Mood disorders in everyday life: a systematic review of experience sampling and ecological momentary assessment studies

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.

Day-to-day affect fluctuations in adults with childhood trauma history: a two-week ecological momentary assessment study

BACKGROUND

Childhood trauma (CT) may increase vulnerability to psychopathology through affective dysregulation (greater variability, autocorrelation, and instability of emotional symptoms). However, CT associations with dynamic affect fluctuations while considering differences in mean affect levels across CT status have been understudied.

METHODS

346 adults (age = 49.25 ± 12.55, 67.0% female) from the Netherlands Study of Depression and Anxiety participated in ecological momentary assessment. Positive and negative affect (PA, NA) were measured five times per day for two weeks by electronic diaries. Retrospectively-reported CT included emotional neglect and emotional/physical/sexual abuse. Linear regressions determined associations between CT and affect fluctuations, controlling for age, sex, education, and mean affect levels.

RESULTS

Compared to those without CT, individuals with CT reported significantly lower mean PA levels (Cohen's d = -0.620) and higher mean NA levels (d = 0.556) throughout the two weeks. CT was linked to significantly greater PA variability (d = 0.336), NA variability (d = 0.353), and NA autocorrelation (d = 0.308), with strongest effects for individuals reporting higher CT scores. However, these effects were entirely explained by differences in mean affect levels between the CT groups. Findings suggested consistency of results in adults with and without lifetime depressive/anxiety disorders and across CT types, with sexual abuse showing the smallest effects.

CONCLUSIONS

Individuals with CT show greater affective dysregulation during the two-week monitoring of emotional symptoms, likely due to their consistently lower PA and higher NA levels. It is essential to consider mean affect level when interpreting the impact of CT on affect dynamics.

How a general vulnerability for psychopathology during adolescence manifests in young adults' daily lives

BACKGROUND

There is widespread interest in the general factor of psychopathology or 'p factor', which has been proposed to reflect vulnerability to psychopathology. We examined to what extent this 'vulnerability' is associated with dysregulations in affect and behavior that occur in daily life. As such we hoped to provide an account of how this vulnerability may be maintained.

METHODS

We used data from the Tracking Adolescents' Individual Lives Survey (TRAILS; N = 2,772) collected at ages 11, 14, 16, 19, and 22 years to fit a bifactor model with a general psychopathology factor, alongside internalizing, externalizing (EXT), attention-deficit/hyperactivity, and autism spectrum problem domains. Following the fifth TRAILS assessment, a subsample of participants (n = 133, age = 22.6, 43% women) with heightened risk for psychopathology completed a 6-month daily diary protocol with one assessment each day. Using a dynamic structural equation approach, we examined to what extent mean intensity, variability, inertia, and within-day co-occurrence of EXT, anxious-tense, and depressed-withdrawn affects and behaviors were associated with general factor scores.

RESULTS

Unexpectedly, higher general factor scores were not associated with higher mean intensity of any of the three types of daily negative affects and behaviors, but were associated with higher variability and less carryover (inertia) EXT affects and behaviors.

CONCLUSIONS

We showed that individual differences in general factor scores do not manifest as differences in average levels of daily affects and behaviors, but instead were related to a type of EXT reactivity to the environment. Future research is necessary to investigate whether reactive irritable moods may be involved in or signal vulnerability sustained psychopathology.

Mixed-Methods Assessment of Maternal Anxiety During the First 8 Weeks After Birth

OBJECTIVE

To describe and compare the experiences of postpartum anxiety among women with generalized anxiety and postpartum-specific anxiety.

DESIGN

Prospective, longitudinal, mixed methods.

SETTING

Academic tertiary center in the mid-Atlantic United States. Study activities were remote.

PARTICIPANTS

Women at 1 to 8 weeks after birth (N = 34).

METHODS

We used mobile surveys to measure daily anxiety ratings and responses to open-ended, theory-driven questions about anxiety. We used the cutoff scores on the State-Trait Anxiety Inventory and Postpartum Specific Anxiety Scale administered 8 weeks after birth to determine the presence of generalized and postpartum-specific anxiety. Participants' responses were analyzed with qualitative description and sorted by anxiety questionnaire scores at 8 weeks after birth. We compared qualitative findings between participants with generalized anxiety and postpartum-specific anxiety.

RESULTS

Participants with generalized anxiety had high levels of overwhelm and felt ill-equipped to handle daily stressors, whereas those with postpartum-specific anxiety felt adept at coping. Participants with generalized anxiety lacked emotional and physical support, and those with postpartum-specific anxiety reported more physical but variable emotional support. Sources of daily anxiety in participants with postpartum-specific anxiety were infant-centric (e.g., infant health, end of maternity leave, breastfeeding), whereas anxiety sources for participants with generalized anxiety were varied (e.g., self-health, partner concerns). Participants with generalized anxiety versus postpartum-specific anxiety were more likely to be multiparous and have comorbid depression symptoms.

CONCLUSION

Symptoms, levels of perceived support, and sources of anxiety differed between participants with generalized versus postpartum-specific anxiety. Our findings can inform postpartum anxiety screening strategies and support interventions.

Directional associations among real-time activity, sleep, mood, and daytime symptoms in major depressive disorder using actigraphy and ecological momentary assessment

Previous research has suggested that individuals with major depressive disorder (MDD) experienced alterations in sleep and activity levels. However, the temporal associations among sleep, activity levels, mood, and daytime symptoms in MDD have not been fully investigated. The present study aimed to fill this gap by utilizing real-time data collected across time points and days. 75 individuals with MDD and 75 age- and gender-matched healthy controls were recruited. Ecological momentary assessments (EMA) were adopted to assess real-time mood status for 7 days, and actigraphy was employed to measure day-to-day sleep-activity patterns. Multilevel modeling analyses were performed. Results revealed a bidirectional association between mood/daytime symptoms and activity levels across EMA intervals. Increased activity levels were predictive of higher alert cognition and positive mood, while an increase in positive mood also predicted more increase in activity levels in depressed individuals. A bidirectional association between sleep and daytime symptoms was also found. Alert cognition was found to be predictive of better sleep in the subsequent night. Contrariwise, higher sleep efficiency predicted improved alert cognition and sleepiness/fatigue the next day. A unidirectional association between sleep and activity levels suggested that higher daytime activity levels predicted a larger increase in sleep efficiency among depressed individuals. This study indicated how mood, activity levels, and sleep were temporally and intricately linked to each other in depressed individuals using actigraphy and EMA. It could pave the way for novel and efficacious treatments for depression that target not just mood but sleep and activity levels.

Development of an open-source solution to facilitate the use of one-button wearables in experience sampling designs

The experience sampling method (ESM) allows for a high degree of ecological validity compared to laboratory research, at the cost of greater effort for participants. It would therefore benefit from implementations that reduce participant effort. In the present paper, we introduce a screenless wrist-worn one-button wearable as an unobtrusive measurement method that can be employed in ESM designs. We developed an open-source Android application to make this commercially available wearable easily configurable and usable. Over the course of six pilot studies, we explored the technical viability (e.g., battery life, reliability of inputs) of this wearable. We compared data quality between wearables and smartphones in a within-subjects design, exploring both the input options of using the number of button presses as a Likert scale, as well as using the angle of the device as a Physical Analogue Scale. Assessments of Extraversion made with either of these methods were highly correlated to comparable assessments made with comparable methods on a smartphone (i.e., Likert scale or a Visual Analogue Scale, respectively). Furthermore, in a preregistered ESM field experiment (N = 134, 4 weeks), we compared compliance to real-life event triggers between wearable devices and smartphones. We found higher numbers of logged events in the wearable group, indicating better adherence to the event-contingent scheduling. Overall, despite the device's minimal capabilities and resulting limitations, one-button wearables can be beneficial for use in ESM designs.

Neural response to rewards moderates the within-person association between daily positive events and positive affect during a period of stress exposure

Stress and neural responses to reward can interact to predict psychopathology, but the mechanisms of this interaction are unclear. One possibility is that the strength of neural responses to reward can affect the ability to maintain positive affect during stress. In this study, 105 participants completed a monetary reward task to elicit the reward positivity (RewP), an event-related potential sensitive to rewards. Subsequently, during a stressful period, participants reported on their affect nine times a day and on daily positive and negative events for 10 days. Even during heightened stress, experiencing more positive events was associated with increased positive affect. The RewP significantly moderated this association: Individuals with a larger RewP reported greater increases in positive affect when they experienced more positive events, relative to individuals with a smaller RewP. A blunted RewP might contribute to stress susceptibility by affecting how much individuals engage in positive emotion regulation during stress.

Social interpretation inflexibility moderates emotional reactions to social situations in children and adolescents

Interpretation biases and inflexibility (i.e., difficulties revising interpretations) have been linked to increased internalizing symptoms. Although adolescence is a developmental period characterized by novel social situations and increased vulnerability to internalizing disorders, no studies have examined interpretation inflexibility in adolescents. Additionally, no studies (on adolescents or adults) have examined interpretation flexibility as a protective factor against adverse outcomes of interpersonal events. Using a novel task and a 28-day diary we examined relations among interpretation bias and inflexibility, internalizing symptoms, and negative interpersonal events in a sample of children and adolescents (N = 159, ages 9-18). At baseline, negative interpretation bias was positively correlated with social anxiety symptoms, and positive interpretation bias negatively correlated with social anxiety and depressive symptoms. Inflexible positive interpretations were correlated with higher social anxiety and depressive symptoms, while inflexible negative interpretations were correlated with higher social anxiety. Finally, interpretation inflexibility moderated daily associations between negative interpersonal events and depressive symptoms in daily life, such that higher inflexibility was associated with stronger associations between interpersonal events and subsequent depressive symptoms, potentially increasing depressive symptom instability. These results suggest that interpretation biases and inflexibility may act as both risk and protective factors for adolescent anxiety and depression.

Daily Affective Dynamics in Major Depressive Disorder: The Role of Daily Stressors and Positive Events

This study examined daily affective dynamic indices among individuals with a major depressive disorder (MDD) diagnosis in the past one year at the time of the interview, focusing on affective variability and change in affect in response to daily events (affective reactivity). Data were from the main survey and daily diary project of the Midlife in the United States (MIDUS) study. Participants (N = 1,970; nMDD = 202; nnon-MDD = 1,768) completed structured clinical interviews on mental health and telephone interviews about their daily experiences spanning eight consecutive days. Multilevel models revealed that the MDD group experienced greater positive (PA) and negative affect (NA) variability than the non-MDD group. On days that at least one stressful event was reported, the MDD group experienced a greater decrease in PA and a greater increase in NA. On days that at least one positive event was reported, the MDD group experienced a greater increase in PA and a greater decrease in NA. Changes in affect to daily events, particularly the mood brightening effect, may be indicators of depression and potential targets for intervention. Limitations of the study include a community sample, reliance on self-reported measures of daily stressors and positive events, inclusion of remitted and current MDD participants, and the DSM-III-R based criteria for MDD diagnosis.

Need Fulfillment During Intergroup Contact: Three Experience Sampling Studies

One challenge of modern intergroup contact research has been the question of when and why an interaction is perceived as positive and improves intergroup relations. We propose to consider the perceived fulfillment of the situationally most relevant need. We conducted three intensive longitudinal studies with recent migrants to capture their interactions with the majority out-group (Nmeasurements = 10,297; Nparticipants = 207). The situational need fulfillment mechanism is consistently a strong predictor of perceived interaction quality and positive out-group attitudes following intergroup interactions. The model is specific to out-group contact, robust to various need types, and works at least as well as Allport's contact conditions. As one of the first studies to test intergroup contact theory using intensive longitudinal data, we offer insight into the mechanisms of positive intergroup contact during real-life interactions and find situational motivations to be a key building block for understanding and addressing positive intergroup interactions.Public significance statement: In this article, we provide evidence that the fulfillment of situational needs during real-life intergroup contacts meaningfully predicts perceived interaction quality and positive outgroup attitudes. Methodologically, this offers a testament to the emerging practice of capturing real-life interactions using intensive longitudinal data. Theoretically, our results give weight to motivational fulfillment as a flexible and effective mechanism for understanding positive intergroup contact.

Protocol for randomized personalized trial for stress management compared to standard of care

Stress is a significant public health burden in the United States, with most Americans reporting unhealthy levels of stress. Stress management techniques include various evidence-based treatments shown to be effective but with heterogeneous treatment responses, indicating a lack of uniform benefits for all individuals. Designed to assess a participant's response to a specific intervention, personalized (N-of-1) trials provide guidance for which treatment (s) work (s) best for the individual. Prior studies examining the effects of mindfulness meditation, yoga, and walking for stress reduction found all three interventions to be associated with significant reductions in self-reported measures of stress. Delivering these treatments using a personalized trial approach has the potential to assist clinicians in identifying the best stress management techniques for individuals with persistently high stress while fostering treatment decisions that consider their personal condition/barriers. This trial will evaluate a personalized approach compared to standard of care for three interventions (guided mindfulness meditation; guided yoga; and guided brisk walking) to manage perceived stress. Participants will respond to daily surveys and wear a Fitbit device for 18 weeks. After a 2-week baseline period, participants in the personalized trial groups will receive 12 weeks of interventions in randomized order, while participants in the standard-of-care group will have access to all interventions for self-directed stress management. After intervention, all participants will undergo 2 weeks of observation, followed by two additional weeks of the stress management intervention of their choosing while continuing outcome measurement. At study completion, all participants will be sent a satisfaction survey. The primary analysis will compare perceived stress levels between the personalized and standard of care arms. The results of this trial will provide further support for the use of personalized designs for managing stress. Clinical Trial Registration: clinicaltrials.gov, NCT05408832. Protocol version: 9/14/2022, 21-0968-MRB.

Opportunities for digital health technology: identifying unmet needs for bipolar misdiagnosis and depression care management

Introduction

Digital health technologies (DHTs) driven by artificial intelligence applications, particularly those including predictive models derived with machine learning methods, have garnered substantial attention and financial investment in recent years. Yet, there is little evidence of widespread adoption and scant proof of gains in patient health outcomes. One factor of this paradox is the disconnect between DHT developers and digital health ecosystem stakeholders, which can result in developing technologies that are highly sophisticated but clinically irrelevant. Here, we aimed to uncover challenges faced by psychiatrists treating patients with major depressive disorder (MDD). Specifically, we focused on challenges psychiatrists raised about bipolar disorder (BD) misdiagnosis.

Methods

We conducted semi-structured interviews with 10 United States-based psychiatrists. We applied text and thematic analysis to the resulting interview transcripts.

Results

Three main themes emerged: (1) BD is often misdiagnosed, (2) information crucial to evaluating BD is often occluded from clinical observation, and (3) BD misdiagnosis has important treatment implications.

Discussion

Using upstream stakeholder engagement methods, we were able to identify a narrow, unforeseen, and clinically relevant problem. We propose an organizing framework for development of digital tools based upon clinician-identified unmet need.

Specificity of affective dynamics of bipolar and major depressive disorder

OBJECTIVE

Here, we examine whether the dynamics of the four dimensions of the circumplex model of affect assessed by ecological momentary assessment (EMA) differ among those with bipolar disorder (BD) and major depressive disorder (MDD).

METHODS

Participants aged 11-85 years (n = 362) reported momentary sad, anxious, active, and energetic dimensional states four times per day for 2 weeks. Individuals with lifetime mood disorder subtypes of bipolar-I, bipolar-II, and MDD derived from a semistructured clinical interview were compared to each other and to controls without a lifetime history of psychiatric disorders. Random effects from individual means, inertias, innovation (residual) variances, and cross-lags across the four affective dimensions simultaneously were derived from multivariate dynamic structural equation models.

RESULTS

All mood disorder subtypes were associated with higher levels of sad and anxious mood and lower energy than controls. Those with bipolar-I had lower average activation, and lower energy that was independent of activation, compared to MDD or controls. However, increases in activation were more likely to perpetuate in those with bipolar-I. Bipolar-II was characterized by higher lability of sad and anxious mood compared to bipolar-I and controls but not MDD. Compared to BD and controls, those with MDD exhibited cross-augmentation of sadness and anxiety, and sadness blunted energy.

CONCLUSION

Bipolar-I is more strongly characterized by activation and energy than sad and anxious mood. This distinction has potential implications for both specificity of intervention targets and differential pathways underlying these dynamic affective systems. Confirmation of the longer term stability and generalizability of these findings in future studies is necessary.

Functioning in older adults with bipolar disorder: A report on recommendations by the International Society of bipolar disorder (ISBD) older adults with bipolar disorder (OABD) task force

OBJECTIVES

Despite the importance of psychosocial functioning impairment in Bipolar Disorder (BD), its role among Older Adults with BD (OABD) is not well known. The development of guidelines for the assessment of psychosocial functioning helps to facilitate a better understanding of OABD and can lead to better tailored interventions to improve the clinical outcomes of this population.

METHODS

Through a series of virtual meetings, experts from eight countries in the International Society of Bipolar Disorder (ISBD) on OABD task force developed recommendations for the assessment of psychosocial functioning.

RESULTS

We present (1) a conceptualization of functioning in OABD and differences compared with younger patients; (2) factors related to functioning in OABD; (3) current measures of functioning in OABD and their strengths and limitations; and, (4) other potential sources of information to assess functioning.

CONCLUSIONS

The task force created recommendations for assessing functioning in OABD. Current instruments are limited, so measures specifically designed for OABD, such as the validated FAST-O scale, should be more widely adopted. Following the proposed recommendations for assessment can improve research and clinical care in OABD and potentially lead to better treatment outcomes.

Moment-to-moment affective dynamics in schizophrenia and bipolar disorder

BACKGROUND

Affective disturbances in schizophrenia and bipolar disorder may represent a transdiagnostic etiological process as well as a target of intervention. Hypotheses on similarities and differences in various parameters of affective dynamics (intensity, successive/acute changes, variability, and reactivity to stress) between the two disorders were tested.

METHODS

Experience sampling method was used to assess dynamics of positive and negative affect, 10 times a day over 6 consecutive days. Patients with schizophrenia (n = 46) and patients with bipolar disorder (n = 46) were compared against age-matched healthy controls (n = 46).

RESULTS

Compared to controls, the schizophrenia group had significantly more intense momentary negative affect, a lower likelihood of acute changes in positive affect, and reduced within-person variability of positive affect. The bipolar disorder group was not significantly different from either the schizophrenia group or the healthy control group on any affect indexes. Within the schizophrenia group, level of depression was associated with weaker reactivity to stress for negative affect. Within the bipolar disorder group, level of depression was associated with lower positive affect.

CONCLUSIONS

Patients with schizophrenia endured a more stable and negative affective state than healthy individuals, and were less likely to be uplifted in response to happenings in daily life. There is little evidence that these affective constructs characterize the psychopathology of bipolar disorder; such investigation may have been limited by the heterogeneity within group. Our findings supported the clinical importance of assessing multiple facets of affective dynamics beyond the mean levels of intensity.

Less inhibited and more depressed? The puzzling association between mood, inhibitory control and depressive symptoms

BACKGROUND

Inhibitory control (IC) deficits have been proposed as a potential risk factor for depression. However, little is known about the intra-individual daily fluctuations in IC, and its relationship to mood and depressive symptoms. Here, we examined the everyday association between IC and mood, in typical adults with various levels of depressive symptoms.

METHODS

Participants (N = 106) reported their depressive symptoms and completed a Go-NoGo (GNG) task measuring IC at baseline. Then, they completed a 5-day ecological-momentary-assessment (EMA) protocol, in which they reported their current mood and performed a shortened GNG task twice/day using a mobile app. Depressive symptoms were measured again following the EMA. Hierarchical-linear-modeling (HLM) was applied to examine the association between momentary IC and mood, with post-EMA depressive symptoms as a moderator.

RESULTS

Individuals with elevated depressive symptoms demonstrated worse and more variable IC performance over the EMA. In addition, post-EMA depressive symptoms moderated the association between momentary IC and daily mood, such that reduced IC was associated with more negative mood only for those with lower, but not higher, symptoms.

LIMITATIONS

Future investigations should examine the validity of these outcomes in clinical samples, including patients with Major Depressive Disorder.

CONCLUSIONS

Variable, rather than mere reduced, IC, is related to depressive symptoms. Moreover, the role of IC in modulating mood may differ in non-depressed individuals and individuals with sub-clinical depression. These findings contribute to our understanding of IC and mood in real life and help account for some of the discrepant findings related to cognitive control models of depression.

Feasibility of a Smartwatch Platform to Assess Ecological Mobility: Real-Time Online Assessment and Mobility Monitor

BACKGROUND

Early detection of mobility decline is critical to prevent subsequent reductions in quality of life, disability, and mortality. However, traditional approaches to mobility assessment are limited in their ability to capture daily fluctuations that align with sporadic health events. We aim to describe findings from a pilot study of our Real-time Online Assessment and Mobility Monitor (ROAMM) smartwatch application, which uniquely captures multiple streams of data in real time in ecological settings.

METHODS

Data come from a sample of 31 participants (Mage = 74.7, 51.6% female) who used ROAMM for approximately 2 weeks. We describe the usability and feasibility of ROAMM, summarize prompt data using descriptive metrics, and compare prompt data with traditional survey-based questionnaires or other established measures.

RESULTS

Participants were satisfied with ROAMM's function (87.1%) and ranked the usability as "above average." Most were highly engaged (average adjusted compliance = 70.7%) and the majority reported being "likely" to enroll in a 2-year study (77.4%). Some smartwatch features were correlated with their respective traditional measurements (eg, certain GPS-derived life-space mobility features (r = 0.50-0.51, p < .05) and ecologically measured pain (r = 0.72, p = .01), but others were not (eg, ecologically measured fatigue).

CONCLUSIONS

ROAMM was usable, acceptable, and effective at measuring mobility and risk factors for mobility decline in our pilot sample. Additional work with a larger and more diverse sample is necessary to confirm associations between smartwatch-measured features and traditional measures. By monitoring multiple data streams simultaneously in ecological settings, this technology could uniquely contribute to the evolution of mobility measurement and risk factors for mobility loss.

Dyadic Association Between New Parents' Mindfulness and Relationship Satisfaction: Mediating Role of Perceived Stress

The transition to parenthood is marked by increased potential stressors and relationship satisfaction declines among new parents. Recently, it has been suggested that people with greater mindfulness perceived their environment as less stressful during difficult times in life, which in turn, is associated with greater relationship satisfaction. Accordingly, this dyadic diary study evaluated if perceived stress explains the link between new parents' mindfulness and relationship satisfaction. A total of 78 new parent couples (N = 156 participants; M = 6 months postpartum) provided ecologically valid perceived stress and relationship satisfaction data by responding to a questionnaire on their smartphones, between 7 p.m. and midnight, for 14 consecutive days. Data were analyzed using Actor-Partner Interdependence Mediation Model (APIMeM). Results revealed that parents with higher mindfulness reported lower perceived stress, which in turn was associated with them reporting higher relationship satisfaction. In addition, one's mindfulness was directly positively associated with their partner's relationship satisfaction. Lastly, when all partner effects between mindfulness, perceived stress and relationship satisfaction were tested together without defining specific partner paths, one's mindfulness was positively associated with their partners' relationship satisfaction. Our findings extend current knowledge on the dyadic association between mindfulness and relationship satisfaction during the transition to parenthood by highlighting perceived stress as a key variable underlying this relationship.

Depression networks: a systematic review of the network paradigm causal assumptions

The network paradigm for psychiatric disorder nosology was proposed based on the hypothesis that mental disorders are caused by networks of symptoms that are themselves causally related. Researchers have widely applied and integrated this paradigm to examine a variety of mental disorders, particularly depression. Existing studies generally focus on the correlation structure of symptoms, inferring causal relationships. Thus, presumption of causality may not be justified. The goal of this review was to examine the assumptions necessary for causal inference in network studies of depression. Specifically, we examined whether and how network studies address common violations of causal assumptions (i.e. no measurement error, exchangeability, and positivity). Of the 41 studies reviewed, five (12%) studies discussed sources of confounding unrelated to measurement error; none discussed positivity; and five conducted post-hoc analysis for measurement error. Depression network studies, in principle, are conducted under the assumption that symptom relationships are causal. Yet, in practice, studies seldomly discussed or adequately tested assumptions required to infer causality. Researchers continue to design studies that are unable to support the credibility of the network paradigm for the study of depression. There is a critical need to ensure scientific efforts cease to perpetuate problematic designs and findings to a potentially unsubstantiated paradigm.

Daily affect intensity and variability of adolescents and their parents before and during a COVID-19 lockdown

INTRODUCTION

The corona virus (COVID-19) pandemic may have a prolonged impact on people's lives, with multiple waves of infections and lockdowns, but how a lockdown may alter emotional functioning is still hardly understood.

METHODS

In this 100-daily diaries study, we examined how to affect intensity and variability of adolescents (N = 159, M_age  = 13.3, 61.6% female) and parents (N = 159, M_age  = 45.3, 79.9% female) changed after the onset and during (>50 days) the second COVID-19 lockdown in the Netherlands, using preregistered piecewise growth models.

RESULTS

We found only an unexpected increase in parents' positive affect intensity after the lockdown onset, but no immediate changes in negative affect intensity or variability. However, both adolescents and parents reported gradual increases in negative affect intensity and variability as the lockdown prolonged. Lockdown effects did not differ between adolescents and parents. However, within groups, individuals differed. The individual differences in the effects were partly explained by life satisfaction, depressive symptoms, and self-reported lockdown impact.

CONCLUSIONS

Overall, these findings suggests that a lockdown triggers changes in daily affective well-being especially as the lockdown prolongs. Individual differences in the effects indicate heterogeneity in the impact of the lockdown on daily affect that was partly explained by baseline life satisfaction and depressive symptoms. However, more knowledge on the causes of this heterogeneity is needed to be able to increase resilience to lockdown effects in the population.

Descriptive Exploratory Study to Understand Postpartum Anxiety Using Multiple Measures

OBJECTIVE

To compare a general anxiety instrument plus a depression instrument with a specific postpartum anxiety instrument plus a depression instrument to detect postpartum anxiety and to explore trends in daily postpartum anxiety.

DESIGN

Prospective, longitudinal cohort study.

SETTING

Academic tertiary center in the mid-Atlantic United States. Study activities were remote.

PARTICIPANTS

Pregnant women (N = 73) in the third trimester of pregnancy.

METHODS

We administered the State-Trait Anxiety Inventory (STAI), Postpartum Specific Anxiety Scale (PSAS), and Edinburgh Postnatal Depression Scale (EPDS) at 1 and 8 weeks after birth. We used mobile ecological momentary assessment prompts to measure daily anxiety levels (0-10) from 1 to 8 weeks after birth. We defined the presence of anxiety and depression by using the established instrument cutoff scores. We used repeated-measures analysis of variance and dependent-samples t tests to determine the stability of the determined anxiety instruments during the study time frame. We used linear mixed modeling to explore mobile ecological momentary assessment anxiety trends.

RESULTS

The PSAS and EPDS detected more participants with anxiety and/or depression (26.8%, 19/71) than the STAI and EPDS (23.9%, 17/71) at 8 weeks after birth. PSAS scores increased from 1 to 8 weeks after birth (p = .003); STAI scores decreased (p = .01). Daily anxiety ratings changed nonlinearly during the study period, were greatest at 2 weeks, declined and stabilized, and then trended upward toward Week 8.

CONCLUSION

Detection of postpartum anxiety in clinical settings can be improved through addition of the PSAS in routine screening. Timing of anxiety assessment should be considered between 6 to 8 weeks after birth.

Measuring affect dynamics: An empirical framework

A fast-growing body of evidence from experience sampling studies suggests that affect dynamics are associated with well-being and health. But heterogeneity in experience sampling approaches impedes reproducibility and scientific progress. Leveraging a large dataset of 7016 individuals, each providing over 50 affect reports, we introduce an empirically derived framework to help researchers design well-powered and efficient experience sampling studies. Our research reveals three general principles. First, a sample of 200 participants and 20 observations per person yields sufficient power to detect medium-sized associations for most affect dynamic measures. Second, for trait- and time-independent variability measures of affect (e.g., SD), distant sampling study designs (i.e., a few daily measurements spread out over several weeks) lead to more accurate estimates than close sampling study designs (i.e., many daily measurements concentrated over a few days), although differences in accuracy across sampling methods were inconsistent and of little practical significance for temporally dependent affect dynamic measures (i.e., RMSSD, autocorrelation coefficient, TKEO, and PAC). Third, across all affect dynamics measures, sampling exclusively on specific days or time windows leads to little to no improvement over sampling at random times. Because the ideal sampling approach varies for each affect dynamics measure, we provide a companion R package, an online calculator ( https://sergiopirla.shinyapps.io/powerADapp ), and a series of benchmark effect sizes to help researchers address three fundamental hows of experience sampling: How many participants to recruit? How often to solicit them? And for how long?

Understanding health behaviours in context: A systematic review and meta-analysis of ecological momentary assessment studies of five key health behaviours

Ecological Momentary Assessment (EMA) involves repeated, real-time sampling of health behaviours in context. We present the state-of-knowledge in EMA research focused on five key health behaviours (physical activity and sedentary behaviour, dietary behaviour, alcohol consumption, tobacco smoking, sexual health), summarising theoretical (e.g., psychological and contextual predictors) and methodological aspects (e.g., study characteristics, EMA adherence). We searched Ovid MEDLINE, Embase, PsycINFO and Web of Science until February 2021. We included studies focused on any of the aforementioned health behaviours in adult, non-clinical populations that assessed ≥1 psychological/contextual predictor and reported a predictor-behaviour association. A narrative synthesis and random-effects meta-analyses of EMA adherence were conducted. We included 633 studies. The median study duration was 14 days. The most frequently assessed predictors were 'negative feeling states' (21%) and 'motivation and goals' (16.5%). The pooled percentage of EMA adherence was high at 81.4% (95% CI = 80.0%, 82.8%, k = 348) and did not differ by target behaviour but was somewhat higher in student (vs. general population) samples, when EMAs were delivered via mobile phones/smartphones (vs. handheld devices), and when event contingent (vs. fixed) sampling was used. This review showcases how the EMA method has been applied to improve understanding and prediction of health behaviours in context.

Within-day bidirectional associations between physical activity and affect: A real-time ambulatory study in persons with and without depressive and anxiety disorders

BACKGROUND

Ambulatory assessments offer opportunities to study physical activity level (PAL) and affect at the group and person-level. We examined bidirectional associations between PAL and affect in a 3-h timeframe and evaluated whether associations differ between people with and without current or remitted depression/anxiety.

METHODS

Two-week ecological momentary assessment (EMA) and actigraphy data of 359 participants with current (n = 93), remitted (n = 176), or no (n = 90) Composite International Diagnostic Interview depression/anxiety diagnoses were obtained from the Netherlands Study of Depression and Anxiety. Positive affect (PA) and negative affect (NA) were assessed by EMA 5 times per day. Average PAL between EMA assessments were calculated from actigraphy data.

RESULTS

At the group-level, higher PAL was associated with subsequent higher PA (b = 0.109, p < .001) and lower NA (b = -0.043, p < .001), while higher PA (b = 0.066, p < .001) and lower NA (b = -0.053, p < .001) were associated with subsequent higher PAL. The association between higher PAL and subsequent lower NA was stronger for current depression/anxiety patients than controls (p = .01). At the person-level, analyses revealed heterogeneity in bidirectional associations.

CONCLUSIONS

Higher PAL may improve affect, especially among depression/anxiety patients. As the relationships vary at the person-level, ambulatory assessments may help identify who would benefit from behavioral interventions.

Recent developments on psychological factors in medically unexplained symptoms and somatoform disorders

Somatic symptoms which are not fully explained by a medical condition (medically unexplained symptoms) have a high relevance for the public health. They are very common both in the general population and in patients in health care, and may develop into chronic impairing conditions such as somatoform disorders. In recent years, the relevance of specific negative psychological factors for the diagnosis and the stability of somatoform disorders and for the impairment by medically unexplained symptoms gained more and more attention. This resulted-among others- in core changes in the diagnostic classification criteria of somatoform disorders. Against this background, the present "Perspective" will outline recent developments and findings in the area of medically unexplained somatic symptoms and somatoform disorders. Moreover, it will lay a special focus on evidence on specific negative psychological factors that may influence the course of unexplained somatic symptoms and disorders and the impairment caused by these symptoms.

Interrelationships between childhood maltreatment, depressive symptoms, functional impairment, and quality of life in patients with major depressive disorder: A network analysis approach

BACKGROUND

Childhood maltreatment continues to pose a great challenge to psychiatry. Although there is growing evidence demonstrating that childhood maltreatment is an important risk factor for depressive disorders, it remains to be elucidated which specific symptoms occur after exposure to different kinds of childhood maltreatment, and whether certain pathways may account for these associations.

PARTICIPANTS AND SETTINGS

A total of 203 adult patients (18-53 years old) with MDD, diagnosed by Structured Clinical Interview for Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV) criteria, were recruited from the outpatient clinic of Beijing Anding Hospital, Capital Medical University.

METHODS

Childhood maltreatment, depressive symptoms, functional impairment, and quality of life were evaluated by the Childhood Trauma Questionnaire - Short Form (CTQ-SF), 17-item Hamilton Depression Rating Scale (HAMD-17), Sheehan Disability Scale (SDS), and Quality of Life Enjoyment and Satisfaction Questionnaire-Short Form (Q-LES-Q-SF). Undirected network analysis was used to explore the most relevant connections between them. Bayesian network analysis was used to estimate a directed acyclic graph (DAG) while investigating the most likely direction of the putative causal association.

RESULTS

In network analysis, the strongest edges were a positive correlation between emotional abuse and suicidal behavior as well as a negative association between emotional neglect and age of onset. In DAG analysis, emotional abuse emerged as the most pivotal network node, triggering both suicidal behaviors and depression symptoms.

CONCLUSIONS

Emotional abuse appears to be an extremely harmful form of childhood maltreatment in the clinical presentation of depression. This study has promise in informing the clinical intervention of depression.

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.

How Stable, Really? Traditional and Nonlinear Dynamics Approaches to Studying Temporal Fluctuations in Personality and Affect

A pair of quantitative case studies is presented to demonstrate how different approaches to quantifying temporal variability in ratings of traits and affect can provide rich information for personality researchers. Data are presented and analyzed from two college students who completed an Ecological Momentary Assessment protocol sampling ratings of affect and traits up to 24 times daily for one week. Both classical and nonlinear data analytic techniques were applied to the data to summarize and examine the temporal dynamics of both traits and affect. For the purposes of exposition, one Big Five trait rating, extraversion, and the PANAS positive and negative affects, are discussed. The results support previous research demonstrating a high degree of variability in ratings of both traits and affect over time. Analyses using nonlinear and complexity expand on these findings and suggest temporal patterning as well as disorder; implications of phase portraits for understanding variability are discussed. The findings are discussed in light of a processing dynamics approach to resolving the role of variability in understanding personality.

The Impact of Coping Styles and Gender on Situational Coping: An Ecological Momentary Assessment Study With the mHealth Application TrackYourStress

The aim of this study was to investigate the impact of different coping styles on situational coping in everyday life situations and gender differences. An ecological momentary assessment study with the mobile health app TrackYourStress was conducted with 113 participants. The coping styles Positive Thinking, Active Stress Coping, Social Support, Support in Faith, and Alcohol and Cigarette Consumption of the Stress and Coping Inventory were measured at baseline. Situational coping was assessed by the question “How well can you cope with your momentary stress level” over 4 weeks. Multilevel models were conducted to test the effects of the coping styles on situational coping. Additionally, gender differences were evaluated. Positive Thinking (p = 0.03) and Active Stress Coping (p = 0.04) had significant positive impacts on situational coping in the total sample. For women, Social Support had a significant positive effect on situational coping (p = 0.046). For men, Active Stress Coping had a significant positive effect on situational coping (p = 0.001). Women had higher scores on the SCI scale Social Support than men (p = 0.007). These results suggest that different coping styles could be more effective in daily life for women than for men. Taking this into account, interventions tailored to users’ coping styles might lead to better coping outcomes than generalized interventions.

Stress Detection Using Experience Sampling: A Systematic Mapping Study

Stress has been designated the “Health Epidemic of the 21st Century” by the World Health Organization and negatively affects the quality of individuals’ lives by detracting most body systems. In today’s world, different methods are used to track and measure various types of stress. Among these techniques, experience sampling is a unique method for studying everyday stress, which can affect employees’ performance and even their health by threatening them emotionally and physically. The main advantage of experience sampling is that evaluating instantaneous experiences causes less memory bias than traditional retroactive measures. Further, it allows the exploration of temporal relationships in subjective experiences. The objective of this paper is to structure, analyze, and characterize the state of the art of available literature in the field of surveillance of work stress via the experience sampling method. We used the formal research methodology of systematic mapping to conduct a breadth-first review. We found 358 papers between 2010 and 2021 that are classified with respect to focus, research type, and contribution type. The resulting research landscape summarizes the opportunities and challenges of utilizing the experience sampling method on stress detection for practitioners and academics.

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.

Association of real-time assessed mood, affect and suicidal ideation in psychiatric inpatients with unipolar depression

Previous research provided preliminary support of a potential reinforcing effect of suicidal ideation demonstrating reduced negative affect and increased positive affect after thinking about suicide. The present study therefore sought to investigate the role of mood and affect as a proximal risk factor of suicidal ideation in a high-risk sample. Seventy-four psychiatric inpatients (72% female) with unipolar depression and current and/or lifetime suicidal ideation aged 18 to 85 years (M = 37.6, SD = 14.3) took part in an ecological momentary assessment (EMA) over 6 days. Multilevel analyses were calculated. Analyses revealed negative valence of mood and low positive affect to be predictors of subsequent intensity of suicidal ideation (active, passive) as well as predictors of change in suicidal ideation (active, passive) since the last measurement. High negative affect only predicted intensity of passive suicidal ideation. Suicidal ideation (active, passive) was prospectively associated with subsequent negative valence of mood and lower positive affect as well as with higher intensity of negative affect. Suicidal ideation (active, passive) also predicted the change in valence of mood, positive affect and negative affect since the last measurement. Mood and affect should be taken into account as important proximal risk factors of active and passive suicidal ideation. The results do not support the idea of a reinforcing effect of suicidal ideation. In fact, they show a pattern of reduced subsequent positive affect, negative valence of mood and increased negative affect. Replication studies with larger samples and longer EMA follow-ups are needed.

Youth Psychopathology in Daily Life: Systematically Reviewed Characteristics and Potentials of Ecological Momentary Assessment Applications

Traditionally, symptoms of youth psychopathology are assessed with questionnaires, clinical interviews, or laboratory observations. Ecological Momentary Assessment (EMA) could be a particularly valuable additional methodology, since EMA enables examining the daily lives of youths near real-time, considering fluctuations and specific contexts of symptoms. This systematic review aimed to review the characteristics of current EMA applications and to provide a synthesis of their potential in studying youth psychopathology. Following a systematic search in PsycInfo and Medline, we identified 50 studies in clinical samples. Most studies used EMA to examine fluctuations in symptoms, affect, and behavior, and the relation with contextual factors. EMA was also used to investigate interactions between parents and their children over time, and to monitor and predict treatment response. EMA appeared feasible in youth and could provide valuable insights that contribute to understanding youth psychopathology. Benefits, gaps, and suggestions for future research and clinical practice are discussed.

Remote Digital Psychiatry for Mobile Mental Health Assessment and Therapy: MindLogger Platform Development Study

Background

Universal access to assessment and treatment of mental health and learning disorders remains a significant and unmet need. There are many people without access to care because of economic, geographic, and cultural barriers, as well as the limited availability of clinical experts who could help advance our understanding and treatment of mental health.

Objective

This study aims to create an open, configurable software platform to build clinical measures, mobile assessments, tasks, and interventions without programming expertise. Specifically, our primary requirements include an administrator interface for creating and scheduling recurring and customized questionnaires where end users receive and respond to scheduled notifications via an iOS or Android app on a mobile device. Such a platform would help relieve overwhelmed health systems and empower remote and disadvantaged subgroups in need of accurate and effective information, assessment, and care. This platform has the potential to advance scientific research by supporting the collection of data with instruments tailored to specific scientific questions from large, distributed, and diverse populations.

Methods

We searched for products that satisfy these requirements. We designed and developed a new software platform called MindLogger, which exceeds the requirements. To demonstrate the platform’s configurability, we built multiple applets (collections of activities) within the MindLogger mobile app and deployed several of them, including a comprehensive set of assessments underway in a large-scale, longitudinal mental health study.

Results

Of the hundreds of products we researched, we found 10 that met our primary requirements with 4 that support end-to-end encryption, 2 that enable restricted access to individual users’ data, 1 that provides open-source software, and none that satisfy all three. We compared features related to information presentation and data capture capabilities; privacy and security; and access to the product, code, and data. We successfully built MindLogger mobile and web applications, as well as web browser–based tools for building and editing new applets and for administering them to end users. MindLogger has end-to-end encryption, enables restricted access, is open source, and supports a variety of data collection features. One applet is currently collecting data from children and adolescents in our mental health study, and other applets are in different stages of testing and deployment for use in clinical and research settings.

Conclusions

We demonstrated the flexibility and applicability of the MindLogger platform through its deployment in a large-scale, longitudinal, mobile mental health study and by building a variety of other mental health–related applets. With this release, we encourage a broad range of users to apply the MindLogger platform to create and test applets to advance health care and scientific research. We hope that increasing the availability of applets designed to assess and administer interventions will facilitate access to health care in the general population.

Development of a conceptual model for research on cyclical variation of patient reported outcome measurements (PROMs) in patients with chronic conditions: a scoping review

Background

Although circadian, seasonal, and other cycles have been observed for a number of chronic conditions, their impact on patient reported outcomes measurements (PROMs) has not been systematically explored, rendering our understanding of the effect of time of measurement on PROM scores very limited. The aim was to conduct a scoping review to determine what is known about how intra-individual cyclical variation might affect the way individuals with chronic conditions respond to patient-reported outcome measures.

Methods

A protocol of a systematic scoping review was registered on PROSPERO (CRD42017058365). We developed a search strategy based on previous relevant reviews and implemented it in: MEDLINE, Embase, PsycINFO, and CINAHL. No restrictions were placed on article types and backward and forward citation searches were conducted. Screening and data extraction were independently completed by up to four reviewers. An adapted version of CASP criteria was used to appraise the quality of included articles. Concepts that were important in understanding the impact of cyclical variation on PROM scores were elicited from the papers and iteratively refined through discussion amongst the authors.

Results

2420 references resulted from the searches, with 33 articles meeting the inclusion criteria. Most study designs included observational research (particularly ecological momentary assessment), 2 were RCTs and 2 were systematic reviews. Studies mainly focused on specific health conditions: mental health, respiratory and musculoskeletal. There was a lack of qualitative research and theoretical framework to explore these concepts more fully. Five overarching concepts emerged: variation in outcomes, variation of scores, psychological status, individual factors, and environmental/situational factors. A conceptual model was developed outlining the relationships between these concepts.

Conclusions

There is empirical evidence that supports cyclical variation in PROM scores across different chronic conditions, with potential very significant implications for administration and interpretation of PROMs. The proposed conceptual model can support further research in this area.

Supplementary Information

The online version contains supplementary material available at 10.1186/s41687-021-00395-x.

A Public Health Framework for Preventing Mental Disorders in the Context of Pandemics

The COVID-19 pandemic has universally threatened the building blocks of mental health, well-being, and quality of life, namely, expectations of safety, connectedness, hope, and individual and societal efficacy. Consequently, unprecedently large numbers of individuals are significantly stressed and many are at risk for relapse of mental health problems, exacerbations of existing mental and behavioral health problems, and new onset clinical problems. Because of the scope of the problem, a population-based public health perspective is needed, which in the context of disasters has well-established theories and prevention approaches. Public health approaches to disasters and pandemics focus on preventing subclinical problems from becoming clinical disorders, in comparison to clinical care approaches that focus on treating established disorders. Fortunately, specialty care clinicians who typically think about assessing and treating established disorders have the training and clinical competencies to deliver prevention-focused interventions. This paper is designed to help specialty care clinicians who use cognitive-behavioral strategies to understand the biopsychosocial impacts and resource deficits associated with COVID-19-related stressors and the public health perspective to address them. We also provide ways clinicians can help people who are suffering from significant stress and resource deficits bounce back and regain functioning. We describe psychological first aid, stress management, repeated ecological assessment, writing about stressors, problem-solving, and behavioral activation approaches to assist individuals at risk for enduring stress-linked problems.

Affect fluctuations examined with ecological momentary assessment in patients with current or remitted depression and anxiety disorders

BACKGROUND

There is increasing interest in day-to-day affect fluctuations of patients with depressive and anxiety disorders. Few studies have compared repeated assessments of positive affect (PA) and negative affect (NA) across diagnostic groups, and fluctuation patterns were not uniformly defined. The aim of this study is to compare affect fluctuations in patients with a current episode of depressive or anxiety disorder, in remitted patients and in controls, using affect instability as a core concept but also describing other measures of variability and adjusting for possible confounders.

METHODS

Ecological momentary assessment (EMA) data were obtained from 365 participants of the Netherlands Study of Depression and Anxiety with current (n = 95), remitted (n = 178) or no (n = 92) DSM-IV defined depression/anxiety disorder. For 2 weeks, five times per day, participants filled-out items on PA and NA. Affect instability was calculated as the root mean square of successive differences (RMSSD). Tests on group differences in RMSSD, within-person variance, and autocorrelation were performed, controlling for mean affect levels.

RESULTS

Current depression/anxiety patients had the highest affect instability in both PA and NA, followed by remitters and then controls. Instability differences between groups remained significant when controlling for mean affect levels, but differences between current and remitted were no longer significant.

CONCLUSIONS

Patients with a current disorder have higher instability of NA and PA than remitted patients and controls. Especially with regard to NA, this could be interpreted as patients with a current disorder being more sensitive to internal and external stressors and having suboptimal affect regulation.

Systematic review of ecological momentary assessment (EMA) studies of five public health-related behaviours: review protocol

INTRODUCTION

Ecological momentary assessment (EMA) involves repeated, real-time assessments of phenomena (eg, cognitions, emotions, behaviours) over a period of time in naturalistic settings. EMA is increasingly used to study both within-person and between-person processes. We will review EMA studies investigating key health behaviours and synthesise: (1) study characteristics (eg, frequency of assessments, adherence, incentives), (2) associations between psychological predictors and behaviours and (3) moderators of adherence to EMA protocols.

METHODS AND ANALYSIS

This review will focus on EMA studies conducted across five public health behaviours in adult, non-clinical populations: movement behaviour (including physical activity and sedentary behaviour), dietary behaviour, alcohol consumption, tobacco smoking and preventive sexual health behaviours. Studies need to have assessed at least one psychological or contextual predictor of these behaviours. Studies reporting exclusively on physiological outcomes (eg, cortisol) or those not conducted under free-living conditions will be excluded. We will search OVID MEDLINE, Embase, PsycINFO and Web of Science using terms relevant to EMA and the selected health behaviours. Reference lists of existing systematic reviews of EMA studies will be hand searched. Identified articles will be screened by two reviewers. This review is expected to provide a comprehensive summary of EMA studies assessing psychological or contextual predictors of five public health behaviours.

ETHICS AND DISSEMINATION

The results will be disseminated through peer-reviewed publications and presentations. Data from included studies will be made available to other researchers. No ethics are required.

PROSPERO REGISTRATION NUMBER

CRD42020168314.

Fractal biomarker of activity in patients with bipolar disorder

BACKGROUND

The output of many healthy physiological systems displays fractal fluctuations with self-similar temporal structures. Altered fractal patterns are associated with pathological conditions. There is evidence that patients with bipolar disorder have altered daily behaviors.

METHODS

To test whether fractal patterns in motor activity are altered in patients with bipolar disorder, we analyzed 2-week actigraphy data collected from 106 patients with bipolar disorder type I in a euthymic state, 73 unaffected siblings of patients, and 76 controls. To examine the link between fractal patterns and symptoms, we analyzed 180-day actigraphy and mood symptom data that were simultaneously collected from 14 patients.

RESULTS

Compared to controls, patients showed excessive regularity in motor activity fluctuations at small time scales (<1.5 h) as quantified by a larger scaling exponent (α1 > 1), indicating a more rigid motor control system. α1 values of siblings were between those of patients and controls. Further examinations revealed that the group differences in α1 were only significant in females. Sex also affected the group differences in fractal patterns at larger time scales (>2 h) as quantified by scaling exponent α2. Specifically, female patients and siblings had a smaller α2 compared to female controls, indicating more random activity fluctuations; while male patients had a larger α2 compared to male controls. Interestingly, a higher weekly depression score was associated with a lower α1 in the subsequent week.

CONCLUSIONS

Our results show sex- and scale-dependent alterations in fractal activity regulation in patients with bipolar disorder. The mechanisms underlying the alterations are yet to be determined.

Efficacy of early warning signals and spectral periodicity for predicting transitions in bipolar patients: An actigraphy study

Early-warning signals (EWS) have been successfully employed to predict transitions in research fields such as biology, ecology, and psychiatry. The predictive properties of EWS might aid in foreseeing transitions in mood episodes (i.e. recurrent episodes of mania and depression) in bipolar disorder (BD) patients. We analyzed actigraphy data assessed during normal daily life to investigate the feasibility of using EWS to predict mood transitions in bipolar patients. Actigraphy data of 15 patients diagnosed with BD Type I collected continuously for 180 days were used. Our final sample included eight patients that experienced a mood episode, three manic episodes and five depressed episodes. Actigraphy data derived generic EWS (variance and kurtosis) and context-driven EWS (autocorrelation at lag-720) were used to determine if these were associated to upcoming bipolar episodes. Spectral analysis was used to predict changes in the periodicity of the sleep/wake cycle. The study procedures were pre-registered. Results indicated that in seven out of eight patients at least one of the EWS did show a significant change-up till four weeks before episode onset. For the generic EWS the direction of change was always in the expected direction, whereas for the context-driven EWS the observed effect was often in the direction opposite of what was expected. The actigraphy data derived EWS and spectral analysis showed promise for the prediction of upcoming transitions in mood episodes in bipolar patients. Further studies into false positive rates are suggested to improve effectiveness for EWS to identify upcoming bipolar episode onsets.

A Systematic Review of Momentary Assessment Designs for Mood and Anxiety Symptoms

Background: Altering components of ecological momentary assessment (EMA) measures to better suit the purposes of individual studies is a common and oftentimes necessary step. Though the inherent flexibility in EMA has its benefits, no resource exists to provide an overview of the variability in how convergent constructs and symptoms have been assessed in the past. The present study fills that gap by examining EMA measurement design for mood and anxiety symptomatology. Methods: Various search engines were used to identify 234 relevant studies. Items administered, data collection schedules (i.e., beeps per day), response scales (i.e., Likert), data collection platforms (i.e., apps), and psychometric properties (i.e., reliability) were extracted. Results: Study designs varied greatly in all aspects across the identified papers. Over 4,600 extracted items were qualitatively analyzed, resulting in the identification of 12 themes. The most EMA items focused on affect, with categories such as "happiness" and "tension" appearing most frequently. We provide all of our data extraction in the format of an open-source database. Limitations: Despite our best attempts to include as much of the relevant literature as possible, this review and the accompanying database are not exhaustive, but can easily be built upon to include other, newer studies. Conclusions: The fact that the affect theme featured both positive and negative emotional constructs highlights the dichotomous focus on valence and affect within the literature surrounding anxious and depressive symptomatology. We hope that our database will act as a helpful design decision-making resource for researchers studying this kind of symptomatology in the future. Systematic Review Registration: PROSPERO (CRD42019139409).

Use of Ecological Momentary Assessment to Study Suicidal Thoughts and Behavior: a Systematic Review

PURPOSE OF REVIEW

Ecological momentary assessment (EMA) is a recently introduced approach to patient evaluation that consists of asking patients questions in real time and in their usual habitat. This method seeks to contribute to suicide prevention by providing psychiatrists with detailed information about suicidal thoughts and behavior, how these fluctuate over short periods of time, and the short-term risk factors presented by patients. We conducted a systematic review of published research using EMA to study suicidal thoughts and behavior.

RECENT FINDINGS

Several systematic reviews of EMA in mental health have been conducted to date, and the literature contains numerous theoretical papers and compilations on EMA and suicide phenomena. To date, however, no systematic reviews have explored the use of this tool to study suicidal thoughts and behavior. We performed a systematic review of five databases (i.e., PubMed, Embase, Scopus, Web of Science, and PsycINFO) to identify studies on EMA and suicidal thoughts and behavior. An initial search revealed 544 articles. Following the study selection process, 35 studies were included in the review. Almost three-quarters of the studies were published in the last 4 years. The studies reviewed concluded that EMA was generally feasible and well accepted. EMA findings correlated well with the results of a retrospective assessment, though tended to over-represent symptom severity. Our review points to important aspects of suicidal thoughts and behavior, such as its wide fluctuation over short periods of time. Negative affect and disturbed sleep, among others, emerged as short-term predictors of suicidal thoughts and behavior. Therefore, EMA is a potentially useful tool in clinical practice, although not without drawbacks, such as participant fatigue with questionnaires and ethical concerns.

Predictors of affect following discharge from partial hospitalization: a two-week ecological momentary assessment study

BACKGROUND

Little is known about the everyday experiences of individuals transitioning from acute to outpatient psychiatric care, an important period of risk for mood symptom relapse. This study used ecological momentary assessment (EMA) to examine whether specific daily experiences were related to momentary affective states following discharge from a partial hospitalization program (PHP).

METHODS

A sample of 114 adults (Mage = 36 years old, 52% female, 83% White) completed four brief EMA surveys every day for 2 weeks assessing intensity/type of stressful events and social contact, as well as positive/negative affect (PA/NA). Half of participants reported therapeutic skills use.

RESULTS

Stress severity ratings prospectively predicted increased NA. NA predicted spending less time with close relationships. However, interacting with close relationships predicted increased positive affect (PA). Finally, PA predicted spending time with more people. The use of two skills (behavioral activation and interpersonal effectiveness) was concurrently, but not prospectively, associated with improved affect.

CONCLUSIONS

Examining daily experiences of individuals discharging from partial hospitalization provides important information about factors that may influence affective states during the transition from acute to outpatient care. Findings from this study can be used to help prepare patients for discharge and develop interventions for the post-acute period.

Ecological momentary assessment as a measurement tool in depression trials

We used ecological momentary assessment (EMA) to track symptoms during a clinical trial. Thirty-six participants with major depressive disorder (MDD) and MADRS scores ≥20 were enrolled in a nonrandomized 6-week open-label trial of commercially available antidepressants. Twice daily, a mobile device prompted participants to self-report the 6 items of the HamD₆ sub-scale derived from the Hamilton rating scale for depression (HamD₁₇). Morning EMA reports asked "how do you feel now" whereas evening reports gathered a full-day impression. Clinicians who were blinded to the EMA data rated the MADRS, HamD₁₇ and HamD₆ at screen, baseline and weeks 2,4, and 6. Hierarchical linear modeling (HLM) examined the course of the EMA assessments and convergence between EMA scores and clinician ratings. HLM analyses revealed strong correlations between AM and PM EMA derived HamD₆ scores and revealed significant improvements over time. EMA improvements were significantly correlated with the clinician rated HamD₆ scores at endpoint and predicted clinician rated HamD₆ score changes from baseline to endpoint (p < .001). There was a large correlation between EMA and clinician derived HamD₆ scores at each in-person assessment after baseline. Treatment response defined by EMA matched the clinician rated HamD₆ treatment responses in 33 of 36 cases (91.7%). EMA derived symptom scores appear to be efficient and valid measures to track daily symptomatic change in clinical trials and may provide more accurate measures of symptom severity than the episodic "snapshots" that are currently used as clinical outcomes. These findings support further investigation of EMA for assessment in clinical trials.

Maternal Depression History Moderates the Association Between Criticism (but not Praise) and Depressive Symptoms in Youth

Children of mothers with past depression are at increased risk for developing the disorder themselves; however, the specific factors that increase their risk are unclear. Aberrant reactivity to social experiences may be one characteristic that increases risk for depression in offspring. This study investigates whether mothers' depression history is associated with increased reactivity to criticism and decreased reactivity to praise in offspring by examining 72 youths (ages 8-15). Every evening for 21 days, youths reported their depressive symptoms and whether they were criticized and/or praised by their mothers, fathers, siblings, and friends, resulting in 1,382 data entries across participants. Mothers reported their own depression history and current depressive symptoms. Maternal depression history moderated offspring's response to criticism. Although all youths reacted to perceived criticism from family members with transient increases of depressive symptoms, only children of mothers with higher (vs. lower) levels of past depression exhibited cumulative, person-level associations between perceived criticism and their own depressive symptoms. Additionally, only children of depressed mothers exhibited increases in depressive symptoms on days in which they were criticized by friends. Perceived parental praise was associated with lower levels of depression in youths regardless of maternal depression. Youth depressive symptoms were more strongly related to their parents' (vs. siblings or friends) criticism and praise, highlighting parents' more central role in youth depression risk. Taken together, our results reveal that maternal depression history is associated with increased reactivity to perceived criticism across relational contexts potentially contributing to youths' risk for developing depression.

Circadian depression: A mood disorder phenotype

Major mood syndromes are among the most common and disabling mental disorders. However, a lack of clear delineation of their underlying pathophysiological mechanisms is a major barrier to prevention and optimised treatments. Dysfunction of the 24-h circadian system is a candidate mechanism that has genetic, behavioural, and neurobiological links to mood syndromes. Here, we outline evidence for a new clinical phenotype, which we have called 'circadian depression'. We propose that key clinical characteristics of circadian depression include disrupted 24-h sleep-wake cycles, reduced motor activity, low subjective energy, and weight gain. The illness course includes early age-of-onset, phenomena suggestive of bipolarity (defined by bidirectional associations between objective motor and subjective energy/mood states), poor response to conventional antidepressant medications, and concurrent cardiometabolic and inflammatory disturbances. Identifying this phenotype could be clinically valuable, as circadian-targeted strategies show promise for reducing depressive symptoms and stabilising illness course. Further investigation of underlying circadian disturbances in mood syndromes is needed to evaluate the clinical utility of this phenotype and guide the optimal use of circadian-targeted interventions.

Depression risk factors and affect dynamics: An experience sampling study

Affect dynamics reflect individual differences in how emotional information is processed, and may provide insights into how depressive episodes develop. To extend prior studies that examined affect dynamics in currently depressed individuals, the present study tested in 68 non-depressed young adults whether three well-established risk factors for major depressive disorder (MDD) - (a) past episodes of MDD, (b) family history of MDD, and (c) reduced neurophysiological responses to reward - predicted mean levels, instability, or inertia (i.e., inflexibility) of positive affect (PA) and/or negative affect (NA). Momentary PA and NA were assessed up to 6 times per day for 14 days (mean number of surveys completed = 45.89). MDD history and family history of MDD were assessed via semi-structured interview, and neurophysiological responses to reward were indexed using the Reward Positivity, an event-related potential related to depression. After adjusting for current depressive symptoms, results indicated that (a) past episodes of MDD predicted higher mean levels of NA, (b) family history of MDD predicted greater PA inertia, and (c) blunted reactivity to reward predicted greater NA inertia. Collectively, these results suggest that elevated mean levels of NA and inflexibility of PA and NA may be potential mechanisms that confer risk for depression.

A systematic review and meta-analysis of the effect of emotion regulation on cortisol

It is generally acknowledged that hormones are implicated in socioemotional behavior, yet little is known about the role of hormones in the context of emotion regulation. The aims of the present review and meta-analysis were to review and synthesize the available evidence pertaining to the effect of emotion regulation instructions on hormones, and to investigate whether this effect varies according to: type of hormone, context (e.g., emotion-induction procedure), emotion regulation characteristics (e.g., emotion regulation strategy), and presence and type of psychiatric disorder. PubMed, PsycINFO, and CINAHL were searched for experimental studies assessing the effect of instructed emotion regulation on levels of hormones (i.e., testosterone, cortisol, oxytocin, estradiol, and vasopressin) in physically healthy adults. The literature search yielded 17 relevant studies, 16 investigating cortisol and one investigating testosterone. Of these, 12 cortisol studies had eligible data for the meta-analysis. The results of the meta-analysis indicated no statistically significant effect of receiving an emotion regulation instruction compared with receiving no instruction on the cortisol response to subsequent emotion induction (g ​= ​−0.05, p ​= ​.48). However, within-person comparisons of change from an unregulated response to a regulated response indicated a significant change in cortisol levels (g ​= ​0.18, p ​= ​.03) consistent with the specified regulation goal (i.e., either up- or downregulation). No statistically significant effects were found in subgroup meta-analyses conducted according to context, emotion regulation characteristics or psychiatric disorders. Taken together, the findings indicate that emotion-induction procedures are associated with increases in cortisol that may subsequently return to equilibrium regardless of emotion-regulation instructions. Based on the large gaps in research (e.g., few studies investigated other hormones than cortisol, few studies included self-report measures of emotions) identified in the present review, we conclude that the effect of emotion regulation on hormones remains poorly understood.

Prospero registration

CRD42020157336.

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Research on the effect of emotion regulation on hormones has focused on cortisol.

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Emotion regulation does not influence cortisol responses to emotion induction.

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Psychological confounders have received little attention in the reviewed research.

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The effect of emotion regulation on hormones remains poorly understood.

Feasibility of ecological momentary assessment to study depressive symptoms among cancer caregivers

OBJECTIVE

Ecological momentary assessment (EMA) may help with the development of more targeted interventions for caregivers' depression, yet the use of this method has been limited among cancer caregivers. This study aimed to demonstrate the feasibility of EMA among cancer caregivers and the use of EMA data to understand affective correlates of caregiver depressive symptoms.

METHODS

Caregivers (N = 25) completed a depressive symptom assessment (Patient Health Questionnaire-8) and then received eight EMA survey prompts per day for 7 days. EMA surveys assessed affect on the orthogonal dimensions of valence and arousal. Participants completed feedback surveys regarding the EMA protocol at the conclusion of the week-long study.

RESULTS

Of 32 caregivers approached, 25 enrolled and participated (78%), which exceeded the a priori feasibility cutoff of 55%. The prompt completion rate (59%, or 762 of 1,286 issued) did not exceed the a priori cutoff of 65%, although completion was not related to caregivers' age, employment status, physical health quality of life, caregiving stress, or depressive symptoms or the patients' care needs (ps > 0.22). Caregivers' feedback about their study experience was generally positive. Mixed-effects location scale modeling showed caregivers' higher depressive symptoms were related to overall higher reported negative affect and lower positive affect, but not to affective variability.

CONCLUSIONS

Findings from this feasibility study refute potential concerns that an EMA design is too burdensome for distressed caregivers. Clinically, findings suggest the potential importance of not only strategies to reduce overall levels of negative affect, but also to increase opportunities for positive affect.

Increased Reward-Related Activation in the Ventral Striatum During Stress Exposure Associated With Positive Affect in the Daily Life of Young Adults With a Family History of Depression. Preliminary Findings

Background: Being the offspring of a parent with major depression disorder (MDD) is a strong predictor for developing MDD. Blunted striatal responses to reward were identified in individuals with MDD and in asymptomatic individuals with family history of depression (FHD). Stress is a major etiological factor for MDD and was also reported to reduce the striatal responses to reward. The stress-reward interactions in FHD individuals has not been explored yet. Extending neuroimaging results into daily-life experience, self-reported ambulatory measures of positive affect (PA) were shown to be associated with striatal activation during reward processing. A reduction of self-reported PA in daily life is consistently reported in individuals with current MDD. Here, we aimed to test (1) whether increased family risk of depression is associated with blunted neural and self-reported reward responses. (2) the stress-reward interactions at the neural level. We expected a stronger reduction of reward-related striatal activation under stress in FHD individuals compared to HC. (3) the associations between fMRI and daily life self-reported data on reward and stress experiences, with a specific interest in the striatum as a crucial region for reward processing. Method: Participants were 16 asymptomatic young adults with FHD and 16 controls (HC). They performed the Fribourg Reward Task with and without stress induction, using event-related fMRI. We conducted whole-brain analyses comparing the two groups for the main effect of reward (rewarded > not-rewarded) during reward feedback in control (no-stress) and stress conditions. Beta weights extracted from significant activation in this contrast were correlated with self-reported PA and negative affect (NA) assessed over 1 week. Results: Under stress induction, the reward-related activation in the ventral striatum (VS) was higher in the FHD group than in the HC group. Unexpectedly, we did not find significant group differences in the self-reported daily life PA measures. During stress induction, VS reward-related activation correlated positively with PA in both groups and negatively with NA in the HC group. Conclusion: As expected, our results indicate that increased family risk of depression was associated with specific striatum reactivity to reward in a stress condition, and support previous findings that ventral striatal reward-related response is associated with PA. A new unexpected finding is the negative association between NA and reward-related ventral striatal activation in the HC group.