lack of ESM-research on PGD, we evaluated the acceptability and feasibility of assessing PGD symptoms in daily life of bereaved people.

MATERIALS AND METHODS

ESM-items assessing PGD symptoms were developed using cognitive interviewing with five ESM/grief experts. Eighty bereaved adults completed these ESM-items five times a day for two weeks. Before and after this ESM-phase, interviews were administered assessing PGD retrospectively (using the Traumatic Grief Inventory-Clinical Administered). t-tests were performed comparing symptom severity of aggregated moment-to-moment recall (using ESM-items) with retrospective recall (based on interviews) of PGD symptoms. Acceptability of participating in ESM-research (assessed with the Reactions to Research Participation Questionnaire) was examined using descriptive statistics. Feasibility was evaluated by reporting compliance and retention rates.

RESULTS

Minor changes were made to the ESM-items based on expert interviews. Average levels of aggregated moment-to-moment recall of the symptoms "yearning" (d = -1.04), "preoccupation with the deceased" (d = -0.91), "marked sense of disbelief" (d = -0.43), and "intense loneliness" (d = -0.28) were lower compared with retrospective recalling these symptoms. On average, bereaved people were neutral about personal benefits gained through participation in this EMS-study. They indicated that participation did not raise emotional reactions. Compliance and retention rates were 60% and 65%, respectively.

DISCUSSION

Our findings indicate that whereas compliance and retention is challenging, using ESM to study PGD symptoms in daily life might be useful. Nevertheless, more research is needed.

Practitioner and researcher perspectives on the utility of ecological momentary assessment in mental health care: A survey study

BACKGROUND

Ecological momentary assessment (EMA) is a scientific self-monitoring method to capture individuals' daily life experiences. Early on, EMA has been suggested to have the potential to improve mental health care. However, it remains unclear if and how EMA should be implemented. This requires an in-depth investigation of how practitioners and researchers view the implementation of EMA.

OBJECTIVE

Explore the perspectives of mental health practitioners and EMA researchers on the utility of EMA for mental health care.

METHODS

Practitioners (n = 89; psychiatrists, psychologists, psychiatric nurses) and EMA researchers (n = 62) completed a survey about EMA in clinical practice. This survey addressed EMA goals for practitioner and patient, requirements regarding clinical use of EMA, and (dis)advantages of EMA compared to treatment-as-usual. t-Tests were used to determine agreement with each statement and whether practitioners' and researchers' views differed significantly. Linear regression was used to explore predictors of goals and preferences (e.g., EMA experience).

RESULTS

Practitioners and researchers considered EMA to be a useful clinical tool for diverse stages of care. They indicated EMA to be most useful for gaining insight into the context specificity of symptoms (55.0 %), whereas receiving alerts when symptoms increase was rated the least useful (11.3 %, alerts is in 95 % of bootstrap iterations between rank 8 and 10). Compared to treatment-as-usual, EMA was considered easier to use (M = 4.87, t = 5.30, p < .001) and interpret (M = 4.52, t = 3.61, p < .001), but also more burdensome for the patient (M = 4.48, t = 3.17, p < .001). Although participants preferred personalization of the EMA diary, they also suggested that EMA should cost practitioners and patients limited time. The preference for creating personalized EMA was related to the level of experience with EMA. Finally, they highlighted the need for practitioner training and patient full-time access to the EMA feedback.

CONCLUSIONS

This survey study demonstrated that practitioners and researchers expect EMA to have added value for mental health care. Concrete recommendations for implementation of EMA are formulated. This may inform the development of specific clinical applications and user-friendly EMA software.

Do Men and Women Have a Different Association between Fear-Avoidance and Pain Intensity in Chronic Pain? An Experience Sampling Method Cohort-Study

Background: Fear-avoidance is one of the factors associated with chronic pain. However, it remains unclear whether the association between fear-avoidance and pain depends on sex. The present study aimed to investigate whether the association between fear-avoidance and pain intensity differed between men and women in chronic pain patients. Additionally, the potential confounding effect of affective experiences on the association between fear-avoidance and pain intensity was analyzed. Method: This cohort study included hospital referred chronic pain patients (n = 45). Short momentary assessment questions according to the experience sampling method (ESM) were used to repeatedly assess patients’ pain intensity, level of fear-avoidance and positive as well as negative affect during their daily life. Linear mixed-effects models were applied in the statistical analysis. Unadjusted and adjusted models were made, in which the latter corrected for statistically significant affective experiences and baseline variables, taking the Aikake Information Criterion into account to assess a better model of fit. Results: The results demonstrated an association between fear-avoidance and pain intensity that differed for men and women. In men (n = 13), no association between these variables was found (−0.04 (95% CI: −0.14, 0.06) with a p-value of 0.48), whereas in women (n = 32), an increase in fear-avoidance was associated with a (slight) increase in pain intensity (0.18 (95% CI 0.06, 0.30) with a p-value of 0.003). Affect did not confound the above-mentioned findings. Conclusion: Our data supports previous research highlighting the importance of sex differences in pain experience. These findings may be relevant for clinicians to consider more personalized (i.e., gender specific) pain management in chronic pain patients.

Patient-specific affect-abdominal pain interactions in endometriosis: an experience sampling method (ESM) study

OBJECTIVES

Cross-sectional studies show that endometriosis-related pain is associated with affect. Measuring these symptoms in real-time in a longitudinal perspective yields the ability to analyze the temporal relationship between variables. The aim was to evaluate the association between affect and abdominal pain, using the Experience Sampling Method (ESM) as a real-time, randomly repeated assessment.

METHODS

Thirty-four endometriosis patients and 31 healthy subjects completed up to 10 real-time self-assessments concerning abdominal pain and affective symptoms during seven consecutive days.

RESULTS

Endometriosis patients experienced more abdominal pain and negative affective symptoms, and scored lower on positive affect compared to healthy controls. A significant association was found between abdominal pain and both positive and negative affect in endometriosis patients. For healthy controls, less strong or non-significant associations were found. When looking at abdominal pain as a predictor for affect and vice versa, we found that only in endometriosis patients, pain was subsequently accompanied by negative affect, and positive affect may alleviate pain in these patients.

CONCLUSIONS

This study confirms a concurrent and temporal relationship between affect and abdominal pain in endometriosis patients and supports the use of real-time symptom assessment to interpret potential influencers of abdominal complaints in patients with endometriosis.

Using smartphone-based ecological momentary assessment and personalized feedback for patients with chronic cancer-related fatigue: A proof-of-concept study

INTRODUCTION

Chronic cancer-related fatigue (CCRF) is a complex multidimensional problem warranting person-centered care. Providing patients and therapists personalized feedback based on network analysis applied to ecological momentary assessment (EMA) data could facilitate case conceptualization in psycho-oncological care. The aim was to explore patients' and therapists' experiences of using an EMA app and personalized feedback based on network theory to aid case conceptualization in psycho-oncological care.

METHODS

A n = 5 proof-of-concept study was implemented in routine psycho-oncological care. We purposively selected adult cancer patients suffering from severe CCRF who were on the waitlist for psycho-oncological care. During a 3-week period participants filled out the EMA app Energy InSight (fatigue, mood, activity, responding, and context) five times a day. Participants received a descriptive and network feedback report, which they reflected upon during the first therapy sessions. Thematic analysis was used to analyze user experiences.

RESULTS

Patients experienced that filling out the Energy InSight app, as well as receiving descriptive and network-based personalized feedback provided them with insight into their CCRF. Although therapists experienced the discussion of network feedback as challenging, it facilitated the case conceptualization.

DISCUSSION

Using EMA during waitlist for psychological care seemed feasible. Patients experienced beneficial effects from filling out the EMA app and talking over the personalized feedback reports, which in turn aided case conceptualization and personalized care. Based on this evaluation, an improved version of the Energy InSight app and a therapist training for providing network feedback is developed for implementation in psycho-oncological care.

A Web-Based Application for Personalized Ecological Momentary Assessment in Psychiatric Care: User-Centered Development of the PETRA Application

BACKGROUND

Smartphone self-monitoring of mood, symptoms, and contextual factors through ecological momentary assessment (EMA) provides insights into the daily lives of people undergoing psychiatric treatment. Therefore, EMA has the potential to improve their care. To integrate EMA into treatment, a clinical tool that helps clients and clinicians create personalized EMA diaries and interpret the gathered data is needed.

OBJECTIVE

This study aimed to develop a web-based application for personalized EMA in specialized psychiatric care in close collaboration with all stakeholders (ie, clients, clinicians, researchers, and software developers).

METHODS

The participants were 52 clients with mood, anxiety, and psychotic disorders and 45 clinicians (psychiatrists, psychologists, and psychiatric nurses). We engaged them in interviews, focus groups, and usability sessions to determine the requirements for an EMA web application and repeatedly obtained feedback on iteratively improved high-fidelity EMA web application prototypes. We used human-centered design principles to determine important requirements for the web application and designed high-fidelity prototypes that were continuously re-evaluated and adapted.

RESULTS

The iterative development process resulted in Personalized Treatment by Real-time Assessment (PETRA), which is a scientifically grounded web application for the integration of personalized EMA in Dutch clinical care. PETRA includes a decision aid to support clients and clinicians with constructing personalized EMA diaries, an EMA diary item repository, an SMS text message-based diary delivery system, and a feedback module for visualizing the gathered EMA data. PETRA is integrated into electronic health record systems to ensure ease of use and sustainable integration in clinical care and adheres to privacy regulations.

CONCLUSIONS

PETRA was built to fulfill the needs of clients and clinicians for a user-friendly and personalized EMA tool embedded in routine psychiatric care. PETRA is unique in this codevelopment process, its extensive but user-friendly personalization options, its integration into electronic health record systems, its transdiagnostic focus, and its strong scientific foundation in the design of EMA diaries and feedback. The clinical effectiveness of integrating personalized diaries via PETRA into care requires further research. As such, PETRA paves the way for a systematic investigation of the utility of personalized EMA for routine mental health care.

Is the combination of behavioral activation and attention training technique effective to reduce depressive symptomatology? A multiple case study

Background

This study tested whether the combination of BATD and Attention Training Technique (ATT) is effective to reduce depressive symptomatology and investigate the mechanisms of action underlying the effectiveness of treatment with a multiple N-of-1 trials.

Methods

Nine adults with depressive symptoms were randomly included in three different combinations of BATD and ATT, concurrent in Condition 1 and sequential in Conditions 2 and 3 (ATT followed by BATD and BATD followed by ATT, respectively). The sequential components allow investigating the specific changes that occur during the two distinct treatment phases. Multiple self-report and pre–post-assessments were conducted on generic mental health measures (depressive symptoms, life functioning, mood, and well-being) and intervention-specific measures (behavioral activation, behavioral avoidance, self-focused attention, cognitive control and rumination), with two-week and three-month follow-up assessments. We also measured treatment adherence with treatment attendance, homework compliance and a clinical interview.

Results

Participants’ attendance, homework compliance and satisfaction were acceptable in the three conditions, with higher adherence in Condition 1 and Condition 3. Eight participants out of nine reported a reduction in depressive symptomatology and five an improvement in well-being. Most of their progress was maintained 2 weeks after the intervention but not 3 months later. Conditions 1 and 2 seemed to be associated with a higher response to generic mental health measures in comparison with Condition 3. The three conditions were not associated with consistent changes in intervention-specific measures, except for rumination with five participants out of nine reporting an improvement in rumination immediately after the intervention and eight participants 2 weeks after the intervention. The concurrent format was associated with a better improvement in rumination immediately after the intervention. No specific changes of self-focused attention and rumination characterized ATT, and no specific changes of behavioral activation, behavioral avoidance and rumination characterized BATD.

Conclusion

Our three interventions were judged acceptable and showed positive short-term benefit for generic mental health measures and rumination maintained 2 weeks later, but not 3 months later. Results suggest that five sessions of concurrent treatment could be a better option than sequential formats. However, our data did not support the specificity of ATT and BATD treatments.

Clinical Trial Registration: This trial was previously registered with the ClinicalTrials.gov NCT04595539 registration number and the title “Does Attention Training Technique Enhance the Effectiveness of Behavioral Activation Treatment for Depression: A Multiple Baseline Study.”

Clinical feasibility of the Q1.6 Inguinal Hernia application: a prospective cohort study

PURPOSE

Patient-reported outcomes (PROs) are essential to evaluate inguinal hernia surgery. There is a need for digital and disease-specific PRO measurement. Current measuring instruments (PROMs) have several disadvantages, for example, fixed measuring moments with a chance of recall bias. The Q1.6 Inguinal Hernia application has been developed to overcome these challenges. This pilot study reports the first clinical feasibility results.

METHODS

All surgically treated inguinal hernia patients were eligible for inclusion. The application uses "twitch crowdsourcing"; after unlocking a smartphone or tablet, a single short question is asked. This can easily be repeated multiple times a day/week/month. Questions from validated questionnaires were implemented. The adaptive question engine generates an individualised set of questions. Alerts are generated when a complication is suspected.

RESULTS

A total of 229 patients were given over 50.000 questions of which 92% were answered. Pre- and postoperative patient characteristics and their reported clinical outcomes confirmed a standard inguinal hernia population. Compliance with the application was 91.7% after 14 days, 69.0% after 3 months and 28.8% after one year. After months 3, 6 and 11, respectively, 3.0%, 4.4% and 4.5% of patients reported inguinal pain or discomfort (NRS ≥ 4). Patients were highly satisfied (92.8% preferred the app over standard care).

CONCLUSIONS

This smartphone application shows promising results for clinical practice. It might allow for continuous digital patient-reported outcome measurement using non-intrusive, concise questions. Remote monitoring may become standard postoperative care after (inguinal hernia) surgery. The current application will be further improved and evaluated for cost-effectiveness, safety and validity.

Online ACT intervention for fibromyalgia: An exploratory study of feasibility and preliminary effectiveness with smartphone-delivered experiential sampling assessment

INTRODUCTION

Acceptance and commitment therapy (ACT) is an effective treatment for chronic pain conditions. ACT seeks to produce clinical change by enhancing Psychological Flexibility (PF). This exploratory (feasibility and preliminary effectiveness) study presents a pilot application of an online ACT group intervention for fibromyalgia (FM) with an extensive Experiential Sampling (ES) assessment of outcome and process variables via smartphone.

METHOD

5-weekly ACT online group sessions were applied to 9 female FM patients. Questionnaire-based assessments of several clinical outcomes and PF processes were conducted pre- and post-intervention, and at 6-month follow-up. Extensive (6 weeks pre- and 6 weeks post-intervention) smartphone-delivered ES was implemented to gather process and outcome data in the patients' usual contexts. Clinically significant change was evaluated both at the group level and individually.

RESULTS

This treatment format appears to be feasible and acceptable to participants, with good adoption and completion rates (75 %) and excellent rates of treatment completion and clinical adherence (100 %). Participants showed significant reductions in affective pain, distress and biopsychosocial impact of FM both post-intervention and at 6-month follow-up (as measured with questionnaires), as well as significant improvements in satisfaction with actions and emotional discomfort (as measured through ES). Multilevel regression analyses indicated that PF-related processes assessed through ES had a significant impact on clinical outcomes and predicted the impact of FM at the 6-month follow-up.

CONCLUSIONS

A brief online group ACT intervention for FM was both feasible and acceptable to participants. Also, there was preliminary evidence of effectiveness in enhancing pain-related PF and producing clinical benefits in FM.

Building Emotional Awareness and Mental Health (BEAM): A Pilot Randomized Controlled Trial of an App-Based Program for Mothers of Toddlers

Background

Families have faced unprecedented challenges during the COVID-19 pandemic, leading to increased maternal mental health problems and barriers to accessing care. Innovative programs are needed to support both maternal mental health and parenting, and to buffer the long-term impacts of stress on young children. Using a patient-oriented approach, our research team aimed to co-develop and pilot test an App-based psychoeducation and social-connection platform: Building Emotional Awareness and Mental Health (BEAM).

Methods

The co-development process involved a parent advisory board from conceptualization and design, through to direct participation in the program delivery. The BEAM program includes weekly videos and activities based on Unified Protocol therapy modules and emotion-focused parenting strategies, a weekly telehealth group review session, and access to a private online forum for support from other mothers and clinical coaches. A parallel randomized control trial was conducted across two provinces in Canada. Mothers of preschool children (aged 18-36 months old), with moderate-to-severe depression (Patient Health Questionaire-9 ≥ 10), were recruited online and randomized to either the 10-week BEAM intervention or treatment as usual (TAU) control group. Online surveys (ensuring researcher blinding) included questions about feasibility and acceptability of the program and pre/post self-report measures of mental health, parenting, positive coping and child behavior outcomes. The primary outcome measures were symptoms of depression and parenting stress. Data were analyzed using mixed models and an intention-to-treat approach.

Results

65 participants were randomized, by an online allocation tool, to the BEAM (n = 33) and TAU (n = 32) groups. Engagement was relatively high at the beginning of the program, with 78.8% starting the BEAM App and 70.6% attending ≥1 telehealth session. Most respondents felt socially supported, satisfied with the App, and found it easy to use. Pre-post results indicated interaction effects with greater reductions in overall mental health problems, and specifically anxiety and sleep symptoms, among BEAM vs. control participants. There were also time effects with reductions in depression symptoms across both groups. No significant treatment effects emerged for the other mental health symptoms, parenting problems, positive coping, or child behavior outcomes. Descriptive data are included to highlight possible areas of promise for future large efficacy trials. Technological difficulties and other challenges that may have led to attrition and impacted outcomes are discussed. There were no adverse events related to study participation.

Conclusions

The BEAM program has promise as a novel, feasible and acceptable intervention for improving mental health among mothers of young children.

Clinical Trial Registration

[www.ClinicalTrials.gov], identifier [NCT04772677].

The Grow It! app-longitudinal changes in adolescent well-being during the COVID-19 pandemic: a proof-of-concept study

Adolescent mental health and well-being have been adversely impacted by the COVID-19 pandemic. In this preregistered longitudinal study, we evaluated whether adolescents' well-being improved after playing the multiplayer serious game app Grow It! During the first lockdown (May-June 2020), 1282 Dutch adolescents played the Grow It! app (age = 16.67, SD = 3.07, 68% girls). During the second lockdown (December-May 2020 onwards), an independent cohort of 1871 adolescents participated (age = 18.66, SD = 3.70, 81% girls). Adolescents answered online questionnaires regarding affective and cognitive well-being, depressive symptoms, anxiety, and impact of COVID-19 at baseline. Three to six weeks later, the baseline questionnaire was repeated and user experience questions were asked (N = 462 and N = 733 for the first and second cohort). In both cohorts, affective and cognitive well-being increased after playing the Grow It! app (t = - 6.806, p < 0.001; t = - 6.77, p < 0.001; t = - 6.12, p < 0.001; t = - 5.93, p < 0.001; Cohen's d range 0.20-0.32). At the individual level, 41-53% of the adolescents increased in their affective or cognitive well-being. Adolescents with higher risk profiles (i.e., more depressive symptoms, lower atmosphere at home, and more COVID-19 impact) improved more strongly in their well-being. Positive user evaluations and app engagement were unrelated to changes in affective and cognitive well-being. This proof-of-concept study tentatively suggests that Grow It! supported adolescents during the pandemic.

Home alone: Social functioning as a transdiagnostic marker of mental health in youth, exploring retrospective and daily life measurements

PURPOSE

Early detection and intervention of mental health problems in youth are topical given that mental disorders often start early in life. Young people with emerging mental disorders however, often present with non-specific, fluctuating symptoms. Recent reports indicate a decline in social functioning (SF) as an early sign of specific emerging mental disorders such as depression or anxiety, making SF a favorable transdiagnostic approach for earlier detection and intervention. Our aim was to investigate the value of SF in relation to transdiagnostic symptoms, and as a predictor of psychopathology over time, while exploring traditional retrospective versus innovative daily diary measurements of SF in youth.

METHOD

Participants (N = 75) were 16-25 years of age and presented early stage psychiatric symptomatology. Psychiatric symptoms, including anxiety and depression, as well as SF -both in retrospect and in daily life- were assessed at two time points and analyzed cross-sectionally and longitudinally.

RESULTS

A significant and negative association between SF and all psychiatric symptoms was found, and SF was a significant predictor of change in general psychiatric symptoms over time. Results were only significant when SF was measured traditionally retrospective.

CONCLUSION

This study confirms a distinct relation between SF and transdiagnostic psychiatric symptoms in youth, even in a (sub)clinical population, and points towards SF as a predictor of transdiagnostic psychiatric symptoms. Further research is needed to learn more about the added value of daily life versus retrospective measurements.

Stress and emotional arousal in urban environments: A biosocial study with persons having experienced a first-episode of psychosis and persons at risk

This article examines the entanglement between feelings of stress and discomfort, physiological arousal and urban experiences of persons living with early psychosis. It adopts a biosocial approach, using mixed methods combining ambulatory skin conductance monitoring, mobile interviews and contextual data, collected through GPS and video recordings. The study draws on and strives to cross-fertilize two recent strands of research. The first relates to the use of digital phenotyping in mental health research. The second explores stress and emotional arousal in cities using ambulatory physiological measures. Empirically, the paper is based on fieldwork in Basel, Switzerland, with nine participants recruited within the Basel Early Treatment Service (BEATS), and four controls. We focus on three salient elements in our results: visual perception of moving bodies, spatial transitions and openness and enclosure of the built environment. The analysis shows how these elements elicit physiological responses of arousal and expressed feelings of discomfort. In the concluding section we discuss the methodological implications of these results and suggest the notion of regime of attention as a focus for future biosocial research on urban mental health.

Developing a Smart Home Technology Innovation for People With Physical and Mental Health Problems: Considerations and Recommendations

Smart home technologies present an unprecedented opportunity to improve health and health care by providing greater communication and connectivity with services and care providers and by supporting the daily activities of people managing both mental and physical health problems. Based on our experience from conducting smart technology health studies, including a smart home intervention, we provide guidance on developing and implementing such interventions. First, we describe the need for an overarching principle of security and privacy that must be attended to in all aspects of such a project. We then describe 4 key steps in developing a successful smart home innovation for people with mental and physical health conditions. These include (1) setting up the digital infrastructure, (2) ensuring the components of the system communicate, (3) ensuring that the system is designed for the intended population, and (4) engaging stakeholders. Recommendations on how to approach each of these steps are provided along with suggested literature that addresses additional considerations, guidelines, and equipment selection in more depth.

The Effectiveness of a Nonguided Mindfulness App on Perceived Stress in a Nonclinical Dutch Population: Randomized Controlled Trial

BACKGROUND

Mindfulness has become increasingly popular, and positive outcomes have been reported for mindfulness-based interventions (MBIs) in reducing stress. These findings make room for innovative perspectives on how MBIs could be applied, for instance through mobile health (mHealth).

OBJECTIVE

The aim of this study is to investigate whether a nonguided mindfulness mobile app can decrease perceived stress in a nonclinical Dutch population over the course of 8 weeks, with follow-up at 6 months.

METHODS

A randomized controlled trial was performed to compare an experimental group that made use of a structured 8-week mHealth mindfulness program and a control group after 8 weeks, with follow-up after 6 months. Participants were recruited via a national television program. The primary outcome measure was perceived stress as measured by the Perceived Stress Scale, secondary outcomes were symptoms of burnout (measured using the visual analog scale [VAS]) and psychological symptoms (measured using the Four-Dimensional Symptom Questionnaire [4DSQ] at follow-up). Outcomes were analyzed using a multilevel regression model.

RESULTS

At baseline, 587 respondents were included. Results showed no postintervention differences between groups for the level of perceived stress. With regard to the secondary outcome measures, the VAS for emotional exhaustion and physical exhaustion showed significantly lower scores for the experimental group after 8 weeks (P=.04 and P=.01, respectively), but not at follow-up. There were no differences between groups for psychological symptoms measured using the 4DSQ.

CONCLUSIONS

These findings do not support our hypothesis that using the mindfulness app would reduce stress levels. However, our findings related to diminished exhaustion at 8 weeks are encouraging and require further investigation.

TRIAL REGISTRATION

ClinicalTrials.gov NCT05246800; https://clinicaltrials.gov/show/NCT05246800.

A Smartphone Serious Game for Adolescents (Grow It! App): Development, Feasibility, and Acceptance Study

Background

Anxiety and mood problems in adolescents often go unnoticed and may therefore remain untreated. Identifying and preventing the development of emotional problems requires monitoring and effective tools to strengthen adolescents' resilience, for example, by enhancing coping skills.

Objective

This study describes the developmental process, feasibility, and acceptance of Grow It!, a multiplayer serious game app for adolescents aged 12-25 years. The app consists of the experience sampling method (ESM) to monitor thoughts, behaviors, and emotions in daily life to enhance self-insight and daily cognitive behavioral therapy–based challenges to promote adaptive coping.

Methods

Our approach entails an iterative game design process combined with an agile method to develop the smartphone app. The incorporated game features (ie, challenges, chat functionality, and visual representation) in the Grow It! app were co-designed with adolescent end users to increase participant engagement and adherence.

Results

The Grow It! app was delivered for Android and iOS in May 2020. Grow It! was offered to adolescents during the COVID-19 crisis between May and December 2020. Participants of the Grow It! COVID-19 study (sample 1: N=685; mean age 16.19, SD 3.11 years; 193/685, 28.2% boys; sample 2: N=1035; mean age 18.78, SD 3.51 years; 193/1035, 18.64% boys) completed 31.5% (13.2/42) to 49.5% (10.4/21) of challenges. Compliance of ESM was suboptimal (35.1/210, 16.7% to 32.5/105, 30.9%). Follow-up questionnaires indicated an overall score of the app of 7.1 out of 10. Moreover, 72.6% (278/383) to 75.6% (487/644) would recommend the app to friends.

Conclusions

To our knowledge, Grow It! is the first gamified ESM app that both measures individual differences in emotional dynamics and offers an integrated cognitive behavioral therapy–based intervention. Our findings support the feasibility and acceptance, and therefore applicability, of the Grow It! app in adolescents. Further iterations of this serious game app will focus on the increase of compliance and on providing participants feedback through their personal mood profiles.

iHealth: The ethics of artificial intelligence and big data in mental healthcare

The concept of intelligent health (iHealth) in mental healthcare integrates artificial intelligence (AI) and Big Data analytics. This article is an attempt to outline ethical aspects linked to iHealth by focussing on three crucial elements that have been defined in the literature: self-monitoring, ecological momentary assessment (EMA), and data mining. The material for the analysis was obtained by a database search. Studies and reviews providing outcome data for each of the three elements were analyzed. An ethical framing of the results was conducted that shows the chances and challenges of iHealth. The synergy between self-monitoring, EMA, and data mining might enable the prevention of mental illness, the prediction of its onset, the personalization of treatment, and the participation of patients in the treatment process. Challenges arise when it comes to the autonomy of users, privacy and data security of users, and potential bias.

The Importance of Context: An ESM Study in Forensic Psychiatry

Experience Sampling Method (ESM) is a structured diary technique assessing variations in thoughts, mood, and psychiatric symptoms in everyday life. Research has provided ample evidence for the efficacy of the use of ESM in general psychiatry but its use in forensic psychiatry has been limited. Twenty forensic psychiatric patients participated. The PsyMate™ Device emitted a signal 10 times a day on six consecutive days, at unpredictable moments. After each "beep," the patients completed ESM forms assessing current context, thoughts, positive and negative affect, and psychotic experiences. Stress was measured using the average scores of the stress related items. Compliance rate was high (85% beeps responded). Activity stress was related to more negative affect, lower positive affect, and more psychotic symptoms. This finding was restricted to moments when a team member was present; not when patients were alone or with other patients. ESM can be useful in forensic psychiatry and give insights into the relationships between symptoms and mood in different contexts. In this study activity-related stress was contextualized. These findings can be used to personalize interventions.

A Review of Explicit and Implicit Assumptions When Providing Personalized Feedback Based on Self-Report EMA Data

Ecological Momentary Assessment (EMA) in which participants report on their moment-to-moment experiences in their natural environment, is a hot topic. An emerging field in clinical psychology based on either EMA, or what we term Ecological Retrospective Assessment (ERA) as it requires retrospectivity, is the field of personalized feedback. In this field, EMA/ERA-data-driven summaries are presented to participants with the goal of promoting their insight in their experiences. Underlying this procedure are some fundamental assumptions about (i) the relation between true moment-to-moment experiences and retrospective evaluations of those experiences, (ii) the translation of these experiences and evaluations to different types of data, (iii) the comparison of these different types of data, and (iv) the impact of a summary of moment-to-moment experiences on retrospective evaluations of those experiences. We argue that these assumptions deserve further exploration, in order to create a strong evidence-based foundation for the personalized feedback procedure.

Patient-Reported Outcome Measure for Real-time Symptom Assessment in Women With Endometriosis: Focus Group Study

BACKGROUND

Symptoms related to endometriosis have a significant impact on the quality of life, and symptoms often recur. The experience sampling method (ESM), a digital questioning method characterized by randomly repeated momentary assessments, has several advantages over traditionally used measurements, including the ability to assess the temporal relationship between variables such as physical, mental, and social factors.

OBJECTIVE

The aim of this study is to develop an ESM tool for patients with endometriosis to accurately measure symptoms and their course over time, allowing for personalized treatment and adequate monitoring of treatment efficacy in individual patients.

METHODS

On the basis of international guidelines, items from validated questionnaires were selected through a literature review and during focus groups and multidisciplinary expert meetings. Data analysis was conducted using ATLAS.ti (ATLAS.ti Scientific Software Development GmbH). The feasibility and usability of the newly developed momentary assessment tool were tested for 28 consecutive days in 5 patients with endometriosis-related pain symptoms.

RESULTS

Momentary assessment items contained questions concerning endometriosis symptoms, general somatic symptoms, psychological symptoms, contextual information, and the use of food and medication. A morning questionnaire on sleep and sexuality was included. In a pilot study, the patients considered the tool easy to use but time consuming. The average compliance rate of momentary assessments was 37.8% (106/280), with the highest completion rate during the first week (39/70, 56%). Therefore, it is advisable to use the ESM for a maximum of 7 days.

CONCLUSIONS

A new digital tool for endometriosis symptom assessment was developed using the ESM, which may help overcome the limitations of current retrospective questionnaires. After validation and testing, future studies will be planned to evaluate the use of this tool in a clinical setting in order to propose a personalized treatment plan for women with endometriosis.

Personalized versus standard cognitive behavioral therapy for fear of cancer recurrence, depressive symptoms or cancer-related fatigue in cancer survivors: study protocol of a randomized controlled trial (MATCH-study)

Background

Fear of cancer recurrence, depressive symptoms, and cancer-related fatigue are prevalent symptoms among cancer survivors, adversely affecting patients’ quality of life and daily functioning. Effect sizes of interventions targeting these symptoms are mostly small to medium. Personalizing treatment is assumed to improve efficacy. However, thus far the empirical support for this approach is lacking. The aim of this study is to investigate if systematically personalized cognitive behavioral therapy is more efficacious than standard cognitive behavioral therapy in cancer survivors with moderate to severe fear of cancer recurrence, depressive symptoms, and/or cancer-related fatigue.

Methods

The study is designed as a non-blinded, multicenter randomized controlled trial with two treatment arms (ratio 1:1): (a) systematically personalized cognitive behavioral therapy and (b) standard cognitive behavioral therapy. In the standard treatment arm, patients receive an evidence-based diagnosis-specific treatment protocol for fear of cancer recurrence, depressive symptoms, or cancer-related fatigue. In the second arm, treatment is personalized on four dimensions: (a) the allocation of treatment modules based on ecological momentary assessments, (b) treatment delivery, (c) patients’ needs regarding the symptom for which they want to receive treatment, and (d) treatment duration. In total, 190 cancer survivors who experience one or more of the targeted symptoms and ended their medical treatment with curative intent at least 6 months to a maximum of 5 years ago will be included. Primary outcome is limitations in daily functioning. Secondary outcomes are level of fear of cancer recurrence, depressive symptoms, fatigue severity, quality of life, goal attainment, therapist time, and drop-out rates. Participants are assessed at baseline (T0), and after 6 months (T1) and 12 months (T2).

Discussion

To our knowledge, this is the first randomized controlled trial comparing the efficacy of personalized cognitive behavioral therapy to standard cognitive behavioral therapy in cancer survivors. The study has several innovative characteristics, among which is the personalization of interventions on several dimensions. If proven effective, the results of this study provide a first step in developing an evidence-based framework for personalizing therapies in a systematic and replicable way.

Trial registration

The Dutch Trial Register (NTR) NL7481 (NTR7723). Registered on 24 January 2019.

A Group Intervention for Motivational Deficits: Preliminary Investigation of a Blended Care Approach Using Ambulatory Assessment

Motivational deficits are an important predictor of functional outcomes in individuals with a serious mental illness such as schizophrenia and mood spectrum disorders. The aim of the present study was to explore the feasibility, acceptability, and preliminary efficacy of a group version of "Switch," an intervention that targets motivational deficits, enriched with an ecological momentary intervention (EMI) approach (i.e., prompts on the participants' smartphone to encourage the use of trained strategies in their daily life). Eight participants with schizophrenia, schizoaffective, or major depressive disorder entered the study. The intervention took place twice a week for 2 months. Assessment measures included traditional evaluations of motivational negative symptoms, apathy, quality of life and daily functioning, in addition to ambulatory assessment methods strategies, including the experience sampling method (ESM) to assess motivation and related processes, and actigraphy (daily step-count) to assess participants' activity level. Four participants were considered as non-completers (followed less than 2/3 of the program) and four were considered as completers. Only completers presented a decrease in amotivation/apathy and an improvement in functional outcomes after the intervention and at follow-up. Furthermore, mixed-effects ESM models showed significant interaction effects on multiple processes related to motivation, indicating improvements only in completers: heightened motivation, increased engagement in meaningful and effortful activities, better mood, higher levels of confidence, increased frequency of projection into the future (pleasure anticipation), and of positive reminiscence. This preliminary investigation provides evidence that Switch may be an effective intervention, with specific effects on motivation and associated processes.