Experience Sampling Methodology studies of depression: the state of the art

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

Background

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

Methods

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

Results

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

Conclusion

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

Everyday Sexual and Gender Minority Stress and Health: A Systematic Review of Experience Sampling Studies

Sexual and gender minority stress is associated with negative physical and mental health outcomes, such as hypertension and depression. Expanding on previous reviews of the literature on cross-sectional and long-term prospective associations between sexual and gender minority stress and health outcomes, the current systematic review synthesizes the evidence on how everyday sexual and gender minority stress relates to momentary changes in health. The findings of 53 experience sampling studies published between 2007 and 2022 suggest that daily and momentary within-persons fluctuations in minority stressors are associated with cognitive-emotional (e.g., affect, suicidality), behavioral (e.g., substance use), social (e.g., relationship satisfaction), and physical health outcomes (e.g., somatic symptoms). These findings suggest that sexual and gender minority stress is a dynamic process that can vary within individuals over time and significantly impact everyday mental and physical health. We discuss the implications of these findings for minority stress theory, LGBTQ+ health research, LGBTQ+ affirming therapy, and prevention initiatives. The current experience sampling literature is limited by a lack of attention to gender minority stress and a focus on a limited range of health outcomes. Methodological and theoretical considerations for future experience sampling research are discussed in light of these limitations.

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

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

Fear learning and extinction predicts anxiety in daily life: a study of Pavlovian conditioning and ecological momentary assessment

BACKGROUND

The association between anxious mood and aberrant fear learning mechanisms has not been fully elucidated. Studying how fear conditioning and extinction constructs relate to anxiety symptoms and reactivity to stressful and benign moments in everyday life provides a powerful addition to experimental paradigms.

METHOD

Fifty-one young adults completed laboratory-based differential conditioning and extinction tasks with (CS + ) and without (CS-) an aversive unconditional stimulus (US). Electrodermal skin conductance responses were measured during each phase, followed by ecological momentary assessment (EMA) tapping anxiety and stressors six times daily for seven days (2, 142 moments).

RESULTS

Conditioned electrodermal reactivity to the CS + and overgeneralisation to the CS- were associated with greater change in anxiety (measured via EMA), across non-stressful situations, remaining the same across stressful situations. Likewise, during extinction when the CS + is now safe, more electrodermal reactivity to the CS + was associated with more anxiety change across non-stressful situations and remained the same across stressful situations. Also, during extinction when threat is absent, more electrodermal reactivity at the late stage of the CS- was associated with less momentary anxiety change in response to stressful situations; more electrodermal activity at the late stage of the CS + was associated with more anxiety change across non-stressful situations and remained the same across stressful situations.

CONCLUSIONS

Sampling 'in vivo' emotion and stress experiences, study findings revealed links between conditioned electrodermal reactivity and overgeneralisation to safe stimuli and heightened anxious reactivity during non-stressful (i.e. safe) moments in daily life, coupled with less change in response to actual stressors.

Experience sampling methods for the personalised prediction of mental health problems in Spanish university students: protocol for a survey-based observational study within the PROMES-U project

INTRODUCTION

There is a high prevalence of mental health problems among university students. Better prediction and treatment access for this population is needed. In recent years, short-term dynamic factors, which can be assessed using experience sampling methods (ESM), have presented promising results for predicting mental health problems.

METHODS AND ANALYSIS

Undergraduate students from five public universities in Spain are recruited to participate in two web-based surveys (at baseline and at 12-month follow-up). A subgroup of baseline participants is recruited through quota sampling to participate in a 15-day ESM study. The baseline survey collects information regarding distal risk factors, while the ESM study collects short-term dynamic factors such as affect, company or environment. Risk factors will be identified at an individual and population level using logistic regressions and population attributable risk proportions, respectively. Machine learning techniques will be used to develop predictive models for mental health problems. Dynamic structural equation modelling and multilevel mixed-effects models will be considered to develop a series of explanatory models for the occurrence of mental health problems.

ETHICS AND DISSEMINATION

The project complies with national and international regulations, including the Declaration of Helsinki and the Code of Ethics, and has been approved by the IRB Parc de Salut Mar (2020/9198/I) and corresponding IRBs of all participating universities. All respondents are given information regarding access mental health services within their university and region. Individuals with positive responses on suicide items receive a specific alert with indications for consulting with a health professional. Participants are asked to provide informed consent separately for the web-based surveys and for the ESM study. Dissemination of results will include peer-reviewed scientific articles and participation in scientific congresses, reports with recommendations for universities' mental health policy makers, as well as a well-balanced communication strategy to the general public.

STUDY REGISTRATION

osf.io/p7csq.

Increased affective reactivity among depressed individuals can be explained by floor effects: An experience sampling study

Experience sampling studies into daily-life affective reactivity indicate that depressed individuals react more strongly to both positive and negative stimuli than non-depressed individuals, particularly on negative affect (NA). Given the different mean levels of both positive affect (PA) and NA between patients and controls, such findings may be influenced by floor/ceiling effects, leading to violations of the normality and homoscedasticity assumptions underlying the used statistical models. Affect distributions in prior studies suggest that this may have particularly influenced NA-reactivity findings. Here, we investigated the influence of floor/ceiling effects on the observed PA- and NA-reactivity to both positive and negative events. Data came from 346 depressed, non-depressed, and remitted participants from the Netherlands Study of Depression and Anxiety (NESDA). In PA-reactivity analyses, no floor/ceiling effects and assumption violations were observed, and PA-reactivity to positive events, but not negative events, was significantly increased in the depressed and remitted groups versus the non-depressed group. However, NA-scores exhibited a floor effect in the non-depressed group and naively estimated models violated model assumptions. When these violations were accounted for in subsequent analyses, group differences in NA-reactivity that had been present in the naive models were no longer observed. In conclusion, we found increased PA-reactivity to positive events but no evidence of increased NA-reactivity in depressed individuals when accounting for violations of assumptions. The results indicate that affective-reactivity results are very sensitive to modeling choices and that previously observed increased NA-reactivity in depressed individuals may (partially) reflect unaddressed assumption violations resulting from floor effects in NA.

A Hybrid Ecological Momentary Compassion–Focused Intervention for Enhancing Resilience in Help-Seeking Young People: Prospective Study of Baseline Characteristics in the EMIcompass Trial

Background

Young people are a target population for mental health–related early intervention and prevention. Although evidence for early intervention is promising, availability of and access to youth mental health services remain limited. Therefore, the development of an evidence-based hybrid intervention is urgently needed.

Objective

This study aimed to present a manual for a hybrid intervention, combining an ecological momentary intervention and face-to-face sessions aimed for enhancing resilience in help-seeking young people based on compassion-focused interventions, and explore whether participants’ baseline characteristics are associated with putative mechanisms and outcomes of the EMIcompass intervention. Specifically, we aimed to explore initial signals as to whether participants’ sociodemographic, clinical, and functional characteristics at baseline are associated with putative mechanisms (ie, change in self-compassion, change in emotion regulation, working alliance, training frequency); and whether participants’ sociodemographic, clinical, and functional characteristics, self-compassion, and emotion regulation at baseline are associated with clinical outcomes (ie, psychological distress and general psychopathology at postintervention and 4-week follow-ups) in the experimental condition and obtain first parameter estimates.

Methods

We recruited young people aged 14 to 25 years, with psychological distress, Clinical High At-Risk Mental State, or first episodes of severe mental disorder for an exploratory randomized controlled trial with assessments at baseline and postintervention and 4-week follow-ups. A structured manual was developed and optimized based on a pilot study’s manual, a scoping review of existing literature and manuals, exchange with experts, the team’s clinical experience of working with compassion-focused interventions, and the principles of ecological momentary interventions. This analysis focuses on the experimental condition receiving the EMIcompass intervention.

Results

A total of 46 young individuals were randomized to the experimental condition. There was evidence for initial signals of effects of age (B=0.11, 95% CI 0.00-0.22), general psychopathology (B=0.08, 95% CI −0.01 to 0.16), and clinical stage (B=1.50, 95% CI 0.06-2.93) on change in momentary self-compassion and change in emotion regulation from baseline to postintervention assessments. There was no evidence for associations of other baseline characteristics (eg, gender, minority status, and level of functioning) and putative mechanisms (eg, overall self-compassion, working alliance, and training frequency). In addition, except for an initial signal for an association of momentary self-compassion at baseline and psychological distress (B=−2.83, 95% CI −5.66 to 0.00), we found no evidence that baseline characteristics related to clinical outcomes.

Conclusions

The findings indicated the reach of participants by the intervention largely independent of sociodemographic, clinical, and functional baseline characteristics. The findings need to be confirmed in a definitive trial.

Trial Registration

German Clinical Trials Register NDRKS00017265; https://www.drks.de/drks_web/navigate.do?navigationId=trial.HTML&TRIAL_ID=DRKS00017265

International Registered Report Identifier (IRRID)

RR2-10.2196/27462

Development and evaluation of the HRSD-D, an image-based digital measure of the Hamilton rating scale for depression

The Hamilton rating scale for depression (HRSD) is considered the gold standard for the assessment of major depressive disorder. Nevertheless, it has drawbacks such as reliance on retrospective reports and a relatively long administration time. Using a combination of an experience sampling method with mobile health technology, the present study aimed at developing and conducting initial validation of HRSD-D, the first digital image-based assessment of the HRSD. Fifty-three well-trained HRSD interviewers selected the most representative image for each item from an initial sample of images. Based on their responses, we developed the prototype of HRSD-D in two versions: trait-like (HRSD-DT) and state-like (HRSD-DS). HRSD-DT collects one-time reports on general tendencies to experience depressive symptoms; HRSD-DS collects daily reports on the experience of symptoms. Using a total of 1933 responses collected in a preclinical sample (N = 86), we evaluated the validity and feasibility of HRSD-D, based on participant reports of HRSD-DT at baseline, and 28 consecutive daily reports of HRSD-DS, using smartphone devices. HRSD-D showed good convergent validity with respect to the original HRSD, as evident in high correlations between HRSD-DS and HRSD (up to Bstd = 0.80). Our combined qualitative and quantitative analyses indicate that HRSD-D captured both dynamic and stable features of symptomatology, in a user-friendly monitoring process. HRSD-D is a promising tool for the assessment of trait and state depression and contributes to the use of mobile technologies in mental health research and practice.

Transdiagnostic Psychopathology in a Help-Seeking Population of an Early Recognition Center for Mental Disorders: Protocol for an Experience Sampling Study

BACKGROUND

Prevention in psychiatry provides a promising way to address the burden of mental illness. However, established approaches focus on specific diagnoses and do not address the heterogeneity and manifold potential outcomes of help-seeking populations that present at early recognition services. Conceptualizing the psychopathology manifested in help-seeking populations from a network perspective of interacting symptoms allows transdiagnostic investigations beyond binary disease categories. Furthermore, modern technologies such as smartphones facilitate the application of the Experience Sampling Method (ESM).

OBJECTIVE

This study is a combination of ESM with network analyses to provide valid insights beyond the established assessment instruments in a help-seeking population.

METHODS

We will examine 75 individuals (aged 18-40 years) of the help-seeking population of the Cologne early recognition center. For a maximally naturalistic sample, only minimal exclusion criteria will be applied. We will collect data for 14 days using a mobile app to assess 10 transdiagnostic symptoms (ie, depressive, anxious, and psychotic symptoms) as well as distress level 5 times a day. With these data, we will generate average group-level symptom networks and personalized symptom networks using a 2-step multilevel vector autoregressive model. Additionally, we will explore associations between symptom networks and sociodemographic, risk, and resilience factors, as well as psychosocial functioning.

RESULTS

The protocol was designed in February 2020 and approved by the Ethics Committee of the University Hospital Cologne in October 2020. The protocol was reviewed and funded by the Köln Fortune program in September 2020. Data collection began in November 2020 and was completed in November 2021. Of the 258 participants who were screened, 93 (36%) fulfilled the inclusion criteria and were willing to participate in the study. Of these 93 participants, 86 (92%) completed the study. The first results are expected to be published in 2022.

CONCLUSIONS

This study will provide insights about the feasibility and utility of the ESM in a help-seeking population of an early recognition center. Providing the first explorative phenotyping of transdiagnostic psychopathology in this population, our study will contribute to the innovation of early recognition in psychiatry. The results will help pave the way for prevention and targeted early intervention in a broader patient group, and thus, enable greater intended effects in alleviating the burden of psychiatric disorders.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

DERR1-10.2196/35206.

Journaling Data for Daily PHQ-2 Depression Prediction and Forecasting

Digital health applications are becoming increasingly important for assessing and monitoring the wellbeing of people suffering from mental health conditions like depression. A common target of said applications is to predict the results of self-assessed Patient-Health-Questionnaires (PHQ), indicating current symptom severity of depressive individuals. Many of the currently available approaches to predict PHQ scores use passive data, e.g., from smartphones. However, there are several other scores and data besides PHQ, e.g., the Behavioral Activation for Depression Scale-Short Form (BADSSF), the Center for Epidemiologic Studies Depression Scale (CESD), or the Personality Dynamics Diary (PDD), all of which can be effortlessly collected on a daily basis. In this work, we explore the potential of using actively-collected data to predict and forecast daily PHQ-2 scores on a newly-collected longitudinal dataset. We obtain a best MAE of 1.417 for daily prediction of PHQ-2 scores, which specifically in the used dataset have a range of 0 to 12, using leave-one-subject-out cross-validation, as well as a best MAE of 1.914 for forecasting PHQ-2 scores using data from up to the last 7 days. This illustrates the additive value that can be obtained by incorporating actively-collected data in a depression monitoring application.

Symptom patterns in the daily life of PSC patients

BACKGROUND & AIMS

Patients with primary sclerosing cholangitis (PSC) may suffer from complaints such as pruritus, right upper abdominal quadrant pain (RUQ-A) and fatigue. However, the severity of these complaints, daily and/or seasonal patterns and other factors of influence in PSC are largely unknown. The aim of this study is to assess daily symptoms and patterns thereof in PSC patients in their natural setting.

METHODS

A mobile application was designed according to the experience sampling method. Push notifications with a response time of max 4 h were sent during tiers of 3 months. Questions comprised VAS scales on degree of pruritus, fatigue, RUQ-A, time of the day these symptoms were worst, as well as time of intake of medication. Linear mixed modelling was used to identify patient- and external factors associated with pruritus, fatigue and RUQ-A pain.

RESULTS

A total of 6713 questionnaires were completed by 137 patients. Fatigue was the most prevalent symptom among PSC patients being reported in a striking 71% of measurements, followed by pruritus (38%). Both increased during the day and were associated with longer disease duration. A highly significant correlation between pruritus and day temperature was observed (ρ = -0.14, p = .000), and itch was generally worse during winter (p = .000). Patient preference for the tool was high.

CONCLUSION

Pruritus and fatigue are prevalent symptoms in the daily life of PSC patients and show a distinct diurnal pattern. This may have implications for efficient dosing of anti-pruritic agents. The level of pruritus is highly correlated with day temperature, which may have several implications.

Digital tools for the assessment of pharmacological treatment for depressive disorder: State of the art

Depression is an invalidating disorder, marked by phenotypic heterogeneity. Clinical assessments for treatment adjustments and data-collection for pharmacological research often rely on subjective representations of functioning. Better phenotyping through digital applications may add unseen information and facilitate disentangling the clinical characteristics and impact of depression and its pharmacological treatment in everyday life. Researchers, physicians, and patients benefit from well-understood digital phenotyping approaches to assess the treatment efficacy and side-effects. This review discusses the current possibilities and pitfalls of wearables and technology for the assessment of the pharmacological treatment of depression. Their applications in the whole spectrum of treatment for depression, including diagnosis, treatment of an episode, and monitoring of relapse risk and prevention are discussed. Multiple aspects are to be considered, including concerns that come with collecting sensitive data and health recordings. Also, privacy and trust are addressed. Available applications range from questionnaire-like apps to objective assessment of behavioural patterns and promises in handling suicidality. Nonetheless, interpretation and integration of this high-resolution information with other phenotyping levels, remains challenging. This review provides a state-of-the-art description of wearables and technology in digital phenotyping for monitoring pharmacological treatment in depression, focusing on the challenges and opportunities of its application in clinical trials and research.

The network structure of core depressive symptom-domains in major depressive disorder following antidepressant treatment: a randomized clinical trial

BACKGROUND

Network analysis (NA) conceptualizes psychiatric disorders as complex dynamic systems of mutually interacting symptoms. Major depressive disorder (MDD) is a heterogeneous clinical condition, and very few studies to date have assessed putative changes in its psychopathological network structure in response to antidepressant (AD) treatment.

METHODS

In this randomized trial with adult depressed outpatients (n = 151), we estimated Gaussian graphical models among nine core MDD symptom-domains before and after 8 weeks of treatment with either escitalopram or desvenlafaxine. Networks were examined with the measures of cross-sectional and longitudinal structure and connectivity, centrality and predictability as well as stability and accuracy.

RESULTS

At baseline, the most connected MDD symptom-domains were fatigue-cognitive disturbance, whereas at week 8 they were depressed mood-suicidality. Overall, the most central MDD symptom-domains at baseline and week 8 were, respectively, fatigue and depressed mood; in contrast, the most peripheral symptom-domain across both timepoints was appetite/weight disturbance. Furthermore, the psychopathological network at week 8 was significantly more interconnected than at baseline, and they were also structurally dissimilar.

CONCLUSION

Our findings highlight the utility of focusing on the dynamic interaction between depressive symptoms to better understand how the treatment with ADs unfolds over time. In addition, depressed mood, fatigue, and cognitive/psychomotor disturbance seem to be central MDD symptoms that may be viable targets for novel, focused therapeutic interventions.

Developing and Validating an Experience Sampling Measure of Aggression: The Aggression-ES Scale

Experience sampling methodologies are likely to play an important role in advancing our understanding of momentary influences on aggression, including short-term antecedent psychological states and situations. In this study, we evaluate whether a newly developed experiencing sampling measure of aggression, the Aggression Experience Sampler (Aggression-ES), provides a valid and reliable measure of aggression in experience sampling contexts. Participants were a convenience sample of 23 young adults recruited from the local University community. Data were collected using an experience sampling smartphone application over 8 days. They were analyzed using multilevel structural equation modeling. Our results support the within- and between-person reliability and the criterion validity of the Aggression-ES. The Aggression-ES represents a good choice of measure for use in experience sampling studies of aggression. Further work in other samples will help to provide further validity evidence for the measure.

Do daily mood fluctuations activate ruminative thoughts as a mental habit? Results from an ecological momentary assessment study

It has been suggested that mental habits may underpin a heightened disposition to engage in rumination in response to negative mood. The aim of the current study was to assess the role of habit in the dynamic interplay between affect and ruminative thinking in the flow of daily life experiences. Using mobile ecological momentary assessment, 97 participants recorded affect and rumination ten times daily over six days, after completing measures of trait ruminative brooding and habitual characteristics of negative thinking (e.g. automaticity, lack of conscious awareness, intent and control). Momentary fluctuations in negative (increased) and positive (decreased) affect was prospectively associated with greater rumination-levels at the next sampling occasion. The degree to which affect triggered a subsequent ruminative response was moderated by habitual characteristics of negative thinking in a theoretically consistent way. Stronger temporal pairing of negative affect and rumination was also associated with greater emotional inertia but less carry-over of rumination from one moment to the next. Depression vulnerability may be in the form of rumination being habitually triggered in response to momentary fluctuations in affect, with deleterious effect on mood. The findings may have clinical implications, as targeting the habitual nature of rumination might help reduce depression vulnerability.

How to Include Patients' Perspectives in the Study of the Mind: A Review of Studies on Depression

Depression has been widely studied by researchers from different fields, but its causes, and mechanism of action are still not clear. A difficulty emerges from the shifting from objective diagnosis or analysis to exploration of subjective feelings and experiences that influence the individuals' expression, communication and coping in facing depression. The integration of the experiential dimension of the first-person in studies on depression-and related methodological recommendations-are needed to improve the validity and generalizability of research findings. It will allow the development of timely and effective actions of care. Starting from providing a summary of the literature on theoretical assumptions and considerations for the study of the mind, with particular attention to the experiential dimension of patients with depression (aim #1 and #2), this contribution is aimed to provide practical suggestions for the design of research able to incorporate first- and third-person accounts (aim #3). It is also aimed to review qualified phenomenological methods for the acquisition and interpretation of experiential data in patients with depression (aim #4). Recognizing the first-person perspective in the study of depression is a major step toward a better understanding and treatment of this disorder. Theoretical constructs and technique suggestions that result from this review offer a valid starting point for the inclusion of the experiential dimension to common third-person research in the study of the mind.

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.

Screening for Depression in Daily Life: Development and External Validation of a Prediction Model Based on Actigraphy and Experience Sampling Method

Background

In many countries, depressed individuals often first visit primary care settings for consultation, but a considerable number of clinically depressed patients remain unidentified. Introducing additional screening tools may facilitate the diagnostic process.

Objective

This study aimed to examine whether experience sampling method (ESM)-based measures of depressive affect and behaviors can discriminate depressed from nondepressed individuals. In addition, the added value of actigraphy-based measures was examined.

Methods

We used data from 2 samples to develop and validate prediction models. The development data set included 14 days of ESM and continuous actigraphy of currently depressed (n=43) and nondepressed individuals (n=82). The validation data set included 30 days of ESM and continuous actigraphy of currently depressed (n=27) and nondepressed individuals (n=27). Backward stepwise logistic regression analysis was applied to build the prediction models. Performance of the models was assessed with goodness-of-fit indices, calibration curves, and discriminative ability (area under the receiver operating characteristic curve [AUC]).

Results

In the development data set, the discriminative ability was good for the actigraphy model (AUC=0.790) and excellent for both the ESM (AUC=0.991) and the combined-domains model (AUC=0.993). In the validation data set, the discriminative ability was reasonable for the actigraphy model (AUC=0.648) and excellent for both the ESM (AUC=0.891) and the combined-domains model (AUC=0.892).

Conclusions

ESM is a good diagnostic predictor and is easy to calculate, and it therefore holds promise for implementation in clinical practice. Actigraphy shows no added value to ESM as a diagnostic predictor but might still be useful when ESM use is restricted.

Measuring psychopathology as it unfolds in daily life: addressing key assumptions of intensive longitudinal methods in the TRAILS TRANS-ID study

BACKGROUND

Intensive longitudinal (IL) designs provide the potential to study symptoms as they evolve in real-time within individuals. This has promising clinical implications, potentially allowing conclusions at the level of specific individuals. The current study aimed to establish the feasibility of IL designs, as indicated by self-rated burden and attrition, in the context of psychiatry. Additionally, we evaluated three core assumptions about the instruments (diary items) used in IL designs. These assumptions are: diary items (1) reflect experiences that change over time within individuals (indicated by item variability), (2) are interpreted consistently over time, and (3) correspond to retrospective assessments of psychopathology.

METHODS

TRAILS TRANS-ID is an add-on IL study in the clinical cohort of the TRAILS study. Daily diaries on psychopathological symptoms for six consecutive months were completed by 134 at risk young adults (age 22.6 ± 0.6 years). At baseline, immediately after the diary period, and one year after the diary period, participants completed a diagnostic interview.

RESULTS

Excellent compliance (88.5% of the diaries completed), low participant burden (M = 3.21; SD = 1.42; range 1-10), and low attrition (8.2%) supported the feasibility of six-month IL designs. Diary items differed in their variability over time. Evaluation of the consistency of diary item interpretations showed that within-individual variability in scores could not be attributed to changing interpretations over time. Further, daily symptom reports reasonably correlated with retrospective assessments (over a six month period) of psychopathology obtained with the diagnostic interview, suggesting that both measures might complement each other.

CONCLUSION

The current study is the first to show that IL designs over extensive periods (i.e., multiple months) in psychiatry are feasible, and meet three core assumptions to study change in psychopathology. This might allow for addressing novel and promising hypotheses in our field, and might substantially alter how we treat and study mental ill-health.

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.

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.

Ambulatory Assessment

In recent years, significant technological advances have changed our understanding of dynamic processes in clinical psychology. A particularly important agent of change has been ambulatory assessment (AA). AA is the assessment of individuals in their daily lives, combining the twin benefits of increased ecological validity and minimized retrospective biases. These benefits make AA particularly well-suited to the assessment of dynamic processes, and recent advancements in technology are providing exciting new opportunities to understand these processes in new ways. In the current article, we briefly detail the capabilities currently offered by smartphones and mobile physiological devices, as well as some of the practical and ethical challenges of incorporating these new technologies into AA research. We then provide several examples of recent innovative applications of AA methodology in clinical research, assessment, and intervention and provide a case example of AA data generated from a study utilizing multiple mobile devices. In this way, we aim to provide a sense of direction for researchers planning AA studies of their own.

A Complex Network Perspective on Clinical Science

Contemporary classification systems for mental disorders assume that abnormal behaviors are expressions of latent disease entities. An alternative to the latent disease model is the complex network approach. Instead of assuming that symptoms arise from an underlying disease entity, the complex network approach holds that disorders exist as systems of interrelated elements of a network. This approach also provides a framework for the understanding of therapeutic change. Depending on the structure of the network, change can occur abruptly once the network reaches a critical threshold (the tipping point). Homogeneous and highly connected networks often recover more slowly from local perturbations when the network approaches the tipping point, potentially making it possible to predict treatment change, relapse, and recovery. In this article, we discuss the complex network approach as an alternative to the latent disease model and its implications for classification, therapy, relapse, and recovery.

Combining Standard Conventional Measures and Ecological Momentary Assessment of Depression, Anxiety and Coping Using Smartphone Application in Minor Stroke Population: A Longitudinal Study Protocol

Context: Stroke has several consequences on survivors’ daily life even for those who experience short-lasting neurological symptoms with no functional disability. Depression and anxiety are common psychological disorders occurring after a stroke. They affect long-term outcomes and quality of life but they are difficult to diagnose because of the neurobiological consequences of brain lesions. Current research priority is given to the improvement of the detection and prevention of those post-stroke psychological disorders. Although previous studies have brought promising perspectives, their designs based on retrospective tools involve some limits regarding their ecological validity. Ecological Momentary Assessment (EMA) is an alternative to conventional instruments that could be a key in research for understanding processes that underlined post-stroke depression and anxiety onset. We aim to evaluate the feasibility and validity of anxiety, depression and coping EMA for minor stroke patients.

Methods: Patients hospitalized in an Intensive Neuro-vascular Care Unit between April 2016 and January 2017 for a minor stroke is involved in a study based on an EMA methodology. We use a smartphone application in order to assess anxiety and depression symptoms and coping strategies four times a day during 1 week at three different times after stroke (hospital discharge, 2 and 4 months). Participants’ self-reports and clinician-rates of anxiety, depression and coping are collected simultaneously using conventional and standard instruments. Feasibility of the EMA method will be assessed considering the participation and compliance rate. Validity will be the assessed by comparing EMA and conventional self-report and clinician-rated measures.

Discussion: We expect this study to contribute to the development of EMA using smartphone in minor stroke population. EMA method offers promising research perspective in the assessment and understanding of post-stroke psychological disorders. The development of EMA in stroke population could lead to clinical implications such as remotely psychological follow-ups during early supported discharge.

Trial registration: European Clinical Trials Database Number 2014-A01937-40

Immediate Mood Scaler: Tracking Symptoms of Depression and Anxiety Using a Novel Mobile Mood Scale

BACKGROUND

Mood disorders are dynamic disorders characterized by multimodal symptoms. Clinical assessment of symptoms is currently limited to relatively sparse, routine clinic visits, requiring retrospective recollection of symptoms present in the weeks preceding the visit. Novel advances in mobile tools now support ecological momentary assessment of mood, conducted frequently using mobile devices, outside the clinical setting. Such mood assessment may help circumvent problems associated with infrequent reporting and better characterize the dynamic presentation of mood symptoms, informing the delivery of novel treatment options.

OBJECTIVES

The aim of our study was to validate the Immediate Mood Scaler (IMS), a newly developed, iPad-deliverable 22-item self-report tool designed to capture current mood states.

METHODS

A total of 110 individuals completed standardized questionnaires (Patient Health Questionnaire, 9-item [PHQ-9]; generalized anxiety disorder, 7-Item [GAD-7]; and rumination scale) and IMS at baseline. Of the total, 56 completed at least one additional session of IMS, and 17 completed one additional administration of PHQ-9 and GAD-7. We conducted exploratory Principal Axis Factor Analysis to assess dimensionality of IMS, and computed zero-order correlations to investigate associations between IMS and standardized scales. Linear Mixed Model (LMM) was used to assess IMS stability across time and to test predictability of PHQ-9 and GAD-7 score by IMS.

RESULTS

Strong correlations were found between standard mood scales and the IMS at baseline (r=.57-.59, P<.001). A factor analysis revealed a 12-item IMS ("IMS-12") with two factors: a "depression" factor and an "anxiety" factor. IMS-12 depression subscale was more strongly correlated with PHQ-9 than with GAD-7 (z=1.88, P=.03), but the reverse pattern was not found for IMS-12 anxiety subscale. IMS-12 showed less stability over time compared with PHQ-9 and GAD-7 (.65 vs .91), potentially reflecting more sensitivity to mood dynamics. In addition, IMS-12 ratings indicated that individuals with mild to moderate depression had greater mood fluctuations compared with individuals with severe depression (.42 vs .79; P=.04). Finally, IMS-12 significantly contributed to the prediction of subsequent PHQ-9 (beta=1.03, P=.02) and GAD-7 scores (beta =.93, P=.01).

CONCLUSIONS

Collectively, these data suggest that the 12-item IMS (IMS-12) is a valid tool to assess momentary mood symptoms related to anxiety and depression. Although IMS-12 shows good correlation with standardized scales, it further captures mood fluctuations better and significantly adds to the prediction of the scales. Results are discussed in the context of providing continuous symptom quantification that may inform novel treatment options and support personalized treatment plans.

Development of a Mobile Phone App to Support Self-Monitoring of Emotional Well-Being: A Mental Health Digital Innovation

BACKGROUND

Emotional well-being is a primary component of mental health and well-being. Monitoring changes in emotional state daily over extended periods is, however, difficult using traditional methodologies. Providing mental health support is also challenging when approximately only 1 in 2 people with mental health issues seek professional help. Mobile phone technology offers a sustainable means of enhancing self-management of emotional well-being.

OBJECTIVE

This paper aims to describe the development of a mobile phone tool designed to monitor emotional changes in a natural everyday context and in real time.

METHODS

This evidence-informed mobile phone app monitors emotional mental health and well-being, and it provides links to mental health organization websites and resources. The app obtains data via self-report psychological questionnaires, experience sampling methodology (ESM), and automated behavioral data collection.

RESULTS

Feedback from 11 individuals (age range 16-52 years; 4 males, 7 females), who tested the app over 30 days, confirmed via survey and focus group methods that the app was functional and usable.

CONCLUSIONS

Recommendations for future researchers and developers of mental health apps to be used for research are also presented. The methodology described in this paper offers a powerful tool for a range of potential mental health research studies and provides a valuable standard against which development of future mental health apps should be considered.

Differences in Connection Strength between Mental Symptoms Might Be Explained by Differences in Variance: Reanalysis of Network Data Did Not Confirm Staging

Background

The network approach to psychopathology conceives mental disorders as sets of symptoms causally impacting on each other. The strengths of the connections between symptoms are key elements in the description of those symptom networks. Typically, the connections are analysed as linear associations (i.e., correlations or regression coefficients). However, there is insufficient awareness of the fact that differences in variance may account for differences in connection strength. Differences in variance frequently occur when subgroups are based on skewed data. An illustrative example is a study published in PLoS One (2013;8(3):e59559) that aimed to test the hypothesis that the development of psychopathology through “staging” was characterized by increasing connection strength between mental states. Three mental states (negative affect, positive affect, and paranoia) were studied in severity subgroups of a general population sample. The connection strength was found to increase with increasing severity in six of nine models. However, the method used (linear mixed modelling) is not suitable for skewed data.

Methods

We reanalysed the data using inverse Gaussian generalized linear mixed modelling, a method suited for positively skewed data (such as symptoms in the general population).

Results

The distribution of positive affect was normal, but the distributions of negative affect and paranoia were heavily skewed. The variance of the skewed variables increased with increasing severity. Reanalysis of the data did not confirm increasing connection strength, except for one of nine models.

Conclusions

Reanalysis of the data did not provide convincing evidence in support of staging as characterized by increasing connection strength between mental states. Network researchers should be aware that differences in connection strength between symptoms may be caused by differences in variances, in which case they should not be interpreted as differences in impact of one symptom on another symptom.

Isolating biomarkers for symptomatic states: considering symptom-substrate chronometry

A long-standing goal of psychopathology research is to develop objective markers of symptomatic states, yet progress has been far slower than expected. Although prior reviews have attributed this state of affairs to diagnostic heterogeneity, symptom comorbidity and phenotypic complexity, little attention has been paid to the implications of intra-individual symptom dynamics and inter-relatedness for biomarker study designs. In this critical review, we consider the impact of short-term symptom fluctuations on widely used study designs that regress the 'average level' of a given symptom against biological data collected at a single time point, and summarize findings from ambulatory assessment studies suggesting that such designs may be sub-optimal to detect symptom-substrate relationships. Although such designs have a crucial role in advancing our understanding of biological substrates related to more stable, longer-term changes (for example, gray matter thinning during a depressive episode), they may be less optimal for the detection of symptoms that exhibit high frequency fluctuations, are susceptible to common reporting biases, or may be heavily influenced by the presence of other symptoms. We propose that a greater emphasis on intra-individual symptom chronometry may be useful for identifying subgroups of patients with common, proximal pathological indicators. Taken together, these three recent developments in the areas of symptom conceptualization and measurement raise important considerations for future studies attempting to identify reliable biomarkers in psychiatry.

Factors contributing to depressive mood states in everyday life: A systematic review

BACKGROUND

Although accumulated evidence suggests that fluctuations in depressed mood are common among individuals with depression, and may be associated with onset, duration, and severity of illness, a systematic appraisal of putative predictors of depressed mood is lacking.

METHODS

A systematic search for relevant studies in the literature was conducted using PsycInfo and PubMed databases via EbscoHost in February 2016. The search was limited to articles using the experience sampling method, an approach suitable for capturing in situ fluctuations in mood states.

RESULTS

Forty-two studies met inclusion criteria for the review, from which three key risk factors (poor sleep, stress, and significant life events) and two protective factors (physical activity and quality of social interactions) were identified. The majority of papers supported concurrent and lagged associations between these putative protective/risk factors and depressed mood.

LIMITATIONS

Despite support for each of the proposed protective/risk factors, few studies evaluated multiple factors in the same study. Moreover, the time course for the effects of these predictors on depressed mood remains largely unknown.

CONCLUSIONS

The present review identified several putative risk and protective factors for depressed mood. A review of the literature suggests that poor sleep, negative social interactions, and stressful negative events may temporally precede spikes in depressed mood. In contrast, exercise and positive social interactions have been shown to predict subsequent declines in depressed mood. However, the lack of multivariate models in which the unique contributions of various predictors could be evaluated means that the current state of knowledge prevents firm conclusions about which factors are most predictive of depressed mood. More complex modeling of these effects is necessary in order to provide insights useful for clinical treatment in daily life of the depressed mood component of depressive disorders.

Computational psychiatry as a bridge from neuroscience to clinical applications

Translating advances in neuroscience into benefits for patients with mental illness presents enormous challenges because it involves both the most complex organ, the brain, and its interaction with a similarly complex environment. Dealing with such complexities demands powerful techniques. Computational psychiatry combines multiple levels and types of computation with multiple types of data in an effort to improve understanding, prediction and treatment of mental illness. Computational psychiatry, broadly defined, encompasses two complementary approaches: data driven and theory driven. Data-driven approaches apply machine-learning methods to high-dimensional data to improve classification of disease, predict treatment outcomes or improve treatment selection. These approaches are generally agnostic as to the underlying mechanisms. Theory-driven approaches, in contrast, use models that instantiate prior knowledge of, or explicit hypotheses about, such mechanisms, possibly at multiple levels of analysis and abstraction. We review recent advances in both approaches, with an emphasis on clinical applications, and highlight the utility of combining them.

The temporal dynamics of cortisol and affective states in depressed and non-depressed individuals

OBJECTIVES

Cortisol levels have been related to mood disorders at the group level, but not much is known about how cortisol relates to affective states within individuals over time. We examined the temporal dynamics of cortisol and affective states in depressed and non-depressed individuals in daily life. Specifically, we addressed the direction and timing of the effects, as well as individual differences.

METHODS

Thirty depressed and non-depressed participants (aged 20-50 years) filled out questionnaires regarding their affect and sampled saliva three times a day for 30 days in their natural environment. They were pair-matched on age, gender, smoking behavior and body mass index. The multivariate time series (T=90) of every participant were analyzed using vector autoregressive (VAR) modeling to assess lagged effects of cortisol on affect, and vice versa. Contemporaneous effects were assessed using the residuals of the VAR models. Impulse response function analysis was used to examine the timing of effects.

RESULTS

For 29 out of 30 participants, a VAR model could be constructed. A significant relationship between cortisol and positive or negative affect was found for the majority of the participants, but the direction, sign, and timing of the relationship varied among individuals.

CONCLUSION

This approach proves to be a valuable addition to traditional group designs, because our results showed that daily life fluctuations in cortisol can influence affective states, and vice versa, but not in all individuals and in varying ways. Future studies may examine whether these individual differences relate to susceptibility for or progression of mood disorders.

Effectiveness of mobile technologies delivering Ecological Momentary Interventions for stress and anxiety: a systematic review

OBJECTIVES

Mobile technologies may be suitable for delivering Ecological Momentary Interventions (EMI) to treat anxiety in real-time. This review aims to synthesize evidence on the effectiveness of EMI for treating anxiety conditions.

MATERIALS AND METHODS

Four databases and the reference lists of previous studies were searched. A total of 1949 abstracts were double screened for inclusion. Sufficient studies were available to undertake a quantitative meta-analysis on EMIs on generalized anxiety symptoms.

RESULTS

The 15 randomized trials and randomized controlled trials examined anxiety (n = 7), stress (n = 3), anxiety and stress (n = 2), panic disorder (n = 2), and social phobia (n = 1). Eight EMIs comprised self-monitoring integrated with therapy modules, seven comprised multimedia content, and three comprised self-monitoring only. The quality of studies presented high risk of biases. Meta-analysis (n = 7) demonstrated that EMIs reduced generalized anxiety compared to control and/or comparison groups (Effect Size (ES) = 0.32, 95% CI, 0.12-0.53). Most EMIs targeting stress were reported effective relative to control as were the two EMIs targeting panic disorders. The EMI targeting social phobia was not effective.

DISCUSSION

EMIs have potential in treating both anxiety and stress. However, few high-quality trials have been conducted for specific anxiety disorders. Further trials are needed to assess the value of EMI technologies for anxiety in enhancing existing treatments.

CONCLUSION

This study found a small significant effect of EMI studies on reducing generalized anxiety. Studies on stress demonstrated EMI was effective compared to control, with the small number of studies on panic and social phobia demonstrating mixed results.

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

Background

Interventions based on the experience sampling method (ESM) are ideally suited to provide insight into personal, contextualized affective patterns in the flow of daily life. Recently, we showed that an ESM-intervention focusing on positive affect was associated with a decrease in symptoms in patients with depression. The aim of the present study was to examine whether ESM-intervention increased patient empowerment.

Methods

Depressed out-patients (n = 102) receiving psychopharmacological treatment who had participated in a randomized controlled trial with three arms: (i) an experimental group receiving six weeks of ESM self-monitoring combined with weekly feedback sessions, (ii) a pseudo-experimental group participating in six weeks of ESM self-monitoring without feedback, and (iii) a control group (treatment as usual only). Patients were recruited in the Netherlands between January 2010 and February 2012. Self-report empowerment scores were obtained pre- and post-intervention.

Results

There was an effect of group × assessment period, indicating that the experimental (B = 7.26, P = 0.061, d = 0.44, statistically imprecise) and pseudo-experimental group (B = 11.19, P = 0.003, d = 0.76) increased more in reported empowerment compared to the control group. In the pseudo-experimental group, 29% of the participants showed a statistically reliable increase in empowerment score and 0% reliable decrease compared to 17% reliable increase and 21% reliable decrease in the control group. The experimental group showed 19% reliable increase and 4% reliable decrease.

Conclusions

These findings tentatively suggest that self-monitoring to complement standard antidepressant treatment may increase patients’ feelings of empowerment. Further research is necessary to investigate long-term empowering effects of self-monitoring in combination with person-tailored feedback.

A Contingency-Oriented Approach to Understanding Borderline Personality Disorder: Situational Triggers and Symptoms

This article tested a contingency-oriented perspective to examine the dynamic relationships between in-the-moment borderline personality disorder (BPD) symptom events and in-the-moment triggers. An experience sampling study with 282 adults, including 77 participants with BPD, obtained reports of situational triggers and BPD symptom events five times daily for 2 weeks. Triggers included being rejected, betrayed, abandoned, offended, and disappointed; having one's self-concept threatened; being in a boring situation; and being alone. BPD was associated with increased situational triggers. Multilevel models revealed significant within-person associations between situational triggers and BPD symptoms for the average participant in the study, with significant individual variance in the strength and direction of trigger-symptom contingencies. Most trigger-symptom contingencies were stronger for individuals with greater borderline symptomatology, suggesting that triggers are meaningfully related to BPD. These findings highlight possible proximal mechanisms that maintain BPD and help explain the course of a disorder often described as chaotic and unpredictable.

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

OBJECTIVES

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

DESIGN

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

SETTINGS

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

PARTICIPANTS

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

INTERVENTION

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

MAIN OUTCOME

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

RESULTS

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

CONCLUSION

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

TRIAL REGISTRATION

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

Does assessing suicidality frequently and repeatedly cause harm? A randomized control study

Assessing suicidality is common in mental health practice and is fundamental to suicide research. Although necessary, there is significant concern that such assessments have unintended harmful consequences. Using a longitudinal randomized control design, the authors evaluated whether repeated and frequent assessments of suicide-related thoughts and behaviors negatively affected individuals, including those at-risk for suicide-related outcomes. Adults (N = 282), including many diagnosed with borderline personality disorder (BPD), were recruited through psychiatric outpatient clinics and from the community at large, and were randomly assigned to assessment groups. A control assessment group responded to questions regarding negative psychological experiences several times each day during a 2-week main observation phase. During the same observation period, an intensive suicide assessment group responded to the same questions, along with questions regarding suicidal behavior and ideation. Negative psychological outcomes were measured during the main observation phase (for BPD symptoms unrelated to suicide and for BPD-relevant emotions) and/or at the end of each week during the main observation phase and monthly for 6 months thereafter (for all outcomes, including suicidal ideation and behavior). Results revealed little evidence that intensive suicide assessment triggered negative outcomes, including suicidal ideation or behavior, even among people with BPD. A handful of effects did reach or approach significance, though these were temporary and nonrobust. However, given the seriousness of some outcomes, the authors recommend that researchers or clinicians who implement experience sampling methods including suicide-related items carefully consider the benefits of asking about suicide and to inform participants about possible risks.

Neuroticism developmental courses--implications for depression, anxiety and everyday emotional experience; a prospective study from adolescence to young adulthood

BACKGROUND

Neuroticism is frequently discussed as a risk factor for psychopathology. According to the maturity principle, neuroticism decreases over the course of life, but not uniformly across individuals. However, the implications of differences in personality maturation on mental health have not been well studied so far. Hence, we hypothesized that different forms of neuroticism development from adolescence to young adulthood are associated with differences in depression, anxiety and everyday emotional experience at the age of 25.

METHODS

A sample of 266 adolescents from the general population was examined three times over ten years (age at T0: 15, T1: 20 and T2: 25) using questionnaires, interviews and ecological momentary assessment (EMA). At all measurement points, neuroticism was assessed with the NEO inventory. At T2, diagnoses of major depression and anxiety disorders were captured with a structured clinical interview (M-CIDI). Phone-based EMA was used to assess emotional experience and affective instability over a two-week period at T2.

RESULTS

The best fitting model was a latent class growth analysis with two groups of neuroticism development. Most individuals (n = 205) showed moderate values whereas 61 participants were clustered into a group with elevated neuroticism levels. In both groups neuroticism significantly changed during the ten year period with a peak at the age of 20. Individuals with a higher absolute level were at 14-fold increased risk for depression and 7-fold risk for anxiety disorders at the age of 25. In EMA, increased negative affect and arousal as well as decreased positive emotions were found in this high group.

CONCLUSIONS

Other than expected, personality did not mature in our sample. However, there was a significant change of neuroticism values from adolescence to young adulthood. Further, over 20% of our participants showed a neuroticism development which was associated with adverse outcomes such as negatively toned emotional experience and a heightened risk to suffer from depressive and anxiety disorders in young adulthood. These high-risk persons need to be identified early to provide interventions supporting continuous personality maturation.

Do Patients With Multiple Sclerosis Show Different Daily Physical Activity Patterns From Healthy Individuals?

Background Reduced physical activity is an important consequence of multiple sclerosis (MS). However, little is known about the real quantity and type of daily activities that people with MS perform in their own home environment.

OBJECTIVE

To gain insight into differences in the amount and patterns of physical activities performed over a 24-hour period in the own community environment of patients with MS and healthy individuals. Methods A total of 43 ambulatory patients with MS and 26 age- and gender-matched healthy individuals participated. Physical activity recorded with an ambulatory activity monitor was classified into postures and motions. Multilevel analyses were conducted to investigate whether the pattern of physical activities across daily periods (morning, afternoon, and evening) was dependent on the group (MS vs healthy individuals). Results Results showed a significant overall lower amount of dynamic activity as compared with a group of healthy controls (P < .001). Patients with MS started with lower physical activity levels already in the morning (P < .001), and this difference persisted in the afternoon (P = .002) and evening (P = .032). Conclusion Activity monitoring gives insight into real-world daily physical behavior. Our findings suggest that patients with MS may adopt a deliberate anticipatory strategy of lower activity in the morning, which persists throughout the day. Future trials evaluating daily changes in physical activity behavior should simultaneously sample self-report measures of energy levels and fatigue to elucidate the complex interaction between symptoms and physical activity.

A therapeutic application of the experience sampling method in the treatment of depression: a randomized controlled trial

In depression, the ability to experience daily life positive affect predicts recovery and reduces relapse rates. Interventions based on the experience sampling method (ESM-I) are ideally suited to provide insight in personal, contextualized patterns of positive affect. The aim of this study was to examine whether add-on ESM-derived feedback on personalized patterns of positive affect is feasible and useful to patients, and results in a reduction of depressive symptomatology. Depressed outpatients (n=102) receiving pharmacological treatment participated in a randomized controlled trial with three arms: an experimental group receiving add-on ESM-derived feedback, a pseudo-experimental group participating in ESM but receiving no feedback, and a control group. The experimental group participated in an ESM procedure (three days per week over a 6-week period) using a palmtop. This group received weekly standardized feedback on personalized patterns of positive affect. Hamilton Depression Rating Scale - 17 (HDRS) and Inventory of Depressive Symptoms (IDS) scores were obtained before and after the intervention. During a 6-month follow-up period, five HDRS and IDS assessments were completed. Add-on ESM-derived feedback resulted in a significant and clinically relevant stronger decrease in HDRS score relative to the control group (p<0.01; -5.5 point reduction in HDRS at 6 months). Compared to the pseudo-experimental group, a clinically relevant decrease in HDRS score was apparent at 6 months (B=-3.6, p=0.053). Self-reported depressive complaints (IDS) yielded the same pattern over time. The use of ESM-I was deemed acceptable and the provided feedback easy to understand. Patients attempted to apply suggestions from ESM-derived feedback to daily life. These data suggest that the efficacy of traditional passive pharmacological approach to treatment of major depression can be enhanced by using person-tailored daily life information regarding positive affect.

Ambulatory assessment

Ambulatory assessment (AA) covers a wide range of assessment methods to study people in their natural environment, including self-report, observational, and biological/physiological/behavioral. AA methods minimize retrospective biases while gathering ecologically valid data from patients' everyday life in real time or near real time. Here, we report on the major characteristics of AA, and we provide examples of applications of AA in clinical psychology (a) to investigate mechanisms and dynamics of symptoms, (b) to predict the future recurrence or onset of symptoms, (c) to monitor treatment effects, (d) to predict treatment success, (e) to prevent relapse, and (f) as interventions. In addition, we present and discuss the most pressing and compelling future AA applications: technological developments (the smartphone), improved ecological validity of laboratory results by combined lab-field studies, and investigating gene-environment interactions. We conclude with a discussion of acceptability, compliance, privacy, and ethical issues.