Effects of momentary self-monitoring on empowerment in a randomized controlled trial in patients with depression

The experience sampling methodology as a digital clinical tool for more person-centered mental health care: an implementation research agenda

This position paper by the international IMMERSE consortium reviews the evidence of a digital mental health solution based on Experience Sampling Methodology (ESM) for advancing person-centered mental health care and outlines a research agenda for implementing innovative digital mental health tools into routine clinical practice. ESM is a structured diary technique recording real-time self-report data about the current mental state using a mobile application. We will review how ESM may contribute to (1) service user engagement and empowerment, (2) self-management and recovery, (3) goal direction in clinical assessment and management of care, and (4) shared decision-making. However, despite the evidence demonstrating the value of ESM-based approaches in enhancing person-centered mental health care, it is hardly integrated into clinical practice. Therefore, we propose a global research agenda for implementing ESM in routine mental health care addressing six key challenges: (1) the motivation and ability of service users to adhere to the ESM monitoring, reporting and feedback, (2) the motivation and competence of clinicians in routine healthcare delivery settings to integrate ESM in the workflow, (3) the technical requirements and (4) governance requirements for integrating these data in the clinical workflow, (5) the financial and competence related resources related to IT-infrastructure and clinician time, and (6) implementation studies that build the evidence-base. While focused on ESM, the research agenda holds broader implications for implementing digital innovations in mental health. This paper calls for a shift in focus from developing new digital interventions to overcoming implementation barriers, essential for achieving a true transformation toward person-centered care in mental health.

Leveraging Single-Case Experimental Designs to Promote Personalized Psychological Treatment: Step-by-Step Implementation Protocol with Stakeholder Involvement of an Outpatient Clinic for Personalized Psychotherapy

Our objective is to implement a single-case experimental design (SCED) infrastructure in combination with experience-sampling methods (ESM) into the standard diagnostic procedure of a German outpatient research and training clinic. Building on the idea of routine outcome monitoring, the SCED infrastructure introduces intensive longitudinal data collection, individual effectiveness measures, and the opportunity for systematic manipulation to push personalization efforts further. It aims to empower psychotherapists and patients to evaluate their own treatment (idiographic perspective) and to enable researchers to analyze open questions of personalized psychotherapy (nomothetic perspective). Organized around the principles of agile research, we plan to develop, implement, and evaluate the SCED infrastructure in six successive studies with continuous stakeholder involvement: In the project development phase, the business model for the SCED infrastructure is developed that describes its vision in consideration of the context (Study 1). Also, the infrastructure's prototype is specified, encompassing the SCED procedure, ESM protocol, and ESM survey (Study 2 and 3). During the optimization phase, feasibility and acceptability are tested and the infrastructure is adapted accordingly (Study 4). The evaluation phase includes a pilot implementation study to assess implementation outcomes (Study 5), followed by actual implementation using a within-institution A-B design (Study 6). The sustainability phase involves continuous monitoring and improvement. We discuss to what extent the generated data could be used to address current questions of personalized psychotherapy research. Anticipated barriers and limitations during the implementation processes are outlined.

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.

When a test is more than just a test: Findings from patient interviews and survey in the trial of a technology to measure antidepressant medication response (the PReDicT Trial)

BACKGROUND

A RCT of a novel intervention to detect antidepressant medication response (the PReDicT Test) took place in five European countries, accompanied by a nested study of its acceptability and implementation presented here. The RCT results indicated no effect of the intervention on depression at 8 weeks (primary outcome), although effects on anxiety at 8 weeks and functioning at 24 weeks were found.

METHODS

The nested study used mixed methods. The aim was to explore patient experiences of the Test including acceptability and implementation, to inform its use within care. A bespoke survey was completed by trial participants in five countries (n = 778) at week 8. Semi-structured interviews were carried out in two countries soon after week 8 (UK n = 22, Germany n = 20). Quantitative data was analysed descriptively; for qualitative data, thematic analysis was carried out using a framework approach. Results of the two datasets were interrogated together.

OUTCOMES

Survey results showed the intervention was well received, with a majority of participants indicating they would use it again, and it gave them helpful extra information; a small minority indicated the Test made them feel worse. Qualitative data showed the Test had unexpected properties, including: instigating a process of reflection, giving participants feedback on progress and new understanding about their illness, and making participants feel supported and more engaged in treatment.

INTERPRETATION

The qualitative and quantitative results are generally consistent. The Test's unexpected properties may explain why the RCT showed little effect, as properties were experienced across both trial arms. Beyond the RCT, the qualitative data sheds light on measurement reactivity, i.e., how measurements of depression can impact patients.

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).

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.

Novel digital methods for gathering intensive time series data in mental health research: scoping review of a rapidly evolving field

Recent technological advances enable the collection of intensive longitudinal data. This scoping review aimed to provide an overview of methods for collecting intensive time series data in mental health research as well as basic principles, current applications, target constructs, and statistical methods for this type of data.In January 2021, the database MEDLINE was searched. Original articles were identified that (1) used active or passive data collection methods to gather intensive longitudinal data in daily life, (2) had a minimum sample size of N ⩾ 100 participants, and (3) included individuals with subclinical or clinical mental health problems.In total, 3799 original articles were identified, of which 174 met inclusion criteria. The most widely used methods were diary techniques (e.g. Experience Sampling Methodology), various types of sensors (e.g. accelerometer), and app usage data. Target constructs included affect, various symptom domains, cognitive processes, sleep, dysfunctional behaviour, physical activity, and social media use. There was strong evidence on feasibility of, and high compliance with, active and passive data collection methods in diverse clinical settings and groups. Study designs, sampling schedules, and measures varied considerably across studies, limiting the generalisability of findings.Gathering intensive longitudinal data has significant potential to advance mental health research. However, more methodological research is required to establish and meet critical quality standards in this rapidly evolving field. Advanced approaches such as digital phenotyping, ecological momentary interventions, and machine-learning methods will be required to efficiently use intensive longitudinal data and deliver personalised digital interventions and services for improving public mental health.

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.

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.

Personalized networks of social anxiety disorder and depression and implications for treatment

INTRODUCTION

Social anxiety disorder (SAD) and major depressive disorder (MDD) often co-occur; however, there is limited research evaluating how cognitive-affective and behavioral factors maintain SAD and MDD for specific individuals. Evidence suggests that individuals exhibit symptom-level heterogeneity, necessitating a person-specific approach to assessment and intervention. We compared group and person-specific models of SAD-MDD comorbidity and hypothesized that individuals would demonstrate person-specific patterns of comorbidity factors that differed from the group.

METHODS

Cisgender women (N = 35) with SAD and a current or past major depressive episode were recruited. Ages ranged from 18 to 37 years old and a majority of women were White (n = 18; 51.43%). Brief ecological momentary assessment surveys related to SAD-MDD comorbidity were administered five times a day for a month (T = 4,357).

RESULTS

Multilevel and person-specific network analyses were used to examine between-, within-, and person-specific patterns. Intra-daily depressed mood demonstrated the strongest connections to other variables and exhibited additional, unexpected temporal effects. All models demonstrated person-specific patterns relevant to SAD-MDD comorbidity.

LIMITATIONS

These results are descriptive in nature from women with a similar psychiatric profile. Future research integrating intensive EMA and personalized modeling within the context of experimental design is needed to determine the extent to which individuals truly differ from the group.

CONCLUSIONS

Patterns of SAD-MDD comorbidity varied substantially across women, underscoring the potential for results from person-specific (idiographic) networks to inform the development and implementation of personalized directives for clinical assessment and intervention.

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.

Effectiveness of Resource Groups for Improving Empowerment, Quality of Life, and Functioning of People With Severe Mental Illness: A Randomized Clinical Trial

Importance

Although the importance of recovery-oriented care for people with severe mental illness (SMI) is widely acknowledged, essential elements such as personalization and involvement of significant others are not adequately implemented in practice.

Objective

To determine whether using resource groups (RGs) within flexible assertive community treatment (FACT) has favorable effects on empowerment and recovery-related outcomes in people with SMI.

Design, Setting, and Participants

This assessor-blind, multisite randomized clinical trial was conducted from September 1, 2017, to September 30, 2020, with follow-up at 9 and 18 months. A total of 158 participants aged 18 to 65 years meeting the criteria for SMI were randomly allocated to FACT plus RG vs FACT as usual (1:1) in 20 FACT teams throughout the Netherlands. Data were analyzed from September 1, 2020, to January 31, 2021. The study was prespecified in the trial protocol and data from the intent-to-treat population were analyzed.

Interventions

In the FACT plus RG condition, patients chose members from their informal and formal networks to form an RG that meets quarterly to discuss self-formulated recovery goals. The RG was integrated into the multidisciplinary support provided by the FACT team. In the FACT as-usual condition, empowerment (defined as overcoming powerlessness and gaining control of one's life) and involvement of significant others was also part of the provided care, but without the structure of the RG.

Main Outcomes and Measures

The primary outcome was self-reported empowerment, measured with the Netherlands Empowerment List.

Results

A total of 158 participants with SMI (median age, 38 [median absolute deviation, 13] years; 93 men [58.9%]) were randomized to FACT plus RG (n = 80) or FACT as usual (n = 78) care. Intention-to-treat analyses showed that randomization to the RG condition was associated with a clinically significant increase in empowerment (Cohen d, 0.54; 95% CI, 0.21-0.86) and improved outcomes with small to medium effect sizes in terms of quality of life (Cohen d, 0.25; 95% CI, -0.07 to 0.56), personal recovery (Cohen d, 0.38; 95% CI, 0.06-0.69), quality of social contact (Cohen d, 0.24; 95% CI, -0.07 to 0.56), disability (Cohen d, 0.29; 95% CI, -0.03 to 0.60), general functioning (Cohen d, 0.30; 95% CI, -0.01 to 0.62), and social functioning (Cohen d, 0.28; 95% CI, -0.04 to 0.59). No differences between conditions were found regarding psychopathological symptoms, attachment, frequency of social contact, and employment. Compared with FACT as usual, participants who stayed with the assigned treatment in the RG condition were more satisfied with treatment at 9 (Cohen d = 0.45; t135 = -2.62; P = .009) and 18 (Cohen d = 0.41; t116 = -2.22; P = .02) months.

Conclusions and Relevance

These findings show that working with RGs improves empowerment and other mental health outcomes in people with SMI who receive community-based mental health services. This method of network-oriented care empowers people with SMI within their own environment.

Trial Registration

Netherlands Trial Register Identifier: NL6548.

Routine provision of feedback from patient-reported outcome measurements to healthcare providers and patients in clinical practice

BACKGROUND

Patient-reported outcomes measures (PROMs) assess a patient's subjective appraisal of health outcomes from their own perspective. Despite hypothesised benefits that feedback  on PROMs can support decision-making in clinical practice and improve outcomes, there is uncertainty surrounding the effectiveness of PROMs feedback.

OBJECTIVES

To assess the effects of PROMs feedback to patients, or healthcare workers, or both on patient-reported health outcomes and processes of care.

SEARCH METHODS

We searched MEDLINE, Embase, CENTRAL, two other databases and two clinical trial registries on 5 October 2020. We searched grey literature and consulted experts in the field.

SELECTION CRITERIA

Two review authors independently screened and selected studies for inclusion. We included randomised trials directly comparing the effects on outcomes and processes of care of PROMs feedback to healthcare professionals and patients, or both with the impact of not providing such information.

DATA COLLECTION AND ANALYSIS

Two groups of two authors independently extracted data from the included studies and evaluated study quality. We followed standard methodological procedures expected by Cochrane and EPOC. We used the GRADE approach to assess the certainty of the evidence. We conducted meta-analyses of the results where possible.

MAIN RESULTS

We identified 116 randomised trials which assessed the effectiveness of PROMs feedback in improving processes or outcomes of care, or both in a broad range of disciplines including psychiatry, primary care, and oncology. Studies were conducted across diverse ambulatory primary and secondary care settings in North America, Europe and Australasia. A total of 49,785 patients were included across all the studies. The certainty of the evidence varied between very low and moderate. Many of the studies included in the review were at risk of performance and detection bias. The evidence suggests moderate certainty that PROMs feedback probably improves quality of life (standardised mean difference (SMD) 0.15, 95% confidence interval (CI) 0.05 to 0.26; 11 studies; 2687 participants), and leads to an increase in patient-physician communication (SMD 0.36, 95% CI 0.21 to 0.52; 5 studies; 658 participants), diagnosis and notation (risk ratio (RR) 1.73, 95% CI 1.44 to 2.08; 21 studies; 7223 participants), and disease control (RR 1.25, 95% CI 1.10 to 1.41; 14 studies; 2806 participants). The intervention probably makes little or no difference for general health perceptions (SMD 0.04, 95% CI -0.17 to 0.24; 2 studies, 552 participants; low-certainty evidence), social functioning (SMD 0.02, 95% CI -0.06 to 0.09; 15 studies; 2632 participants; moderate-certainty evidence), and pain (SMD 0.00, 95% CI -0.09 to 0.08; 9 studies; 2386 participants; moderate-certainty evidence). We are uncertain about the effect of PROMs feedback on physical functioning (14 studies; 2788 participants) and mental functioning (34 studies; 7782 participants), as well as fatigue (4 studies; 741 participants), as the certainty of the evidence was very low. We did not find studies reporting on adverse effects defined as distress following or related to PROM completion.

AUTHORS' CONCLUSIONS

PROM feedback probably produces moderate improvements in communication between healthcare professionals and patients as well as in diagnosis and notation, and disease control, and small improvements to quality of life. Our confidence in the effects is limited by the risk of bias, heterogeneity and small number of trials conducted to assess outcomes of interest. It is unclear whether   many of these improvements are clinically meaningful or sustainable in the long term. There is a need for more high-quality studies in this area, particularly studies which employ cluster designs and utilise techniques to maintain allocation concealment.

Personalizing Psychological Care for Chronic Cancer-Related Fatigue: A Case Study on Symptom Dynamics

Approximately 25% of cancer patients suffer from chronic cancer-related fatigue (CCRF), which is a complex, multifactorial condition. While there are evidence-based interventions, it remains unclear what treatment works best for the individual patient. Psychological network models can offer a schematic representation of interrelations among fatigue and protective and perpetuating factors for the individual patient. We explored whether feedback based on these individual fatigue networks can help personalize psychological care for CCRF. A 34-year old woman with CCRF was referred to our mental healthcare institute for psycho-oncology. During the waitlist period, she filled out an experience sampling app for 101 days, including five daily assessments of fatigue, pain, mood, activity and fatigue coping. The interplay between items was visualized in network graphs at the moment-level and day-level, which were discussed with the patient. For example, acceptance of fatigue in the past three hours was associated with less hopelessness and less fatigue in the following moment. At the day-level, acceptance was also being associated with less fatigue, less hopelessness, a better mood, and more motivation to do things. The patient recognized these patterns and explained how unexpected waves of fatigue can make her feel hopeless. This started a dialogue on how cultivating acceptance could potentially help her handle the fatigue. The patient would discuss this with her therapist. Feedback based on individual fatigue networks can provide direct insight into how one copes with CCRF and subsequently offer directions for treatment. Further research is needed in order to implement this in clinical practice.

Patients' experience of an ecological momentary intervention involving self-monitoring and personalized feedback for depression

Experts in clinical mental health research count on personalized approaches based on self-monitoring and self-management to improve treatment efficacy in psychiatry. Among other things, researchers expect that Ecological Momentary Interventions (EMI) based on self-monitoring and personalized feedback will reduce depressive symptoms. Clinical trial findings have, however, been conflicting. A recent trial (ZELF-i) investigated whether depression treatment might be enhanced by an add-on EMI with self-monitoring items and feedback focused on positive affect and activities (Do-module) or on negative affect and thinking patterns (Think-module). There was no statistical evidence that this EMI impacted clinical or functional outcomes beyond the effects of regular care, regardless of module content. In apparent contrast, 86% of the participants who completed the intervention indicated they would recommend it to others. In the present study, we used in-depth interviews (n = 20) to better understand the EMI's personal and clinical benefits and downsides. A thematic analysis of the interviews generated six areas of impact with various subthemes. In line with the trial results, few participants reported behavioral changes or symptom improvement over time; the self-assessments mainly amplified momentary mood, in either direction. The most often mentioned benefits were an increase in self-awareness, insight, and self-management (e.g., a stronger sense of control over complaints). Consistently, these domains received the highest ratings in our evaluation questionnaire (n = 89). Furthermore, the EMI instilled a routine into the days of individuals without regular jobs or other activities. Participants reported few downsides. The experiences were rather similar between the two modules. This study suggests that EMI might contribute to health by helping individuals deal with their symptoms, rather than reducing them. Measures on self-awareness, insight, and self-management should be more emphatically involved in future EMI research.

Zoom or In-Person: An Ecological Momentary Assessment Study of Time with Friends and Depressive Symptoms on Affect in Emerging Adults

INTRODUCTION

Depression is associated with increased negative affect (NA) and low positive affect (PA), as well as interpersonal difficulties. Although most studies examine symptoms and affect at only one time point, ecological momentary assessment (EMA) captures data on affect and activity in real time and across contexts. The present study used EMA to explore the links between in-person and virtual social interactions, depressive symptoms, and momentary affect.

METHODS

Emerging adults (N=86) completed a self-report measure of both general depression and dysphoria symptoms, followed by EMA surveys 8 times daily for one week, reporting momentary affect (PA and NA) and social context (in-person and virtual interactions with friends).

RESULTS

In-person, but not virtual, presence of friends was associated with increased PA overall. Depressive symptoms were linked to less time with in-person friends and elevated NA. There was also a significant interaction between in-person presence of friends and dysphoria in predicting NA, such that presence of in-person friends was associated with lower NA only for those low in dysphoria.

DISCUSSION

Findings suggest that time with in-person friends is associated with increased PA overall and decreased NA only for those lower in depressive symptoms, but these effects do not generalize to virtual interactions. Those with greater depressive symptoms may be less responsive to positive stimuli and experience less of an effect of friends' presence on affect. Alternatively, maladaptive social behaviors characteristic of depression may influence the effect of social interactions on affect.

Ecological Momentary Assessment Using Smartphones in Patients With Depression: Feasibility Study

Background

Ecological momentary assessment (EMA) is a promising tool in the management of psychiatric disorders and particularly depression. It allows for a real-time evaluation of symptoms and an earlier detection of relapse or treatment efficacy. The generalization of the smartphone in the modern world offers a new, large-scale support for EMA.

Objective

The main objective of this study was twofold: (1) to assess patients’ compliance with an EMA smartphone app defined by the number of EMAs completed, and (2) to estimate the external validity of the EMA using a correlation between self-esteem/guilt/mood variables and Hamilton Depression Rating Scale (HDRS) score.

Methods

Eleven patients at the Pitié-Salpêtrière Hospital, Paris, France, were monitored for 28 days by means of a smartphone app. Every patient enrolled in the study had two types of assessment: (1) three outpatient consultations with a psychiatrist at three different time points (days 1, 15, and 28), and (2) real-time data collection using an EMA smartphone app with a single, fixed notification per day at 3 pm for 28 days. The results of the real-time data collected were reviewed during the three outpatient consultations by a psychiatrist using a dashboard that aggregated all of the patients’ data into a user-friendly format.

Results

Of the 11 patients in the study, 6 patients attended the 3 outpatient consultations with the psychiatrist and completed the HDRS at each consultation. We found a positive correlation between the HDRS score and the variables of self-esteem, guilt, and mood (Spearman correlation coefficient 0.57). Seven patients completed the daily EMAs for 28 days or longer, with an average response rate to the EMAs of 62.5% (175/280). Furthermore, we observed a positive correlation between the number of responses to EMAs and the duration of follow-up (Spearman correlation coefficient 0.63).

Conclusions

This preliminary study with a prolonged follow-up demonstrates significant patient compliance with the smartphone app. In addition, the self-assessments performed by patients seemed faithful to the standardized measurements performed by the psychiatrist. The results also suggest that for some patients it is more convenient to use the smartphone app than to attend outpatient consultations.

A Long-Term, Real-Life Parkinson Monitoring Database Combining Unscripted Objective and Subjective Recordings

Accurate real-life monitoring of motor and non-motor symptoms is a challenge in Parkinson’s disease (PD). The unobtrusive capturing of symptoms and their naturalistic fluctuations within or between days can improve evaluation and titration of therapy. First-generation commercial PD motion sensors are promising to augment clinical decision-making in general neurological consultation, but concerns remain regarding their short-term validity, and long-term real-life usability. In addition, tools monitoring real-life subjective experiences of motor and non-motor symptoms are lacking. The dataset presented in this paper constitutes a combination of objective kinematic data and subjective experiential data, recorded parallel to each other in a naturalistic, long-term real-life setting. The objective data consists of accelerometer and gyroscope data, and the subjective data consists of data from ecological momentary assessments. Twenty PD patients were monitored without daily life restrictions for fourteen consecutive days. The two types of data can be used to address hypotheses on naturalistic motor and/or non-motor symptomatology in PD.

Screening accuracy of a 14-day smartphone ambulatory assessment of depression symptoms and mood dynamics in a general population sample: Comparison with the PHQ-9 depression screening

Introduction

Major depression affects over 300 million people worldwide, but cases are often detected late or remain undetected. This increases the risk of symptom deterioration and chronification. Consequently, there is a high demand for low threshold but clinically sound approaches to depression detection. Recent studies show a great willingness among users of mobile health apps to assess daily depression symptoms. In this pilot study, we present a provisional validation of the depression screening app Moodpath. The app offers a 14-day ambulatory assessment (AA) of depression symptoms based on the ICD-10 criteria as well as ecologically momentary mood ratings that allow the study of short-term mood dynamics.

Materials and methods

N = 113 Moodpath users were selected through consecutive sampling and filled out the Patient Health Questionnaire (PHQ-9) after completing 14 days of AA with 3 question blocks (morning, midday, and evening) per day. The psychometric properties (sensitivity, specificity, accuracy) of the ambulatory Moodpath screening were assessed based on the retrospective PHQ-9 screening result. In addition, several indicators of mood dynamics (e.g. average, inertia, instability), were calculated and investigated for their individual and incremental predictive value using regression models.

Results

We found a strong linear relationship between the PHQ-9 score and the AA Moodpath depression score (r = .76, p < .001). The app-based screening demonstrated a high sensitivity (.879) and acceptable specificity (.745). Different indicators of mood dynamics covered substantial amounts of PHQ-9 variance, depending on the number of days with mood data that were included in the analyses.

Discussion

AA and PHQ-9 shared a large proportion of variance but may not measure exactly the same construct. This may be due to the differences in the underlying diagnostic systems or due to differences in momentary and retrospective assessments. Further validation through structured clinical interviews is indicated. The results suggest that ambulatory assessed mood indicators are a promising addition to multimodal depression screening tools. Improving app-based AA screenings requires adapted screening algorithms and corresponding methods for the analysis of dynamic processes over time.

An evaluation of the efficacy of two add-on ecological momentary intervention modules for depression in a pragmatic randomized controlled trial (ZELF-i)

BACKGROUND

Depression treatment might be enhanced by ecological momentary interventions (EMI) based on self-monitoring and person-specific feedback. This study is the first to examine the efficacy of two different EMI modules for depression in routine clinical practice.

METHODS

Outpatients starting depression treatment at secondary mental health services (N = 161; MIDS-DEPRESSION = 35.9, s.d. = 10.7; MAGE = 32.8, s.d. = 12.1; 46% male) participated in a pragmatic randomized controlled trial with three arms. Two experimental groups engaged in 28 days of systematic self-monitoring (5 times per day), and received weekly feedback on either positive affect and activities (Do-module) or negative affect and thinking patterns (Think-module). The control group received no additional intervention. Participants completed questionnaires on depressive symptoms (primary outcome), social functioning, and empowerment before and after the intervention period, and at four measurements during a 6-month follow-up period.

RESULTS

Of the 90 (out of 110) participants who completed the intervention, 86% would recommend it. However, the experimental groups did not show significantly more or faster changes over time than the control group in terms of depressive symptoms, social functioning, and empowerment. Furthermore, the trajectories of the two EMI modules were very similar.

CONCLUSIONS

We did not find statistical evidence that this type of EMI augments the efficacy of regular depression treatment, regardless of module content. We cannot rule out that EMIs have a positive impact on other domains or provide a more efficient way of delivering care. Nonetheless, EMI's promise of effectiveness has not materialized yet.

Affect Recall Bias: Being Resilient by Distorting Reality

Background

According to a growing body of literature, people are quite inaccurate in recalling past affective experiences. Nevertheless, the mechanism underlying this recall bias (i.e., the tendency to overestimate and/or underestimate positive or negative past emotional experiences) remains unclear, and its association with mental health has not been studied yet.

Methods

We adopted a smartphone-based Ecological Momentary Assessment to monitor daily affect (n = 92) and investigate the association between affect recall bias, mental health and resilience.

Results

While the tendency to overestimate negative affective experiences was observed in participants reporting mild depressive symptoms, positive affect (PA) overestimation as compared to PA underestimation was associated with better mental health (i.e. higher psychological well-being and lower depressive and anxiety symptoms) through the enhancement of resilience. Furthermore, positively biased participants (i.e. PA over estimators) benefited from greater well-being, even when compared to accurate individuals.

Conclusions

While people appear to use retrospective PA overestimation as a strategy to enhance well-being and resilience, they are not likely to underestimate past negative experiences to feel better. Accordingly, owning an optimistic vision of the past may represent an adaptive “distortion” of reality that fosters people’s mental health. The clinical implications of cultivating PA and learning strategies to regulate both negative and positive emotions are discussed.

Mobile Health Daily Life Monitoring for Parkinson Disease: Development and Validation of Ecological Momentary Assessments

BACKGROUND

Parkinson disease monitoring is currently transitioning from periodic clinical assessments to continuous daily life monitoring in free-living conditions. Traditional Parkinson disease monitoring methods lack intraday fluctuation detection. Electronic diaries (eDiaries) hold the potential to collect subjective experiences on the severity and burden of motor and nonmotor symptoms in free-living conditions.

OBJECTIVE

This study aimed to develop a Parkinson disease-specific eDiary based on ecological momentary assessments (EMAs) and to explore its validation.

METHODS

An observational cohort of 20 patients with Parkinson disease used the smartphone-based EMA eDiary for 14 consecutive days without adjusting free-living routines. The eDiary app presented an identical questionnaire consisting of questions regarding affect, context, motor and nonmotor symptoms, and motor performance 7 times daily at semirandomized moments. In addition, patients were asked to complete a morning and an evening questionnaire.

RESULTS

Mean affect correlated moderate-to-strong and moderate with motor performance (R=0.38 to 0.75; P<.001) and motor symptom (R=0.34 to 0.50; P<.001) items, respectively. The motor performance showed a weak-to-moderate negative correlation with motor symptoms (R=-0.31 to -0.48; P<.001). Mean group answers given for on-medication conditions vs wearing-off-medication conditions differed significantly (P<.05); however, not enough questionnaires were completed for the wearing-off-medication condition to reproduce these findings on individual levels.

CONCLUSIONS

We presented a Parkinson disease-specific EMA eDiary. Correlations between given answers support the internal validity of the eDiary and underline EMA's potential in free-living Parkinson disease monitoring. Careful patient selection and EMA design adjustment to this targeted population and their fluctuations are necessary to generate robust proof of EMA validation in future work. Combining clinical Parkinson disease knowledge with practical EMA experience is inevitable to design and perform studies, which will lead to the successful integration of eDiaries in free-living Parkinson disease monitoring.

Implementing Experience Sampling Technology for Functional Analysis in Family Medicine - A Design Thinking Approach

BACKGROUND

A paradigm shift in health care from illness to wellbeing requires new assessment technologies and intervention strategies. Self-monitoring tools based on the Experience Sampling Method (ESM) might provide a solution. They enable patients to monitor both vulnerability and resilience in daily life. Although ESM solutions are extensively used in research, a translation from science into daily clinical practice is needed.

OBJECTIVE

To investigate the redesign process of an existing platform for ESM data collection for detailed functional analysis and disease management used by psychological assistants to the general practitioner (PAGPs) in family medicine.

METHODS

The experience-sampling platform was reconceptualized according to the design thinking framework in three phases. PAGPs were closely involved in co-creation sessions. In the 'understand' phase, knowledge about end-users' characteristics and current eHealth use was collected (nominal group technique - 2 sessions with N = 15). In the 'explore' phase, the key needs concerning the platform content and functionalities were evaluated and prioritized (empathy mapping - 1 session with N = 5, moderated user testing - 1 session with N = 4). In the 'materialize' phase, the adjusted version of the platform was tested in daily clinical practice (4 months with N = 4). The whole process was extensively logged, analyzed using content analysis, and discussed with an interprofessional project group.

RESULTS

In the 'understand' phase, PAGPs emphasized the variability in symptoms reported by patients. Therefore, moment-to-moment assessment of mood and behavior in a daily life context could be valuable. In the 'explore' phase, (motivational) functionalities, technological performance and instructions turned out to be important user requirements and could be improved. In the 'materialize' phase, PAGPs encountered barriers to implement the experience-sampling platform. They were insufficiently facilitated by the regional primary care group and general practitioners.

CONCLUSION

The redesign process in co-creation yielded meaningful insights into the needs, desires and daily routines in family medicine. Severe barriers were encountered related to the use and uptake of the experience-sampling platform in settings where health care professionals lack the time, knowledge and skills. Future research should focus on the applicability of this platform in family medicine and incorporate patient experiences.

Client experiences of blending a coping-focused therapy for auditory verbal hallucinations with smartphone-based ecological momentary assessment and intervention

This study explored participants' experiences of a novel intervention blending ecological momentary assessment and intervention (EMA/I) digital technologies with four face-to-face therapy sessions to improve coping in people who experience persisting auditory verbal hallucinations (hear voices). A smartphone app was used to deliver prompts to facilitate both self-monitoring and self-management of voices. Analysis of data recorded by the app was also used in-session to develop an idiographic formulation of antecedents of and responses to voice-hearing episodes. Semi-structured interviews were conducted with 12 participants who completed the blended therapy. A thematic approach was used to analyse the data, generating four main themes, with associated subthemes: (1) Therapy experience changed by digital technology; (2) Valuing face-to-face component; (3) Preference for different phases of the digital technology; (4) Not as bothered by voices. Key findings revealed that participants perceived EMA/I technology as helping capture their experience more accurately and communicate this more effectively to the therapist, which, in combination with coping prompts developed in-session, deepened the therapeutic relationship. These findings add to the emerging literature that shows blended therapy can play an important role in the treatment of people with psychosis, and suggest potential of EMA/I as a technology for other clinical populations.

Insights of Patients and Clinicians on the Promise of the Experience Sampling Method for Psychiatric Care

OBJECTIVE

This qualitative study aimed to map the relevance of the experience sampling method (ESM) for psychiatric practice and identify barriers and facilitators for implementation, as perceived by patients and clinicians.

METHODS

Participants were 22 patients with various diagnoses and 21 clinicians (e.g., psychiatrists, psychologists) who participated in interviews or focus groups. Using Atlas.TI, the authors conducted qualitative thematic analysis to analyze the transcripts, resulting in four themes: applications, advantages, undesirable effects, and requirements for implementation of ESM in care.

RESULTS

Clinicians and patients believed ESM could be relevant in every phase of care to increase patients' awareness, insight, and self-management; personalize interventions; and alert patients to rising symptoms. Further, ESM was expected to improve the patient-clinician relationship; lead to objective, personalized, reliable and visual data; and increase efficiency of care. However, participants warned against high assessment burden and potential symptom worsening.

CONCLUSIONS

This study provides first evidence that the potential of ESM is recognized by both patients and clinicians. Key recommendations for optimal implementation of ESM in psychiatric care include flexible application of ESM, collaboration between patient and clinician, regular evaluation, awareness of negative reactivity, availability to patients with different psychiatric syndromes, and implementation by an interdisciplinary team of patients, clinicians, researchers, and information technology specialists.

Using Intensive Longitudinal Data to Study Treatment Effects in Patients with Major Depression: A Systematic Review

Depression is a disabling condition, causing suffering worldwide. The purpose of this paper is to review studies that have used Intensive Longitudinal Data (ILD) in research on depression treatment. Intensive longitudinal data in the form of daily diaries, experience sampling method (ESM), and ecological momentary assessment (EMA) are increasingly used in psychotherapy research to gather individualized data. A systematic search was conducted in the research databases PsycINFO, PubMed and Scopus on depression treatment assessed with ILD methods. Seven studies met inclusion criteria; two focused on the effects of cognitive therapy/cognitive behavioral therapy (CBT)/Self-System Therapy (SST); one focused on the effects of physical exercise; and four examined ESM as an add-on intervention to pharmacological treatment. ILD is useful when studying changes in complex patterns of patients’ functioning, such as daily affective reactivity, empowerment, daily dose-response effects of physical activity on PA, and associations between activity and depressive symptoms. Results also showed that ESM registration in itself can help patients with major depression (MDD) to engage more in physical and social activities and to spend less time alone or resting.

Current State and Future Directions of Technology-Based Ecological Momentary Assessment and Intervention for Major Depressive Disorder: A Systematic Review

Ecological momentary assessment (EMA) and ecological momentary intervention (EMI) are alternative approaches to retrospective self-reports and face-to-face treatments, and they make it possible to repeatedly assess patients in naturalistic settings and extend psychological support into real life. The increase in smartphone applications and the availability of low-cost wearable biosensors have further improved the potential of EMA and EMI, which, however, have not yet been applied in clinical practice. Here, we conducted a systematic review, using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines, to explore the state of the art of technology-based EMA and EMI for major depressive disorder (MDD). A total of 33 articles were included (EMA = 26; EMI = 7). First, we provide a detailed analysis of the included studies from technical (sampling methods, duration, prompts), clinical (fields of application, adherence rates, dropouts, intervention effectiveness), and technological (adopted devices) perspectives. Then, we identify the advantages of using information and communications technologies (ICTs) to extend the potential of these approaches to the understanding, assessment, and intervention in depression. Furthermore, we point out the relevant issues that still need to be addressed within this field, and we discuss how EMA and EMI could benefit from the use of sensors and biosensors, along with recent advances in machine learning for affective modelling.

Smartphone-based ecological momentary assessment and intervention in a blended coping-focused therapy for distressing voices: Development and case illustration

Common approaches to the psychological treatment of distressing voice hearing experiences, such as cognitive behavioural therapy, aim to promote more adaptive cognitive, emotional and behavioural responses to these experiences. Digital technologies such as smartphones show promise for supporting and enhancing these treatments by linking immediate therapeutic settings to the context of daily life. Two promising technologies include ecological momentary assessment and intervention (EMA/I), which may offer a means of advanced assessment and support in daily life, and inform the tailoring of interventions to suit individual needs. In this study, a highly novel intervention approach was developed involving four face-to-face sessions with a psychologist blended with EMA/I between sessions in order to improve coping with distressing voice hearing experiences. The authors describe the background and development of this approach along-side a single case illustration, which supported feasibility and acceptability. This study details how digital technologies such as EMA/I may be used in future as clinical tools to enhance standard psychological treatments and clinical care of people with persisting and distressing experiences.

Self-monitoring and personalized feedback based on the experiencing sampling method as a tool to boost depression treatment: a protocol of a pragmatic randomized controlled trial (ZELF-i)

BACKGROUND

Depression is a leading cause of disability worldwide. To reduce the societal burden and improve quality of life for individual patients, treatments for depression need to be optimized. There is a particular need for person-tailored interventions that reinforce self-management of patients. Systematic self-monitoring and personalized feedback through the Experience Sampling Method (ESM) could provide such a person-tailored, empowering intervention that enhances treatment outcomes. The primary aim of this study is to investigate the efficacy of self-monitoring and personalized feedback as an add-on tool in the treatment of depressive complaints in a natural setting.

METHODS

The ZELF-i study is a pragmatic multi-site randomized controlled trial (RCT). We aim to recruit 150 individuals with depressive symptoms aged between 18 and 65 years, who have an intake for outpatient basic or specialized treatment at a mental health care organization in the North of the Netherlands. After the intake, participants will be randomly allocated to one of three study arms: two experimental groups engaging in 28 days of systematic self-monitoring (5 times per day) and receiving weekly personalized feedback on positive affect and activities ("Do"-module) or on negative affect and thinking patterns ("Think"-module), and a control group receiving no additional intervention. Self-report inventories of depressive symptoms, psychosocial functioning and feelings of empowerment will be administered before and after the intervention period, and at follow-up measurements at 1, 2, 3 and 6 months. The patient-experienced utility of the intervention will be investigated by a combination of quantitative and qualitative research methods.

DISCUSSION

The present study is the first to examine the effects of add-on self-monitoring and personalized feedback on depressive complaints in clinical practice. It is also the first to evaluate two different ESM modules targeted at both of depression's core symptoms. Lastly, it is the first study that uses a combination of qualitative and quantitative methods to evaluate the patient-experienced utility of ESM with personalized feedback as an intervention for depression. Results of the present study may improve treatment for depression, if the intervention is found to be effective.

TRIAL REGISTRATION

Dutch Trial Register, NTR5707 , registered prospectively 1 February 2016.

Ecological assessment of daily suicidal thoughts and attempts among suicidal teens after psychiatric hospitalization: Lessons about feasibility and acceptability

Despite its potential to yield information about the dynamic course of suicidal ideation/behavior in individuals' natural environment, Ecological Momentary Assessment (EMA) has been strikingly underutilized among suicidal teens. This study reports on feasibility and acceptability of ecological assessment of daily suicide risk-related outcomes ("daily diaries," a special case of EMA) among adolescent inpatients in the critical post-discharge period. Thirty-four adolescents (76% female; ages 13-17) responded to daily electronic surveys for four weeks after discharge. Survey adherence was 69% (n = 650 days) and decreased each week. Adherence was half as likely among adolescents without attempt history (OR = 0.50, CI = 0.27-0.95). Mid- and end-point study responses indicated high acceptability of daily diaries. Most adolescents reported no change or more positive change in their thoughts/mood after daily surveys. Suicidal ideation was reported on 24.4% (n = 159) of the days. In the month post discharge, more teens reported suicidal thoughts using daily surveys (70.6%) compared to end-of-study assessment (45.2%) (Chi-square = 4.24, p = .039). Two participants (5.9%) reported an attempt. Ideation frequency and duration varied across time, suggesting utility of frequent assessments in this context. EMA data collection with high-risk adolescents offers a feasible approach to examining real-time suicidal ideation/behavior, yielding nuanced information that is critical to advancing suicide prevention efforts.

Use of the experience sampling method in the context of clinical trials

Objective

The experience sampling method (ESM) is a structured diary technique to appraise subjective experiences in daily life. It is applied in psychiatric patients, as well as in patients with somatic illness. Despite the potential of ESM assessment, the improved logistics and its increased administration in research, its use in clinical trials remains limited. This paper introduces ESM for clinical trials in psychiatry and beyond.

Methods

ESM is an ecologically valid method that yields a comprehensive view of an individual's daily life. It allows the assessment of various constructs (eg, quality of life, psychopathology) and psychological mechanisms (eg, stress-sensitivity, coping). These constructs are difficult to assess using cross-sectional questionnaires. ESM can be applied in treatment monitoring, as an ecological momentary intervention, in clinical trials, or in single case clinical trials. Technological advances (eg, smartphone applications) make its implementation easier.

Results

Advantages of ESM are highlighted and disadvantages are discussed. Furthermore, the ecological nature of ESM data and its consequences are explored, including the potential pitfalls of ambiguously formulated research questions and the specificities of ESM in statistical analyses. The last section focuses on ESM in relation to clinical trials and discusses its future use in optimising clinical decision-making.

Conclusions

ESM can be a valuable asset in clinical trial research and should be used more often to study the benefits of treatment in psychiatry and somatic health.

Imagine your mood: Study design and protocol of a randomized controlled micro-trial using app-based experience sampling methodology to explore processes of change during relapse prevention interventions for recurrent depression

Background

Relapse prevention strategies include continuation of antidepressant medication and preventive psychological interventions. This study aims to gain understanding that may inform tailoring of relapse prevention to individual differences, to improve their effects. Such treatment personalization may be based on repeated assessments within one individual, using experience sampling methodology. As a first step towards informing decisions based on this methodology, insight is needed in individual differences in risk of relapse and response to treatment, and how relapse prevention strategies may differentially target vulnerability for relapse.

Methods

The smartphone application ‘Imagine your mood’ has been developed specifically for this study to assess emotions, imagery, cognitions, and behaviors in daily life. Parallel to the randomized controlled trial ‘Disrupting the rhythm of depression’, 45 remitted recurrently depressed individuals taking continuation antidepressant medication will be randomly assigned to either continuing antidepressant medication (n = 15), continuing antidepressant medication combined with an eight-session preventive cognitive therapy (n = 15), or tapering of antidepressant medication in combination with preventive cognitive therapy (n = 15). Relapse and return of depressive symptomatology over a 24-month follow-up will be assessed. Additionally, matched never depressed individuals (n = 15) will be recruited as controls.

Discussion

This innovative study combines the strengths of a randomized controlled trial and experience sampling methodology in a micro-trial to explore individual differences in risk of relapse and what works for whom to prevent relapse. Results may ultimately pave the way for therapists to tailor relapse prevention strategies to individual (affective) vulnerability.

Trial registration

ISRCTN15472145, retrospectively registered.

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

BACKGROUND

The experience sampling method (ESM) builds an intensive time series of experiences and contexts in the flow of daily life, typically consisting of around 70 reports, collected at 8-10 random time points per day over a period of up to 10 days.

METHODS

With the advent of widespread smartphone use, ESM can be used in routine clinical practice. Multiple examples of ESM data collections across different patient groups and settings are shown and discussed, varying from an ESM evaluation of a 6-week randomized trial of mindfulness, to a twin study on emotion dynamics in daily life.

RESULTS

Research shows that ESM-based self-monitoring and feedback can enhance resilience by strengthening the capacity to use natural rewards. Personalized trajectories of starting or stopping medication can be more easily initiated and predicted if sensitive feedback data are available in real time. In addition, personalized trajectories of symptoms, cognitive abilities, symptoms impacting on other symptoms, the capacity of the dynamic system of mental health to "bounce back" from disturbance, and patterns of environmental reactivity yield uniquely personal data to support shared decision making and prediction in clinical practice. Finally, ESM makes it possible to develop insight into previous implicit patterns of thought, experience, and behavior, particularly if rapid personalized feedback is available.

CONCLUSIONS

ESM enhances clinical practice and research. It is empowering, providing co-ownership of the process of diagnosis, treatment evaluation, and routine outcome measurement. Blended care, based on a mix of face-to-face and ESM-based outside-the-office treatment, may reduce costs and improve outcomes.

Usability, Acceptability, and Adherence to an Electronic Self-Monitoring System in Patients With Major Depression Discharged From Inpatient Wards

Background

Patients suffering from depression have a high risk of relapse and readmission in the weeks following discharge from inpatient wards. Electronic self-monitoring systems that offer patient-communication features are now available to offer daily support to patients, but the usability, acceptability, and adherence to these systems has only been sparsely investigated.

Objective

We aim to test the usability, acceptability, adherence, and clinical outcome of a newly developed computer-based electronic self-assessment system (the Daybuilder system) in patients suffering from depression, in the period from discharge until commencing outpatient treatment in the Intensive Outpatient Unit for Affective Disorders.

Methods

Patients suffering from unipolar major depression that were referred from inpatient wards to an intensive outpatient unit were included in this study before their discharge, and were followed for four weeks. User satisfaction was assessed using semiqualitative questionnaires and the System Usability Scale (SUS). Patients were interviewed at baseline and at endpoint with the Hamilton depression rating scale (HAM-D17), the Major Depression Inventory (MDI), and the 5-item World Health Organization Well-Being Index (WHO-5). In this four-week period patients used the Daybuilder system to self-monitor mood, sleep, activity, and medication adherence on a daily basis. The system displayed a graphical representation of the data that was simultaneously displayed to patients and clinicians. Patients were phoned weekly to discuss their data entries. The primary outcomes were usability, acceptability, and adherence to the system. The secondary outcomes were changes in: the electronically self-assessed mood, sleep, and activity scores; and scores from the HAM-D17, MDI, and WHO-5 scales.

Results

In total, 76% of enrolled patients (34/45) completed the four-week study. Five patients were readmitted due to relapse. The 34 patients that completed the study entered data for mood on 93.8% of the days (872/930), sleep on 89.8% of the days (835/930), activity on 85.6% of the days (796/930), and medication on 88.0 % of the days (818/930). SUS scores were 86.2 (standard deviation [SD] 9.7) and 79% of the patients (27/34) found that the system lived up to their expectations. A significant improvement in depression severity was found on the HAM-D17 from 18.0 (SD 6.5) to 13.3 (SD 7.3; P<.01), on the MDI from 27.1 (SD 13.1) to 22.1 (SD 12.7; P=.006), and in quality of life on the WHO-5 from 31.3 (SD 22.9) to 43.4 (SD 22.1; P<.001) scales, but not on self-assessed mood (P=.08). Mood and sleep parameters were highly variable from day-to-day. Sleep-offset was significantly delayed from baseline, averaging 48 minutes (standard error 12 minutes; P<.001). Furthermore, when estimating delay of sleep-onset (with sleep quality included in the model) during the study period, this showed a significant negative effect on mood (P=.03)

Conclusions

The Daybuilder systems performed well technically, and patients were satisfied with the system and had high adherence to self-assessments. The dropout rate and the gradual delay in sleep emphasize the need for continued clinical support for these patients, especially when considering sleep guidance.