A pilot study using ecological momentary assessment via smartphone application to identify adolescent problematic internet use

Mobile app measuring sleep and behaviors: A trial in adolescents with addiction

INTRODUCTION

The smartphones generalisation allows the development of attractive "real-life" monitoring tools for care and research enabling the measurement of addictive behaviours and comorbidities such as sleep disorders. The study objective was to assess the interest of a mobile app collecting such information among adolescents with addictive behaviours in order to enhance the availability of behavioural data in consultation.

METHODS

An open label randomised pilot study was held along two parallel arms. The patients randomised to the intervention group (n=18) used a mobile app to provide daily data for 15 days relating to their sleep and their behaviour (addictive behaviours with or without substances). The patients in the control group (n=18) used a paper diary allowing the collection of the same data, only the medium differed.

RESULTS

The patients' median age was 16 years [15.0-16.5]. A median of 67% and 10% of the expected information was completed respectively in the intervention and control groups during the 15 days of follow-up and could be used in consultation (P=0.08). The patient's knowledge, attitudes, intentions to change, behaviour change and seeking help related to the use of the diaries appeared higher in the intervention group (20.5/30) than in the control group (11/20).

CONCLUSION

This study described the high patient compliance with the data collection by means of the app. The diary app seems to have been more impactful for patients than the paper diary. This app could represent an important tool to improve the therapeutic alliance and care due to a better knowledge of the behaviours on the part of the clinician but also a better awareness of the patients themselves.

Anxiety and restrained eating in everyday life: An ecological momentary assessment study

BACKGROUND

Restrained eating has been related to psychological distress like anxiety and eating disorder symptomatology, but little is known about this relationship in daily life in non-clinical populations. We aimed to understand concurrent and temporal associations between momentary anxiety and restrained eating in everyday life within and across persons in a non-clinical sample, and examined whether this association remains after controlling for eating disorder symptomatology.

METHODS

We used a 10-day ecological momentary assessment (EMA) protocol. Participants (n = 123) completed a baseline survey with demographics and eating disorder symptomatology questions, and three EMA surveys per day reporting anxiety and restrained eating intentions. We applied mixed-effects and random intercept cross-lagged models to analyze the data.

RESULTS

Momentary anxiety and restrained eating were concurrently significantly positively associated within and between persons. When participants had more anxiety than was typical for them, they were more likely to intend to restrain eating, and people with overall higher anxiety symptoms tended to report greater restrained eating over the study period. These associations remained significant after adjusting for eating disorder symptomatology. There were no significant temporal cross-lagged effects. Anxiety-restrained eating association did not spill over into the next assessment window.

LIMITATIONS

The time window between prompts may have been too long to capture potential temporal effects, and we did not examine actual behavioral food restrictions.

CONCLUSION

Daily-life anxiety may be related to concurrent restrained eating intentions, above and beyond baseline eating disorder symptomatology. Research is needed exploring daily-life anxiety as a potential intervention target to address restrained eating.

Transforming Digital Phenotyping Raw Data Into Actionable Biomarkers, Quality Metrics, and Data Visualizations Using Cortex Software Package: Tutorial

As digital phenotyping, the capture of active and passive data from consumer devices such as smartphones, becomes more common, the need to properly process the data and derive replicable features from it has become paramount. Cortex is an open-source data processing pipeline for digital phenotyping data, optimized for use with the mindLAMP apps, which is used by nearly 100 research teams across the world. Cortex is designed to help teams (1) assess digital phenotyping data quality in real time, (2) derive replicable clinical features from the data, and (3) enable easy-to-share data visualizations. Cortex offers many options to work with digital phenotyping data, although some common approaches are likely of value to all teams using it. This paper highlights the reasoning, code, and example steps necessary to fully work with digital phenotyping data in a streamlined manner. Covering how to work with the data, assess its quality, derive features, and visualize findings, this paper is designed to offer the reader the knowledge and skills to apply toward analyzing any digital phenotyping data set. More specifically, the paper will teach the reader the ins and outs of the Cortex Python package. This includes background information on its interaction with the mindLAMP platform, some basic commands to learn what data can be pulled and how, and more advanced use of the package mixed with basic Python with the goal of creating a correlation matrix. After the tutorial, different use cases of Cortex are discussed, along with limitations. Toward highlighting clinical applications, this paper also provides 3 easy ways to implement examples of Cortex use in real-world settings. By understanding how to work with digital phenotyping data and providing ready-to-deploy code with Cortex, the paper aims to show how the new field of digital phenotyping can be both accessible to all and rigorous in methodology.

Review: Digital experiences and their impact on the lives of adolescents with pre-existing anxiety, depression, eating and nonsuicidal self-injury conditions - a systematic review

BACKGROUND

Published systematic reviews provide evidence linking positive and negative digital experiences to adolescent mental health. However, these reviews focus on the general public rather than the digital experiences of adolescents with different pre-existing mental health conditions and so may be limited in their clinical relevance. We review publications relating to anxiety, depression, eating disorders and nonsuicidal self-injury to identify common and condition-specific digital experiences and how these may be implicated in the origins and maintenance of these mental health conditions.

METHODS

A systematic literature search using a combination of mental health, digital experience (including social media use), and age of the target population terms was conducted on four databases. Detailed findings from the included studies were summarised using a combination of thematic and narrative methods.

RESULTS

Five qualitative and 21 quantitative studies met the eligibility criteria for inclusion (n = 5021). Nine studies included adolescents with depression, one with eating problems, two with nonsuicidal self-injury and 14 with multiple emotional health conditions. The review identified six themes related to the target populations' digital experiences: (a) social connectivity and peer support; (b) escape and/or distraction; (c) social validation and social comparison; (d) accessing/creation of potentially harmful content; (e) cyberbullying; and (f) difficulties with self-regulation during engagement with digital media.

CONCLUSIONS

Digital practices of adolescents with pre-existing clinical vulnerabilities are complex and encompass a range of positive and negative experiences, which appear to have common elements across different clinical populations. The literature is currently too limited to identify disorder-specific practices, with too few direct or indirect comparisons between conditions.

Relationship between depressive symptoms and internet usage time among adolescents: Results from a nationwide survey

Adolescent depression is becoming a public health problem. In this study the association between depressive symptoms and internet usage time in adolescents was examined, with data collected from the China Education Tracking Survey (CEPS). The survey is publicly available and carried out nationwide. A logistic regression analysis was conducted with odds ratios (OR) and 95% confidence intervals (CI), the subgroup analysis examined the relationships between internet usage time and depressive symptoms. A total of 10,705 adolescents were involved, where 46.4% of them are caught by the internet for more than two hours per day. Adolescents keeping on the internet for 6-8 h per day were reported to have higher odds of depressive symptoms than adolescents who were free from it with the confounders of individual, family, and school adjusted, which were observed among groups with a medium family economic status without living with their father and with a sleep time less than nine hours. The results revealed that adolescents spending more time online had a higher risk of experiencing depression symptoms. This study suggested that it is helpful for mental health professionals to evaluate and develop prevention interventions for depressive symptoms in adolescents promptly through monitoring and managing online time.

Response Patterns to Weekly Short Message Service Health Surveys Among Diverse Youth at High Risk for Acquiring HIV

HIV researchers use short messaging service (SMS)-based surveys to monitor health behaviors more closely than what would be possible with in-person assessment. Benefits are tempered by nonresponse to completing surveys. Understanding response patterns and their associated study participant characteristics would guide more tailored use of SMS-based surveys for HIV studies. We examined response to weekly 7-item SMS surveys administered as part of an HIV prevention trial. Using Mixture hidden Markov models (MHMM), we identified the underlying response patterns shared by subgroups of participants over time and quantified the association between these response patterns and participant characteristics. Three underlying response patterns were identified; responders, responders with phone-related errors, and non-responders. Non-responders versus responders were more likely to be younger, male, cis-gender, Black and Latinx participants with histories of homelessness, incarceration, and social support service utilization. Responders with phone-related errors compared to non-responders were more likely to be Black, Latinx, female, students, and have a history of incarceration and social support service utilization. More nuanced results from MHMM analyses better inform what strategies to use for increasing SMS response rates, including assisting in securing phone ownership/service for responders with phone-related errors and identifying alternative strategies for non-responders. Actively collecting and monitoring non-delivery notification data available from SMS gateway service companies offers another opportunity to identify and connect with participants when they are willing but unable to respond during follow-up.

Exploring the digital footprint of depression: a PRISMA systematic literature review of the empirical evidence

BACKGROUND

This PRISMA systematic literature review examined the use of digital data collection methods (including ecological momentary assessment [EMA], experience sampling method [ESM], digital biomarkers, passive sensing, mobile sensing, ambulatory assessment, and time-series analysis), emphasizing on digital phenotyping (DP) to study depression. DP is defined as the use of digital data to profile health information objectively.

AIMS

Four distinct yet interrelated goals underpin this study: (a) to identify empirical research examining the use of DP to study depression; (b) to describe the different methods and technology employed; (c) to integrate the evidence regarding the efficacy of digital data in the examination, diagnosis, and monitoring of depression and (d) to clarify DP definitions and digital mental health records terminology.

RESULTS

Overall, 118 studies were assessed as eligible. Considering the terms employed, "EMA", "ESM", and "DP" were the most predominant. A variety of DP data sources were reported, including voice, language, keyboard typing kinematics, mobile phone calls and texts, geocoded activity, actigraphy sensor-related recordings (i.e., steps, sleep, circadian rhythm), and self-reported apps' information. Reviewed studies employed subjectively and objectively recorded digital data in combination with interviews and psychometric scales.

CONCLUSIONS

Findings suggest links between a person's digital records and depression. Future research recommendations include (a) deriving consensus regarding the DP definition and (b) expanding the literature to consider a person's broader contextual and developmental circumstances in relation to their digital data/records.

Problematic Internet Use Before and During the COVID-19 Pandemic in Youth in Outpatient Mental Health Treatment: App-Based Ecological Momentary Assessment Study

BACKGROUND

Youth with existing psychiatric illness are more apt to use the internet as a coping skill. Because many "in-person" coping skills were not easily accessible during the COVID-19 pandemic, youth in outpatient mental health treatment may have been particularly vulnerable to the development of problematic internet use (PIU). The identification of a pandemic-associated worsening of PIU in this population is critical in order to guide clinical care; if these youth have become dependent upon the internet to regulate their negative emotions, PIU must be addressed as part of mental health treatment. However, many existing studies of youth digital media use in the pandemic do not include youth in psychiatric treatment or are reliant upon cross-sectional methodology and self-report measures of digital media use.

OBJECTIVE

This is a retrospective cohort study that used data collected from an app-based ecological momentary assessment protocol to examine potential pandemic-associated changes in digital media youth in outpatient mental health treatment. Secondary analyses assessed for differences in digital media use dependent upon personal and familial COVID-19 exposure and familial hospitalization, as well as factors associated with PIU in this population.

METHODS

The participants were aged 12-23 years and were receiving mental health treatment in an outpatient community hospital setting. All participants completed a 6-week daily ecological momentary assessment protocol on their personal smartphones. Questions were asked about depression (PHQ-8 [8-item Patient Health Questionnaire]), anxiety (GAD-7 [7-item General Anxiety Disorder]), PIU (PIU-SF-6 [Problematic Internet Use Short Form 6]), digital media use based on Apple's daily screen time reports, and personal and familial COVID-19 exposure. The analyses compared screen time, psychiatric symptoms, and PIU between cohorts, as well as between youth with personal or familial COVID-19 exposures and those without. The analyses also assessed for demographic and psychiatric factors associated with clinically significant PIU-SF-6 scores.

RESULTS

A total of 69 participants completed the study. The participants recruited during the pandemic were significantly more likely to meet the criteria for PIU based on their average PIU-SF-6 score (P=.02) and to spend more time using social media each day (P=.049). The overall amount of daily screen time did not differ between cohorts. Secondary analyses revealed a significant increase in average daily screen time among subjects who were exposed to COVID-19 (P=.01). Youth with clinically significant PIU-SF-6 scores were younger and more likely to have higher PHQ-8 (P=.003) and GAD-7 (P=.003) scores. No differences in scale scores or media use were found between subjects based on familial COVID-19 exposure or hospitalization.

CONCLUSIONS

Our findings support our hypothesis that PIU may have worsened for youth in mental health treatment during the pandemic, particularly the problematic use of social media. Mental health clinicians should incorporate screening for PIU into routine clinical care in order to prevent potential familial conflict and subsequent psychiatric crises that might stem from unrecognized PIU.

Global Collaboration Around Digital Mental Health: The LAMP Consortium

Despite the great potential, there has been a lack of progress in the development of sharable and scalable tools for digital mental health due to difficulty in reproducibility and clinical application. The LAMP Platform was developed to address this gap by creating a single platform that works for a variety of clinical and research use cases. The study aims to understand how a consortium of clinical and research sites can help onboard, execute, and expand digital health research, software, and use cases. The Division of Digital Psychiatry implemented a formal consortium with goal of expanding the reach of mindLAMP as a digital mental health platform, enabling  diverse studies and expanded use cases, and supportint growth of mindLAMP and consortium members’ research. The LAMP Consortium has brought together 54 sites from across the world, encouraging collaboration and idea sharing. These sites’ locations range from the USA to the Czech Republic to Australia, and apply the many features of LAMP to research, clinical, research and clinical, and industry use. The most popular features were surveys, sharing/viewing data, and GPS passive data collection. A user support network is necessary to encourage research and clinical use of the LAMP Platform. Resources like documentation, an online forum, and newsletters are essential to promote cooperation between many types of sites that is essential to advancing the field of digital mental health.

Piloting Smartphone Digital Phenotyping to Understand Problematic Internet Use in an Adolescent and Young Adult Sample

Problematic Internet use (PIU) preferentially affects youth development, particularly youth with psychiatric conditions. Studies attempting to understand PIU and its impact on adolescent mental health have been limited by cross-sectional design and self-report data. Even with a small sample size, digital phenotyping (DP) methodology can address these limitations through repeated sampling and collection of survey and sensor data through personal smartphones. This study pilots a 6-week DP protocol in 28 youth in mental health treatment in order to assess relationships between PIU, mood symptoms, and daily behaviors like smartphone engagement and daily travel in this high-risk population. Our results found shared associations between depression and PIU, where symptom severity of both worsened in the setting of decreased smartphone engagement. These clinically relevant findings indicate that, rather than uniformly worsening mental health, increased digital engagement may actually provide short-term relief from negative affect in youth with psychiatric comorbidities.

Review: Prevalence of Addictions among Transgender and Gender Diverse Subgroups

We conducted an analysis of the prevalence of substance and behavioral addictions across different transgender and gender diverse (TGD) subgroups. We performed a scoping review using MEDLINE and Google Scholar databases and examined 12 addictions, including alcohol, nicotine, cannabis, illicit drugs, gambling, eating/food, internet, sex, love, exercise, work, and shopping. We presented prevalence rates for each addiction as a function of an individual’s gender identity (stratified into transgender females, transgender males, and gender nonconforming), and used cisgender women and men as reference groups. We included 55 studies in our final analysis, the majority of which investigated substance use disorders among TGD subgroups. Overall findings indicated that substantial differences in substance use exist among US TGD subgroups. There were far fewer publications that examined the prevalence of behavioral addictions across TGD subgroups. However, despite limited research in this area, findings still suggest that notable differences in behavioral addictions may exist between individual TGD subgroups. The conclusions of our review may provide clinicians with a better ability to screen for and treat at-risk individuals within the TGD community.