Smartphone-based objective monitoring in bipolar disorder: status and considerations

Multimodal Digital Phenotyping Study in Patients With Major Depressive Episodes and Healthy Controls (Mobile Monitoring of Mood): Observational Longitudinal Study

BACKGROUND

Mood disorders are among the most common mental health conditions worldwide. Wearables and consumer-grade personal digital devices create digital traces that can be collected, processed, and analyzed, offering a unique opportunity to quantify and monitor individuals with mental disorders in their natural living environments.

OBJECTIVE

This study comprised (1) 3 subcohorts of patients with a major depressive episode, either with major depressive disorder, bipolar disorder, or concurrent borderline personality disorder, and (2) a healthy control group. We investigated whether differences in behavioral patterns could be observed at the group level, that is, patients versus healthy controls. We studied the volume and temporal patterns of smartphone screen and app use, communication, sleep, mobility, and physical activity. We investigated whether patients or controls exhibited more homogenous temporal patterns of activity when compared with other individuals in the same group. We examined which variables were associated with the severity of depression.

METHODS

In total, 188 participants were recruited to complete a 2-phase study. In the first 2 weeks, data from bed sensors, actigraphy, smartphones, and 5 sets of daily questions were collected. In the second phase, which lasted up to 1 year, only passive smartphone data and biweekly 9-item Patient Health Questionnaire data were collected. Survival analysis, statistical tests, and linear mixed models were performed.

RESULTS

Survival analysis showed no statistically significant difference in adherence. Most participants did not stay in the study for 1 year. Weekday location variance showed lower values for patients (control: mean -10.04, SD 2.73; patient: mean -11.91, SD 2.50; Mann-Whitney U [MWU] test P=.004). Normalized entropy of location was lower among patients (control: mean 2.10, SD 1.38; patient: mean 1.57, SD 1.10; MWU test P=.05). The temporal communication patterns of controls were more diverse compared to those of patients (MWU test P<.001). In contrast, patients exhibited more varied temporal patterns of smartphone use compared to the controls. We found that the duration of incoming calls (β=-0.08, 95% CI -0.12 to -0.04; P<.001) and the SD of activity magnitude (β=-2.05, 95% CI -4.18 to -0.20; P=.02) over the 14 days before the 9-item Patient Health Questionnaire records were negatively associated with depression severity. Conversely, the duration of outgoing calls showed a positive association with depression severity (β=0.05, 95% CI 0.00-0.09; P=.02).

CONCLUSIONS

Our work shows the important features for future analyses of behavioral markers of mood disorders. However, among outpatients with mild to moderate depressive disorders, the group-level differences from healthy controls in any single modality remain relatively modest. Therefore, future studies need to combine data from multiple modalities to detect more subtle differences and identify individualized signatures. The high dropout rates for longer study periods remain a challenge and limit the generalizability.

Remote sensing mental health: A systematic review of factors essential to clinical translation from validation research

Background

Mental illness remains a major global health challenge largely due to the absence of definitive biomarkers applicable to diagnostics and care processes. Although remote sensing technologies, embedded in devices such as smartphones and wearables, offer a promising avenue for improved mental health assessments, their clinical integration has been slow.

Objective

This scoping review, following preferred reporting items for systematic reviews and meta-analyses guidelines, explores validation studies of remote sensing in clinical mental health populations, aiming to identify critical factors for clinical translation.

Methods

Comprehensive searches were conducted in six databases. The analysis, using narrative synthesis, examined clinical and socio-demographic characteristics of the populations studied, sensing purposes, temporal considerations and reference mental health assessments used for validation.

Results

The narrative synthesis of 50 included studies indicates that ten different sensor types have been studied for tracking and diagnosing mental illnesses, primarily focusing on physical activity and sleep patterns. There were many variations in the sensor methodologies used that may affect data quality and participant burden. Observation durations, and thus data resolution, varied by patient diagnosis. Currently, reference assessments predominantly rely on deficit focussed self-reports, and socio-demographic information is underreported, therefore representativeness of the general population is uncertain.

Conclusion

To fully harness the potential of remote sensing in mental health, issues such as reliance on self-reported assessments, and lack of socio-demographic context pertaining to generalizability need to be addressed. Striking a balance between resolution, data quality, and participant burden whilst clearly reporting limitations, will ensure effective technology use. The scant reporting on participants' socio-demographic data suggests a knowledge gap in understanding the effectiveness of passive sensing techniques in disadvantaged populations.

Identifying Medications Underlying Communication Atypicalities in Psychotic and Affective Disorders: A Pharmacovigilance Study Within the FDA Adverse Event Reporting System

PURPOSE

Communication atypicalities are considered promising markers of a broad range of clinical conditions. However, little is known about the mechanisms and confounders underlying them. Medications might have a crucial, relatively unknown role both as potential confounders and offering an insight on the mechanisms at work. The integration of regulatory documents with disproportionality analyses provides a more comprehensive picture to account for in future investigations of communication-related markers. The aim of this study was to identify a list of drugs potentially associated with communicative atypicalities within psychotic and affective disorders.

METHOD

We developed a query using the Medical Dictionary for Regulatory Activities to search for communicative atypicalities within the FDA Adverse Event Reporting System (updated June 2021). A Bonferroni-corrected disproportionality analysis (reporting odds ratio) was separately performed on spontaneous reports involving psychotic, affective, and non-neuropsychiatric disorders, to account for the confounding role of different underlying conditions. Drug-adverse event associations not already reported in the Side Effect Resource database of labeled adverse drug reactions (unexpected) were subjected to further robustness analyses to account for expected biases.

RESULTS

A list of 291 expected and 91 unexpected potential confounding medications was identified, including drugs that may irritate (inhalants) or desiccate (anticholinergics) the larynx, impair speech motor control (antipsychotics), or induce nodules (acitretin) or necrosis (vascular endothelial growth factor receptor inhibitors) on vocal cords; sedatives and stimulants; neurotoxic agents (anti-infectives); and agents acting on neurotransmitter pathways (dopamine agonists).

CONCLUSIONS

We provide a list of medications to account for in future studies of communication-related markers in affective and psychotic disorders. The current test case illustrates rigorous procedures for digital phenotyping, and the methodological tools implemented for large-scale disproportionality analyses can be considered a road map for investigations of communication-related markers in other clinical populations.

SUPPLEMENTAL MATERIAL

https://doi.org/10.23641/asha.23721345.

Acceptability of Personal Sensing Among People With Alcohol Use Disorder: Observational Study

BACKGROUND

Personal sensing may improve digital therapeutics for mental health care by facilitating early screening, symptom monitoring, risk prediction, and personalized adaptive interventions. However, further development and the use of personal sensing requires a better understanding of its acceptability to people targeted for these applications.

OBJECTIVE

We aimed to assess the acceptability of active and passive personal sensing methods in a sample of people with moderate to severe alcohol use disorder using both behavioral and self-report measures. This sample was recruited as part of a larger grant-funded project to develop a machine learning algorithm to predict lapses.

METHODS

Participants (N=154; n=77, 50% female; mean age 41, SD 11.9 years; n=134, 87% White and n=150, 97% non-Hispanic) in early recovery (1-8 weeks of abstinence) were recruited to participate in a 3-month longitudinal study. Participants were modestly compensated for engaging with active (eg, ecological momentary assessment [EMA], audio check-in, and sleep quality) and passive (eg, geolocation, cellular communication logs, and SMS text message content) sensing methods that were selected to tap into constructs from the Relapse Prevention model by Marlatt. We assessed 3 behavioral indicators of acceptability: participants' choices about their participation in the study at various stages in the procedure, their choice to opt in to provide data for each sensing method, and their adherence to a subset of the active methods (EMA and audio check-in). We also assessed 3 self-report measures of acceptability (interference, dislike, and willingness to use for 1 year) for each method.

RESULTS

Of the 192 eligible individuals screened, 191 consented to personal sensing. Most of these individuals (169/191, 88.5%) also returned 1 week later to formally enroll, and 154 participated through the first month follow-up visit. All participants in our analysis sample opted in to provide data for EMA, sleep quality, geolocation, and cellular communication logs. Out of 154 participants, 1 (0.6%) did not provide SMS text message content and 3 (1.9%) did not provide any audio check-ins. The average adherence rate for the 4 times daily EMA was .80. The adherence rate for the daily audio check-in was .54. Aggregate participant ratings indicated that all personal sensing methods were significantly more acceptable (all P<.001) compared with neutral across subjective measures of interference, dislike, and willingness to use for 1 year. Participants did not significantly differ in their dislike of active methods compared with passive methods (P=.23). However, participants reported a higher willingness to use passive (vs active) methods for 1 year (P=.04).

CONCLUSIONS

These results suggest that active and passive sensing methods are acceptable for people with alcohol use disorder over a longer period than has previously been assessed. Important individual differences were observed across people and methods, indicating opportunities for future improvement.

Speech as a promising biosignal in precision psychiatry

Health research and health care alike are presently based on infrequent assessments that provide an incomplete picture of clinical functioning. Consequently, opportunities to identify and prevent health events before they occur are missed. New health technologies are addressing these critical issues by enabling the continual monitoring of health-related processes using speech. These technologies are a great match for the healthcare environment because they make high-frequency assessments non-invasive and highly scalable. Indeed, existing tools can now extract a wide variety of health-relevant biosignals from smartphones by analyzing a person's voice and speech. These biosignals are linked to health-relevant biological pathways and have shown promise in detecting several disorders, including depression and schizophrenia. However, more research is needed to identify the speech signals that matter most, validate these signals against ground-truth outcomes, and translate these data into biomarkers and just-in-time adaptive interventions. We discuss these issues herein by describing how assessing everyday psychological stress through speech can help both researchers and health care providers monitor the impact that stress has on a wide variety of mental and physical health outcomes, such as self-harm, suicide, substance abuse, depression, and disease recurrence. If done appropriately and securely, speech is a novel digital biosignal that could play a key role in predicting high-priority clinical outcomes and delivering tailored interventions that help people when they need it most.

Automated Digital Interventions and Smoking Cessation: Systematic Review and Meta-analysis Relating Efficiency to a Psychological Theory of Intervention Perspective

BACKGROUND

Smoking remains a highly significant preventable global public health problem. In this context, digital interventions offer great advantages in terms of a lack of biological side effects, possibility of automatic delivery, and consequent human resource savings relative to traditional interventions. Such interventions have been studied in randomized controlled trials (RCTs) but have not been systematically reviewed with the inclusion of text-based and multiplatform-based interventions. In addition, this area has not been evaluated from the perspective of the psychological theoretical basis of intervention.

OBJECTIVE

The aim of this paper is to assess the efficiency of digital interventions in RCT studies of smoking cessation and to evaluate the effectiveness of the strategies used for digital interventions.

METHODS

An electronic search of RCTs was conducted using PubMed, Embase, and the Cochrane Library by June 30, 2021. Eligible studies had to compare automated digital intervention (ADI) to the use of a self-help guideline or no intervention. Participants were current smokers (aged 16 years or older). As the main outcome, abstinence after endpoint was extracted from the studies. Systematic review and meta-analysis were conducted to assess the efficiency of ADIs. Metaregressions were conducted to assess the relationship between intervention theory and effectiveness.

RESULTS

A total of 19 trials (15,472 participants) were included in the analysis. The overall abstinence rate (95% CI) at the endpoint was 17.8% (17.0-18.7). The overall risk ratio of the intervention group compared to the controls at the endpoint was 17.8% (17.0-18.7). Cochrane risk-of-bias tool for randomized trials (ROB 2) suggested that most of the studies had a low risk of bias (56.3%). Psychological theory-related constructs or predictors, which refer to other theory-based concepts (rather than only behavioral theory) such as craving or anxiety, are associated with effectiveness.

CONCLUSIONS

This study found that ADI had a clear positive effect compared to self-help guidelines or to no intervention, and effectiveness was associated with theory-related constructs or predictors. ADIs should be promoted by policy makers and clinical practitioners to address the huge gap between the need for smoking cessation and availability of traditional treatment resources. Possible increases in ADI efficiency may be achieved by optimally integrating psychotherapeutic theories and techniques.

TRIAL REGISTRATION

PROSPERO CRD42021256593; https://www.crd.york.ac.uk/prospero/display_record.php?RecordID=256593.

Smartphone-based interventions in bipolar disorder: Systematic review and meta-analyses of efficacy. A position paper from the International Society for Bipolar Disorders (ISBD) Big Data Task Force

BACKGROUND

The clinical effects of smartphone-based interventions for bipolar disorder (BD) have yet to be established.

OBJECTIVES

To examine the efficacy of smartphone-based interventions in BD and how the included studies reported user-engagement indicators.

METHODS

We conducted a systematic search on January 24, 2022, in PubMed, Scopus, Embase, APA PsycINFO, and Web of Science. We used random-effects meta-analysis to calculate the standardized difference (Hedges' g) in pre-post change scores between smartphone intervention and control conditions. The study was pre-registered with PROSPERO (CRD42021226668).

RESULTS

The literature search identified 6034 studies. Thirteen articles fulfilled the selection criteria. We included seven RCTs and performed meta-analyses comparing the pre-post change in depressive and (hypo)manic symptom severity, functioning, quality of life, and perceived stress between smartphone interventions and control conditions. There was significant heterogeneity among studies and no meta-analysis reached statistical significance. Results were also inconclusive regarding affective relapses and psychiatric readmissions. All studies reported positive user-engagement indicators.

CONCLUSION

We did not find evidence to support that smartphone interventions may reduce the severity of depressive or manic symptoms in BD. The high heterogeneity of studies supports the need for expert consensus to establish ideally how studies should be designed and the use of more sensitive outcomes, such as affective relapses and psychiatric hospitalizations, as well as the quantification of mood instability. The ISBD Big Data Task Force provides preliminary recommendations to reduce the heterogeneity and achieve more valid evidence in the field.

Detecting Mental Health Behaviors Using Mobile Interactions: Exploratory Study Focusing on Binge Eating

BACKGROUND

Binge eating is a subjective loss of control while eating, which leads to the consumption of large amounts of food. It can cause significant emotional distress and is often accompanied by purging behaviors (eg, meal skipping, overexercising, or vomiting).

OBJECTIVE

The aim of this study was to explore the potential of mobile sensing to detect indicators of binge-eating episodes, with a view toward informing the design of future context-aware mobile interventions.

METHODS

This study was conducted in 2 stages. The first involved the development of the DeMMI (Detecting Mental health behaviors using Mobile Interactions) app. As part of this, we conducted a consultation session to explore whether the types of sensor data we were proposing to capture were useful and appropriate, as well as to gather feedback on some specific app features relating to self-reporting. The second stage involved conducting a 6-week period of data collection with 10 participants experiencing binge eating (logging both their mood and episodes of binge eating) and 10 comparison participants (logging only mood). An optional interview was conducted after the study, which discussed their experience using the app, and 8 participants (n=3, 38% binge eating and n=5, 63% comparisons) consented.

RESULTS

The findings showed unique differences in the types of sensor data that were triangulated with the individuals' episodes (with nearby Bluetooth devices, screen and app use features, mobility features, and mood scores showing relevance). Participants had a largely positive opinion about the app, its unobtrusive role, and its ease of use. Interacting with the app increased participants' awareness of and reflection on their mood and phone usage patterns. Moreover, they expressed no privacy concerns as these were alleviated by the study information sheet.

CONCLUSIONS

This study contributes a series of recommendations for future studies wishing to scale our approach and for the design of bespoke mobile interventions to support this population.

Loneliness and Social Isolation Detection Using Passive Sensing Techniques: Scoping Review

BACKGROUND

Loneliness and social isolation are associated with multiple health problems, including depression, functional impairment, and death. Mobile sensing using smartphones and wearable devices, such as fitness trackers or smartwatches, as well as ambient sensors, can be used to acquire data remotely on individuals and their daily routines and behaviors in real time. This has opened new possibilities for the early detection of health and social problems, including loneliness and social isolation.

OBJECTIVE

This scoping review aimed to identify and synthesize recent scientific studies that used passive sensing techniques, such as the use of in-home ambient sensors, smartphones, and wearable device sensors, to collect data on device users' daily routines and behaviors to detect loneliness or social isolation. This review also aimed to examine various aspects of these studies, especially target populations, privacy, and validation issues.

METHODS

A scoping review was undertaken, following the PRISMA-ScR (Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews). Studies on the topic under investigation were identified through 6 databases (IEEE Xplore, Scopus, ACM, PubMed, Web of Science, and Embase). The identified studies were screened for the type of passive sensing detection methods for loneliness and social isolation, targeted population, reliability of the detection systems, challenges, and limitations of these detection systems.

RESULTS

After conducting the initial search, a total of 40,071 papers were identified. After screening for inclusion and exclusion criteria, 29 (0.07%) studies were included in this scoping review. Most studies (20/29, 69%) used smartphone and wearable technology to detect loneliness or social isolation, and 72% (21/29) of the studies used a validated reference standard to assess the accuracy of passively collected data for detecting loneliness or social isolation.

CONCLUSIONS

Despite the growing use of passive sensing technologies for detecting loneliness and social isolation, some substantial gaps still remain in this domain. A population heterogeneity issue exists among several studies, indicating that different demographic characteristics, such as age and differences in participants' behaviors, can affect loneliness and social isolation. In addition, despite extensive personal data collection, relatively few studies have addressed privacy and ethical issues. This review provides uncertain evidence regarding the use of passive sensing to detect loneliness and social isolation. Future research is needed using robust study designs, measures, and examinations of privacy and ethical concerns.

Digital phenotyping in psychiatry: A scoping review

BACKGROUND

Digital phenotyping has been defined as the moment-by-moment assessment of an illness state through digital means, promising objective, quantifiable data on psychiatric patients' conditions, and could potentially improve diagnosis and management of mental illness. As it is a rapidly growing field, it is to be expected that new literature is being published frequently.

OBJECTIVE

We conducted this scoping review to assess the current state of literature on digital phenotyping and offer some discussion on the current trends and future direction of this area of research.

METHODS

We searched four databases, PubMed, Ovid MEDLINE, PsycINFO and Web of Science, from inception to August 25th, 2021. We included studies written in English that 1) investigated or applied their findings to diagnose psychiatric disorders and 2) utilized passive sensing for management or diagnosis. Protocols were excluded. A narrative synthesis approach was used, due to the heterogeneity and variability in outcomes and outcome types reported.

RESULTS

Of 10506 unique records identified, we included a total of 107 articles. The number of published studies has increased over tenfold from 2 in 2014 to 28 in 2020, illustrating the field's rapid growth. However, a significant proportion of these (49% of all studies and 87% of primary studies) were proof of concept, pilot or correlational studies examining digital phenotyping's potential. Most (62%) of the primary studies published evaluated individuals with depression (21%), BD (18%) and SZ (23%) (Appendix 1).

CONCLUSION

There is promise shown in certain domains of data and their clinical relevance, which have yet to be fully elucidated. A consensus has yet to be reached on the best methods of data collection and processing, and more multidisciplinary collaboration between physicians and other fields is needed to unlock the full potential of digital phenotyping and allow for statistically powerful clinical trials to prove clinical utility.

Remote Monitoring Systems for Patients With Chronic Diseases in Primary Health Care: Systematic Review

Background

The digital age, with digital sensors, the Internet of Things (IoT), and big data tools, has opened new opportunities for improving the delivery of health care services, with remote monitoring systems playing a crucial role and improving access to patients. The versatility of these systems has been demonstrated during the current COVID-19 pandemic. Health remote monitoring systems (HRMS) present various advantages such as the reduction in patient load at hospitals and health centers. Patients that would most benefit from HRMS are those with chronic diseases, older adults, and patients that experience less severe symptoms recovering from SARS-CoV-2 viral infection.

Objective

This paper aimed to perform a systematic review of the literature of HRMS in primary health care (PHC) settings, identifying the current status of the digitalization of health processes, remote data acquisition, and interactions between health care personnel and patients.

Methods

A systematic literature review was conducted using PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analysis) guidelines to identify articles that explored interventions with HRMS in patients with chronic diseases in the PHC setting.

Results

The literature review yielded 123 publications, 18 of which met the predefined inclusion criteria. The selected articles highlighted that sensors and wearables are already being used in multiple scenarios related to chronic disease management at the PHC level. The studies focused mostly on patients with diabetes (9/26, 35%) and cardiovascular diseases (7/26, 27%). During the evaluation of the implementation of these interventions, the major difficulty that stood out was the integration of information into already existing systems in the PHC infrastructure and in changing working processes of PHC professionals (83%).

Conclusions

The PHC context integrates multidisciplinary teams and patients with often complex, chronic pathologies. Despite the theoretical framework, objective identification of problems, and involvement of stakeholders in the design and implementation processes, these interventions mostly fail to scale up. Despite the inherent limitations of conducting a systematic literature review, the small number of studies in the PHC context is a relevant limitation. This study aimed to demonstrate the importance of matching technological development to the working PHC processes in interventions regarding the use of sensors and wearables for remote monitoring as a source of information for chronic disease management, so that information with clinical value is not lost along the way.

[Digitalized psychiatry : Critical considerations on a new paradigm]

Digitalization and artificial intelligence hold the prospect of new procedures for psychiatry. Machine learning techniques combined with big data should enable algorithmized diagnostics, prediction and therapy that are superior to clinical observation and interaction in terms of accuracy and efficiency. This development converges with the search for new, statistically and biologically based disorder patterns to replace clinical psychopathological disease entities. This article examines the possibilities and the problems of a digitalized psychiatry.

Ecological Momentary Assessment of Bipolar Disorder Symptoms and Partner Affect: Longitudinal Pilot Study

BACKGROUND

The World Health Organization ranks bipolar disorder (BD) as the 7th leading cause of disability. Although the effects on those with BD are well described, less is reported on the impact of BD on cohabiting partners or any interactions between the two; this requires in vivo data collection measured each day over several months.

OBJECTIVE

We set out to demonstrate the utility of ecological momentary assessment with BD couples measured using yoked smartphone apps. When randomly prompted over time, we assumed distinct patterns of association would emerge between BD symptoms (both depression and hypo/mania) and partner mood (positive and negative affect).

METHODS

For this pilot study, we recruited an international sample of young and older adults with BD and their cohabiting partners where available. Both participants and partners downloaded separate apps onto their respective smartphones. Within self-specified "windows of general availability," participants with BD were randomly prompted to briefly report symptoms of depression and hypo/mania (ie, BDS_x), positive and negative mood (ie, POMS-15; partners), and any important events of the day (both). The partner app was yoked to the participant app so that the former was prompted roughly 30 minutes after the participant with BD or the next morning if outside the partner's specified availability.

RESULTS

Four couples provided 312 matched BD symptom and partner mood responses over an average of 123 days (range 65-221 days). Both were GPS- and time-stamped (mean 3:11 hrs between questionnaires, SD 4:51 hrs). Total depression had a small but significant association with positive (r=-.14; P=.02) and negative partner affect (r=.15; P=.01]. Yet total hypo/mania appeared to have no association with positive partner affect (r=-.01; P=.87); instead, negative partner affect was significantly correlated with total hypo/mania (r=.26; P=.01). However, when we look specifically at BD factors, we see that negative partner affect is associated only with affrontive symptoms of hypo/mania (r=.38; P=.01); elation or loss of insight appears unrelated to either positive (r=.10; P=.09) or negative partner affect (r=.02; P=.71). Yet affrontive symptoms of hypo/mania were significantly correlated with negative affect, but only when couples were together (r=.41; P=.01), not when apart (r=.22; P=.12). That is, these angry interpersonal symptoms of hypo/mania appear to be experienced most negatively by spouses when couples are together.

CONCLUSIONS

These initial findings demonstrate the utility of in vivo ambulatory data collection in longitudinal mental health research. Preliminary analyses suggest different BD symptoms are associated with negative and positive partner mood. These negative effects appear greater for hypo/mania than depressive symptoms, but proximity to the person with BD is important.

Clinical Utility of Wearable Sensors and Patient-Reported Surveys in Patients With Schizophrenia: Noninterventional, Observational Study

BACKGROUND

Relapse in schizophrenia may be preceded by early warning signs of biological, sensory, and clinical status. Early detection of warning signs may facilitate intervention and prevent relapses.

OBJECTIVE

This study aims to investigate the feasibility of using wearable devices and self-reported technologies to identify symptom exacerbation correlates and relapse in patients with schizophrenia.

METHODS

In this observational study, patients with schizophrenia were provided with remote sensing devices to continuously monitor activity (Garmin vivofit) and sleep (Philips Actiwatch), and smartphones were used to record patient-reported outcomes. Clinical assessments of symptoms (Positive and Negative Syndrome Scale and Brief Psychiatric Rating Scale) were performed biweekly, and other clinical scales on symptoms (Clinical Global Impression-Schizophrenia, Calgary Depression Scale), psychosocial functioning, physical activity (Yale Physical Activity Survey), and sleep (Pittsburgh Sleep Quality Index) were assessed every 4 weeks. Patients were observed for 4 months, and correlations between clinical assessments and aggregated device metrics data were assessed using a mixed-effect model. An elastic net model was used to predict the clinical symptoms based on the device features.

RESULTS

Of the 40 patients enrolled, 1 patient relapsed after being stable with evaluable postbaseline data. Weekly patient-reported outcomes were moderately correlated with psychiatric symptoms (Brief Psychiatric Rating Scale total score, r=0.29; Calgary Depression Scale total score, r=0.37; and Positive and Negative Syndrome Scale total score, r=0.3). In the elastic net model, sleep and activity features derived from Philips Actigraph and Garmin vivofit were predictive of the sitting index of the Yale Physical Activity Survey and sleep duration component of the Pittsburgh Sleep Quality Index. On the basis of the combined patient data, a high percentage of data coverage and compliance (>80%) was observed for each device.

CONCLUSIONS

This study demonstrated that wearable devices and smartphones could be effectively deployed and potentially used to monitor patients with schizophrenia. Furthermore, metrics-based prediction models can assist in detecting earlier signs of symptom changes. The operational learnings from this study may provide insights to conduct future studies.

TRIAL REGISTRATION

ClinicalTrials.gov NCT02224430; https://www.clinicaltrials.gov/ct2/show/NCT02224430.

Clinical Risk Constellations for the Development of Bipolar Disorders

The early recognition of psychiatric disorders has been a focus of research in the last decades and has led to improvements in clinical care, especially in the area of early psychosis. Like non-affective psychosis, bipolar disorders are often diagnosed with a delay that can lead to long periods of untreated illness and impact long-term outcomes. This article presents the rationale for early recognition in bipolar disorder and presents the current evidence for the identification of risk factors, their assessment and validity in predicting the onset of bipolar disorder.

"How Come You Don't Call Me?" Smartphone Communication App Usage as an Indicator of Loneliness and Social Well-Being across the Adult Lifespan during the COVID-19 Pandemic

Loneliness and lack of social well-being are associated with adverse health outcomes and have increased during the COVID-19 pandemic. Smartphone communication data have been suggested to help monitor loneliness, but this requires further evidence. We investigated the informative value of smartphone communication app data for predicting subjective loneliness and social well-being in a sample of 364 participants ranging from 18 to 78 years of age (52.2% female; mean age = 42.54, SD = 13.22) derived from the CORONA HEALTH APP study from July to December 2020 in Germany. The participants experienced relatively high levels of loneliness and low social well-being during the time period characterized by the COVID-19 pandemic. Apart from positive associations with phone call use times, smartphone communication app use was associated with social well-being and loneliness only when considering the age of participants. Younger participants with higher use times tended to report less social well-being and higher loneliness, while the opposite association was found for older adults. Thus, the informative value of smartphone communication use time was rather small and became evident only in consideration of age. The results highlight the need for further investigations and the need to address several limitations in order to draw conclusions at the population level.

Digital biomarkers from geolocation data in bipolar disorder and schizophrenia: a systematic review

OBJECTIVE

The study sought to explore to what extent geolocation data has been used to study serious mental illness (SMI). SMIs such as bipolar disorder and schizophrenia are characterized by fluctuating symptoms and sudden relapse. Currently, monitoring of people with an SMI is largely done through face-to-face visits. Smartphone-based geolocation sensors create opportunities for continuous monitoring and early intervention.

MATERIALS AND METHODS

We searched MEDLINE, PsycINFO, and Scopus by combining terms related to geolocation and smartphones with SMI concepts. Study selection and data extraction were done in duplicate.

RESULTS

Eighteen publications describing 16 studies were included in our review. Eleven studies focused on bipolar disorder. Common geolocation-derived digital biomarkers were number of locations visited (n = 8), distance traveled (n = 8), time spent at prespecified locations (n = 7), and number of changes in GSM (Global System for Mobile communications) cell (n = 4). Twelve of 14 publications evaluating clinical aspects found an association between geolocation-derived digital biomarker and SMI concepts, especially mood. Geolocation-derived digital biomarkers were more strongly associated with SMI concepts than other information (eg, accelerometer data, smartphone activity, self-reported symptoms). However, small sample sizes and short follow-up warrant cautious interpretation of these findings: of all included studies, 7 had a sample of fewer than 10 patients and 11 had a duration shorter than 12 weeks.

CONCLUSIONS

The growing body of evidence for the association between SMI concepts and geolocation-derived digital biomarkers shows potential for this instrument to be used for continuous monitoring of patients in their everyday lives, but there is a need for larger studies with longer follow-up times.

Smartphone-Based Interventions and Internalizing Disorders in Youth: Systematic Review and Meta-analysis

Background

Mental health disorders in youth are a global issue that have important implications for the future quality of life and morbidity of affected individuals. In the context of public health initiatives, smartphone-based interventions have been suggested to hold the potential to be an effective strategy to reduce the symptoms of mental health disorders in youth; however, further evaluation is needed to confirm their effectiveness. This systematic review and meta-analysis documents and synthesizes existing research on smartphone-based interventions targeting internalizing disorders in youth populations.

Objective

This study aims to synthesize existing research on smartphone-based interventions targeting internalizing disorders in youth populations.

Methods

PubMed and SCOPUS were searched in 2019, and 4334 potentially relevant articles were found. A total of 12 studies were included in the final synthesis. We used the Hedges g meta-analysis approach and a random effects model for analysis.

Results

The results of this review note that depression and anxiety are the most commonly targeted symptoms, and unlike other similar topics, most studies reviewed were linked to a proven treatment. The overall pooled effect from the meta-analysis showed small but significant effects (κ=12; N=1370; Hedges g=0.20; 95% CI 0.02-0.38) for interventions in reducing the symptoms of internalizing disorders. In total, 4 subgroup analyses examining specific symptoms and intervention styles found varied small significant and nonsignificant effects.

Conclusions

Future research should focus on developing robust evaluative frameworks and examining interventions among more diverse populations and settings. More robust research is needed before smartphone-based interventions are scaled up and used at the population level to address youth internalizing disorders.

Mood and Activity Measured Using Smartphones in Unipolar Depressive Disorder

Background: Smartphones comprise a promising tool for symptom monitoring in patients with unipolar depressive disorder (UD) collected as either patient-reportings or possibly as automatically generated smartphone data. However, only limited research has been conducted in clinical populations. We investigated the association between smartphone-collected monitoring data and validated psychiatric ratings and questionnaires in a well-characterized clinical sample of patients diagnosed with UD. Methods: Smartphone data, clinical ratings, and questionnaires from patients with UD were collected 6 months following discharge from psychiatric hospitalization as part of a randomized controlled study. Smartphone data were collected daily, and clinical ratings (i.e., Hamilton Depression Rating Scale 17-item) were conducted three times during the study. We investigated associations between (1) smartphone-based patient-reported mood and activity and clinical ratings and questionnaires; (2) automatically generated smartphone data resembling physical activity, social activity, and phone usage and clinical ratings; and (3) automatically generated smartphone data and same-day smartphone-based patient-reported mood and activity. Results: A total of 74 patients provided 11,368 days of smartphone data, 196 ratings, and 147 questionnaires. We found that: (1) patient-reported mood and activity were associated with clinical ratings and questionnaires (p < 0.001), so that higher symptom scores were associated with lower patient-reported mood and activity, (2) Out of 30 investigated associations on automatically generated data and clinical ratings of depression, only four showed statistical significance. Further, lower psychosocial functioning was associated with fewer daily steps (p = 0.036) and increased number of incoming (p = 0.032), outgoing (p = 0.015) and missed calls (p = 0.007), and longer phone calls (p = 0.012); (3) Out of 20 investigated associations between automatically generated data and daily patient-reported mood and activity, 12 showed statistical significance. For example, lower patient-reported activity was associated with fewer daily steps, shorter distance traveled, increased incoming and missed calls, and increased screen-time. Conclusion: Smartphone-based self-monitoring is feasible and associated with clinical ratings in UD. Some automatically generated data on behavior may reflect clinical features and psychosocial functioning, but these should be more clearly identified in future studies, potentially combining patient-reported and smartphone-generated data.

Recommendations for the use of long-term experience sampling in bipolar disorder care: a qualitative study of patient and clinician experiences

Background

Self-monitoring has been shown to improve the self-management and treatment of patients with bipolar disorder. However, current self-monitoring methods are limited to once-daily retrospectively assessed mood, which may not suit the rapid mood fluctuations in bipolar disorder. The experience sampling method (ESM), which assesses mood in real-time several times a day, may overcome these limitations. This study set out to assess the experiences of patients and clinicians with the addition of ESM monitoring, real-time alerts, and personalized feedback to clinical care. Participants were twenty patients with bipolar disorder type I/II and their clinicians. For four months, patients completed five ESM assessments per day on mood, symptoms, and activities. Weekly symptom questionnaires alerted patients and clinicians to potential episodes. After the monitoring, a personalized feedback report based on the patient’s data was discussed between patient and clinician. Three months later, patient and clinician were both interviewed.

Results

Thematic analysis of the transcripts resulted in four themes: perceived effects of the monitoring, alerts, and feedback, and recommendations for implementation of ESM. ESM was perceived as helping patients to cope better with their disorder by increasing awareness, offering new insights, and encouraging life style adjustments. ESM was further believed to facilitate communication between patient and clinician and to lead to new treatment directions. However, high assessment burden and pre-occupation with negative mood and having a disorder were also described. Patients and clinicians advocated for increased personalization and embedding of ESM in care.

Conclusions

This study demonstrates that long-term ESM monitoring, alerts, and personalized feedback are perceived as beneficial to the treatment and self-management of patients with bipolar disorder. Future research should further test the clinical utility of ESM. Clinically relevant feedback and technology need to be developed to enable personalized integration of ESM in clinical care.

Assessing the relationship between routine and schizophrenia symptoms with passively sensed measures of behavioral stability

Increased stability in one's daily routine is associated with well-being in the general population and often a goal of behavioral interventions for people with serious mental illnesses like schizophrenia. Assessing behavioral stability has been limited in clinical research by the use of retrospective scales, which are susceptible to reporting biases and memory inaccuracies. Mobile passive sensors, which are less susceptible to these sources of error, have emerged as tools to assess behavioral patterns in a range of populations. The present study developed and examined a metric of behavioral stability from data generated by a passive sensing system carried by 61 individuals with schizophrenia for one year. This metric-the Stability Index-appeared orthogonal from existing measures drawn from passive sensors and matched the predictive performance of state-of-the-art features. Specifically, greater stability in social activity (e.g., calls and messages) were associated with lower symptoms, and greater stability in physical activity (e.g., being still) appeared associated with elevated symptoms. This study provides additional support for the predictive value of individualized over population-level data in psychiatric populations. The Stability Index offers also a promising tool for generating insights about the impact of behavioral stability in schizophrenia-spectrum disorders.

Effects of smartphone-based interventions and monitoring on bipolar disorder: A systematic review and meta-analysis

BACKGROUND

Recently, there has been a range of studies about smartphone-based interventions and monitoring for reducing symptoms of bipolar disorder (BD). However, their efficacy for BD remains unclear.

AIM

To compare the effect of smartphone-based interventions and monitoring with control methods in treating patients with BD.

METHODS

A systematic literature search was performed on PubMed, Embase, Clinical trials, psycINFO, Web of Science, and Cochrane Library. Randomized clinical trials (RCTs) or single-group trials in which smartphone-based interventions and monitoring were compared with control methods or baseline in patients with symptoms of BD were included. Data were synthesized using a random-effects or a fixed-effects model to analyze the effects of psychological interventions and monitoring delivered via smartphone on psychiatric symptoms in patients with BD. The primary outcome measures were set for mania and depression symptoms. Subgroups were created to explore which aspects of smartphone interventions are relevant to the greater or lesser efficacy of treating symptoms.

RESULTS

We identified ten articles, including seven RCTs (985 participants) and three single-group trials (169 participants). Analysis of the between-group study showed that smartphone-based interventions were effective in reducing manic [g = -0.19, 95% confidence interval (CI): -0.33 to -0.04, P = 0.01] and depressive (g = -0.28, 95%CI: -0.55 to -0.01, P < 0.05) symptoms. In within-group analysis, smartphone-based interventions significantly reduced manic (g = 0.17, 95%CI: 0.04 to 0.30, P < 0.01) and depressive (g = 0.48, 95%CI: 0.18 to 0.78) symptoms compared to the baseline. Nevertheless, smartphone-based monitoring systems significantly reduced manic (g = 0.27, 95%CI: 0.02 to 0.51, P < 0.05) but not depressive symptoms. Subgroup analysis indicated that the interventions with psychoeducation had positive effects on depressive (g = -0.62, 95%CI: -0.81 to -0.43, P < 0.01) and manic (g = -0.24, 95%CI: -0.43 to -0.06, P = 0.01) symptoms compared to the controlled conditions, while the interventions without psychoeducation did not (P > 0.05). The contacts between therapists and patients that contributed to the implementation of psychological therapy reduced depression symptoms (g = -0.47, 95%CI: -0.75 to -0.18, P = 0.01).

CONCLUSION

Smartphone-based interventions and monitoring have a significant positive impact on depressive and manic symptoms of BD patients in between-group and within-group analysis.

Smartphone-based activity measurements in patients with newly diagnosed bipolar disorder, unaffected relatives and control individuals

BACKGROUND

In DSM-5 activity is a core criterion for diagnosing hypomania and mania. However, there are no guidelines for quantifying changes in activity. The objectives of the study were (1) to investigate daily smartphone-based self-reported and automatically-generated activity, respectively, against validated measurements of activity; (2) to validate daily smartphone-based self-reported activity and automatically-generated activity against each other; (3) to investigate differences in daily self-reported and automatically-generated smartphone-based activity between patients with bipolar disorder (BD), unaffected relatives (UR) and healthy control individuals (HC).

METHODS

A total of 203 patients with BD, 54 UR, and 109 HC were included. On a smartphone-based app, the participants daily reported their activity level on a scale from -3 to + 3. Additionally, participants owning an android smartphone provided automatically-generated data, including step counts, screen on/off logs, and call- and text-logs. Smartphone-based activity was validated against an activity questionnaire the International Physical Activity Questionnaire (IPAQ) and activity items on observer-based rating scales of depression using the Hamilton Depression Rating scale (HAMD), mania using Young Mania Rating scale (YMRS) and functioning using the Functional Assessment Short Test (FAST). In these analyses, we calculated averages of smartphone-based activity measurements reported in the period corresponding to the days assessed by the questionnaires and rating scales.

RESULTS

(1) Smartphone-based self-reported activity was a valid measure according to scores on the IPAQ and activity items on the HAMD and YMRS, and was associated with FAST scores, whereas the majority of automatically-generated smartphone-based activity measurements were not. (2) Daily smartphone-based self-reported and automatically-generated activity correlated with each other with nearly all measurements. (3) Patients with BD had decreased daily self-reported activity compared with HC. Patients with BD had decreased physical (number of steps) and social activity (more missed calls) but a longer call duration compared with HC. UR also had decreased physical activity compared with HC but did not differ on daily self-reported activity or social activity.

CONCLUSION

Daily self-reported activity measured via smartphone represents overall activity and correlates with measurements of automatically generated smartphone-based activity. Detecting activity levels using smartphones may be clinically helpful in diagnosis and illness monitoring in patients with bipolar disorder. Trial registration clinicaltrials.gov NCT02888262.

Development of an Emotion-Sensitive mHealth Approach for Mood-State Recognition in Bipolar Disorder

Internet- and mobile-based approaches have become increasingly significant to psychological research in the field of bipolar disorders. While research suggests that emotional aspects of bipolar disorders are substantially related to the social and global functioning or the suicidality of patients, these aspects have so far not sufficiently been considered within the context of mobile-based disease management approaches. As a multiprofessional research team, we have developed a new and emotion-sensitive assistance system, which we have adapted to the needs of patients with bipolar disorder. Next to the analysis of self-assessments, third-party assessments, and sensor data, the new assistance system analyzes audio and video data of these patients regarding their emotional content or the presence of emotional cues. In this viewpoint, we describe the theoretical and technological basis of our emotion-sensitive approach and do not present empirical data or a proof of concept. To our knowledge, the new assistance system incorporates the first mobile-based approach to analyze emotional expressions of patients with bipolar disorder. As a next step, the validity and feasibility of our emotion-sensitive approach must be evaluated. In the future, it might benefit diagnostic, prognostic, or even therapeutic purposes and complement existing systems with the help of new and intuitive interaction models.

Translating big data to better treatment in bipolar disorder - a manifesto for coordinated action

Bipolar disorder (BD) is a major healthcare and socio-economic challenge. Despite its substantial burden on society, the research activity in BD is much smaller than its economic impact appears to demand. There is a consensus that the accurate identification of the underlying pathophysiology for BD is fundamental to realize major health benefits through better treatment and preventive regimens. However, to achieve these goals requires coordinated action and innovative approaches to boost the discovery of the neurobiological underpinnings of BD, and rapid translation of research findings into development and testing of better and more specific treatments. To this end, we here propose that only a large-scale coordinated action can be successful in integrating international big-data approaches with real-world clinical interventions. This could be achieved through the creation of a Global Bipolar Disorder Foundation, which could bring government, industry and philanthropy together in common cause. A global initiative for BD research would come at a highly opportune time given the seminal advances promised for our understanding of the genetic and brain basis of the disease and the obvious areas of unmet clinical need. Such an endeavour would embrace the principles of open science and see the strong involvement of user groups and integration of dissemination and public involvement with the research programs. We believe the time is right for a step change in our approach to understanding, treating and even preventing BD effectively.

Mental health ubiquitous monitoring supported by social situation awareness: A systematic review

Traditionally, the process of monitoring and evaluating social behavior related to mental health has based on self-reported information, which is limited by the subjective character of responses and various cognitive biases. Today, however, there is a growing amount of studies that have provided methods to objectively monitor social behavior through ubiquitous devices and have used this information to support mental health services. In this paper, we present a Systematic Literature Review (SLR) to identify, analyze and characterize the state of the art about the use of ubiquitous devices to monitor users' social behavior focused on mental health. For this purpose, we performed an exhaustive literature search on the six main digital libraries. A screening process was conducted on 160 peer-reviewed publications by applying suitable selection criteria to define the appropriate studies to the scope of this SLR. Next, 20 selected studies were forwarded to the data extraction phase. From an analysis of the selected studies, we recognized the types of social situations identified, the process of transforming contextual data into social situations, the use of social situation awareness to support mental health monitoring, and the methods used to evaluate proposed solutions. Additionally, we identified the main trends presented by this research area, as well as open questions and perspectives for future research. Results of this SLR showed that social situation-aware ubiquitous systems represent promising assistance tools for patients and mental health professionals. However, studies still present limitations in methodological rigor and restrictions in experiments, and solutions proposed by them have limitations to be overcome.

Smartphone apps for the treatment of mental health conditions: status and considerations

Clinical and research interest in the potential of mobile health apps for the management of mental health conditions has recently been given added impetus by growing evidence of consumer adoption. In parallel, there is now a developing evidence base that includes meta-analyses demonstrating reductions in symptoms of depression and anxiety, and reduction in suicidal ideation. While these findings are encouraging, recent research continues to identify a number of potential barriers to the widespread adoption of mental health apps. These challenges include poor data governance and data sharing practices; questions of clinical safety relating to the management of adverse events and potentially harmful content; low levels of user engagement and the possibility of 'digital placebo' effects; and workforce barriers to integration with clinical practice. Current efforts to address these include the development of new models of care, such as 'digital clinics' that integrate health apps. Other contemporary innovations in the field such as digital sensing and just-in-time adaptive interventions are showing early promise for providing accessible and personalised care.

Grant Report on SCH: Personalized Depression Treatment Supported by Mobile Sensor Analytics

We report on the newly started project "SCH: Personalized Depression Treatment Supported by Mobile Sensor Analytics". The current best practice guidelines for treating depression call for close monitoring of patients, and periodically adjusting treatment as needed. This project will advance personalized depression treatment by developing a system, DepWatch, that leverages mobile health technologies and machine learning tools. The objective of DepWatch is to assist clinicians with their decision making process in the management of depression. The project comprises two studies. Phase I collects sensory data and other data, e.g., clinical data, ecological momentary assessments (EMA), tolerability and safety data from 250 adult participants with unstable depression symptomatology initiating depression treatment. The data thus collected will be used to develop and validate assessment and prediction models, which will be incorporated into DepWatch system. In Phase II, three clinicians will use DepWatch to support their clinical decision making process. A total of 128 participants under treatment by the three participating clinicians will be recruited for the study. A number of new machine learning techniques will be developed.

Smartphones in mental health: a critical review of background issues, current status and future concerns

There has been increasing interest in the use of smartphone applications (apps) and other consumer technology in mental health care for a number of years. However, the vision of data from apps seamlessly returned to, and integrated in, the electronic medical record (EMR) to assist both psychiatrists and patients has not been widely achieved, due in part to complex issues involved in the use of smartphone and other consumer technology in psychiatry. These issues include consumer technology usage, clinical utility, commercialization, and evolving consumer technology. Technological, legal and commercial issues, as well as medical issues, will determine the role of consumer technology in psychiatry. Recommendations for a more productive direction for the use of consumer technology in psychiatry are provided.

[Ambulatory monitoring and digital phenotyping in the diagnostics and treatment of bipolar disorders]

BACKGROUND

Reliable and valid diagnostics and treatment of bipolar disorders and affective episodes are subject to extensive, especially methodological limitations in the clinical practice.

OBJECTIVE

The use of smartphones and mobile sensor technology for improvement in diagnostics and treatment of bipolar disorders.

METHODS

Critical discussion of current research on the use of ambulatory monitoring and digital phenotyping with bipolar disorders.

RESULTS

In many studies the observation periods were too short and the sensors applied were too inaccurate to enable reliable and valid detection of behavioral changes in the context of affective episodes.

CONCLUSION

The clarification and operationalization of psychopathological constructs to allow for the measurement of objectively observable and ascertainable behavioral changes during depressive and (hypo)manic states are essential for the successful application of modern mobile technologies in the diagnostics and treatment of bipolar disorders.

Methodological Challenges in Randomized Controlled Trials on Smartphone-Based Treatment in Psychiatry: Systematic Review

BACKGROUND

Smartphone-based technology is developing at high speed, and many apps offer potential new ways of monitoring and treating a range of psychiatric disorders and symptoms. However, the effects of most available apps have not been scientifically investigated. Within medicine, randomized controlled trials (RCTs) are the standard method for providing the evidence of effects. However, their rigidity and long time frame may contrast with the field of information technology research. Therefore, a systematic review of methodological challenges in designing and conducting RCTs within mobile health is needed.

OBJECTIVE

This systematic review aimed to (1) identify and describe RCTs investigating the effect of smartphone-based treatment in adult patients with a psychiatric diagnosis, (2) discuss methodological challenges in designing and conducting individual trials, and (3) suggest recommendations for future trials.

METHODS

A systematic search in English was conducted in PubMed, PsycINFO, and EMBASE up to August 12, 2019. The search terms were (1) psychiatric disorders in broad term and for specific disorders AND (2) smartphone or app AND (3) RCT. The Consolidated Standards of Reporting Trials electronic health guidelines were used as a template for data extraction. The focus was on trial design, method, and reporting. Only trials having sufficient information on diagnosis and acceptable diagnostic procedures, having a smartphone as a central part of treatment, and using an RCT design were included.

RESULTS

A total of 27 trials comprising 3312 patients within a range of psychiatric diagnoses were included. Among them, 2 trials were concerning drug or alcohol abuse, 3 psychosis, 10 affective disorders, 9 anxiety and posttraumatic stress disorder, 1 eating disorder, and 1 attention-deficit/hyperactivity disorder. In addition, 1 trial used a cross-diagnostic design, 7 trials included patients with a clinical diagnosis that was subsequently assessed and validated by the researchers, and 11 trials had a sample size above 100. Generally, large between-trial heterogeneity and multiple approaches to patient recruitment, diagnostic procedures, trial design, comparator, outcome measures, and analyses were identified. Only 5 trials published a trial protocol. Furthermore, 1 trial provided information regarding technological updates, and only 18 trials reported on the conflicts of interest. No trial addressed the ethical aspects of using smartphones in treatment.

CONCLUSIONS

This first systematic review of the methodological challenges in designing and conducting RCTs investigating smartphone-based treatment in psychiatric patients suggests an increasing number of trials but with a lower quality compared with classic medical RCTs. Heterogeneity and methodological issues in individual trials limit the evidence. Methodological recommendations are presented.

Toward clinical digital phenotyping: a timely opportunity to consider purpose, quality, and safety

The use of data generated passively by personal electronic devices, such as smartphones, to measure human function in health and disease has generated significant research interest. Particularly in psychiatry, objective, continuous quantitation using patients' own devices may result in clinically useful markers that can be used to refine diagnostic processes, tailor treatment choices, improve condition monitoring for actionable outcomes, such as early signs of relapse, and develop new intervention models. If a principal goal for digital phenotyping is clinical improvement, research needs to attend now to factors that will help or hinder future clinical adoption. We identify four opportunities for research directed toward this goal: exploring intermediate outcomes and underlying disease mechanisms; focusing on purposes that are likely to be used in clinical practice; anticipating quality and safety barriers to adoption; and exploring the potential for digital personalized medicine arising from the integration of digital phenotyping and digital interventions. Clinical relevance also means explicitly addressing consumer needs, preferences, and acceptability as the ultimate users of digital phenotyping interventions. There is a risk that, without such considerations, the potential benefits of digital phenotyping are delayed or not realized because approaches that are feasible for application in healthcare, and the evidence required to support clinical commissioning, are not developed. Practical steps to accelerate this research agenda include the further development of digital phenotyping technology platforms focusing on scalability and equity, establishing shared data repositories and common data standards, and fostering multidisciplinary collaborations between clinical stakeholders (including patients), computer scientists, and researchers.

Findings From a Trial of the Smartphone and OnLine Usage-based eValuation for Depression (SOLVD) Application: What Do Apps Really Tell Us About Patients with Depression? Concordance Between App-Generated Data and Standard Psychiatric Questionnaires for Depression and Anxiety

OBJECTIVE

Depression imposes a notable societal burden, with limited treatment success despite multiple available psychotherapy and medications choices. Potential reasons may include the heterogeneity of depression diagnoses and the presence of comorbid anxiety symptoms. Despite technological advances and the introduction of many mobile phone applications (apps) claiming to relieve depression, major gaps in knowledge still exist regarding what apps truly measure and how they correlate with psychometric questionnaires. The goal of this study was to evaluate whether mobile daily mood self-ratings may be useful in monitoring and classifying depression symptoms in a clinically depressed population compared with standard psychometric instruments including the Patient Health Questionaire-9 (PHQ-9), the Hamilton Rating Scale for Depression (HAM-D), and the Hamilton Anxiety Rating Scale (HAM-A).

METHOD

For this study, 22 patients with major depressive disorder with or without comorbid anxiety disorder were recruited. The diagnosis of depression was confirmed through the Mini International Neuropsychiatric Interview (MINI). Over an 8-week period, daily moods were self-reported through the Smartphone and OnLine Usage-based eValuation for Depression (SOLVD) application, a custom-designed application that was downloaded onto patients' mobile devices. Depression and anxiety symptoms were also measured biweekly using the HAM-D, HAM-A, and PHQ-9.

RESULTS

Significant correlations were observed among self-evaluated mood, daily steps taken, SMS (text) frequency, average call duration, and biweekly psychometric scores (|r|>0.5, P<0.05). The correlation coefficients were higher in individuals with more severe depressive symptoms.

CONCLUSIONS

Although this study, given its limited sample size, was exploratory in nature, it helps fill a significant gap in our knowledge of the concordance between ratings obtained on the Ham-D, Ham-A, and the PHQ-9 psychometric instruments and data obtained via a smartphone app. These questionnaires represent gold-standard, commonly used psychiatric research/clinical instruments, and, thus, this information can serve as a foundation for digital phenotyping for depression and pave the way for interventional studies using smartphone applications.

Current understanding of bipolar disorder: Toward integration of biological basis and treatment strategies

Biological studies of bipolar disorder initially focused on the mechanism of action for antidepressants and antipsychotic drugs, and the roles of monoamines (e.g., serotonin, dopamine) have been extensively studied. Thereafter, based on the mechanism of action of lithium, intracellular signal transduction systems, including inositol metabolism and intracellular calcium signaling, have drawn attention. Involvement of intracellular calcium signaling has been supported by genetics and cellular studies. Elucidation of the neural circuits affected by calcium signaling abnormalities is critical, and our previous study suggested a role of the paraventricular thalamic nucleus. The genetic vulnerability of mitochondria causes calcium dysregulation and results in the hyperexcitability of serotonergic neurons, which are suggested to be susceptible to oxidative stress. Efficacy of anticonvulsants, animal studies of candidate genes, and studies using induced pluripotent stem cell-derived neurons have suggested a relation between bipolar disorder and the hyperexcitability of neurons. Recent genetic findings suggest the roles of polyunsaturated acids. At the systems level, social rhythm therapy targets circadian rhythm abnormalities, and cognitive behavioral therapy may target emotion/cognition (E/C) imbalance. In the future, pharmacological and psychosocial treatments may be combined and optimized based on the biological basis of each patient, which will realize individualized treatment.

Passive Sensing of Health Outcomes Through Smartphones: Systematic Review of Current Solutions and Possible Limitations

BACKGROUND

Technological advancements, together with the decrease in both price and size of a large variety of sensors, has expanded the role and capabilities of regular mobile phones, turning them into powerful yet ubiquitous monitoring systems. At present, smartphones have the potential to continuously collect information about the users, monitor their activities and behaviors in real time, and provide them with feedback and recommendations.

OBJECTIVE

This systematic review aimed to identify recent scientific studies that explored the passive use of smartphones for generating health- and well-being-related outcomes. In addition, it explores users' engagement and possible challenges in using such self-monitoring systems.

METHODS

A systematic review was conducted, following Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines, to identify recent publications that explore the use of smartphones as ubiquitous health monitoring systems. We ran reproducible search queries on PubMed, IEEE Xplore, ACM Digital Library, and Scopus online databases and aimed to find answers to the following questions: (1) What is the study focus of the selected papers? (2) What smartphone sensing technologies and data are used to gather health-related input? (3) How are the developed systems validated? and (4) What are the limitations and challenges when using such sensing systems?

RESULTS

Our bibliographic research returned 7404 unique publications. Of these, 118 met the predefined inclusion criteria, which considered publication dates from 2014 onward, English language, and relevance for the topic of this review. The selected papers highlight that smartphones are already being used in multiple health-related scenarios. Of those, physical activity (29.6%; 35/118) and mental health (27.9; 33/118) are 2 of the most studied applications. Accelerometers (57.7%; 67/118) and global positioning systems (GPS; 40.6%; 48/118) are 2 of the most used sensors in smartphones for collecting data from which the health status or well-being of its users can be inferred.

CONCLUSIONS

One relevant outcome of this systematic review is that although smartphones present many advantages for the passive monitoring of users' health and well-being, there is a lack of correlation between smartphone-generated outcomes and clinical knowledge. Moreover, user engagement and motivation are not always modeled as prerequisites, which directly affects user adherence and full validation of such systems.

Early intervention for obsessive compulsive disorder: An expert consensus statement

Obsessive-compulsive disorder (OCD) is common, emerges early in life and tends to run a chronic, impairing course. Despite the availability of effective treatments, the duration of untreated illness (DUI) is high (up to around 10 years in adults) and is associated with considerable suffering for the individual and their families. This consensus statement represents the views of an international group of expert clinicians, including child and adult psychiatrists, psychologists and neuroscientists, working both in high and low and middle income countries, as well as those with the experience of living with OCD. The statement draws together evidence from epidemiological, clinical, health economic and brain imaging studies documenting the negative impact associated with treatment delay on clinical outcomes, and supporting the importance of early clinical intervention. It draws parallels between OCD and other disorders for which early intervention is recognized as beneficial, such as psychotic disorders and impulsive-compulsive disorders associated with problematic usage of the Internet, for which early intervention may prevent the development of later addictive disorders. It also generates new heuristics for exploring the brain-based mechanisms moderating the 'toxic' effect of an extended DUI in OCD. The statement concludes that there is a global unmet need for early intervention services for OC related disorders to reduce the unnecessary suffering and costly disability associated with under-treatment. New clinical staging models for OCD that may be used to facilitate primary, secondary and tertiary prevention within this context are proposed.

Mobile Phone and Wearable Sensor-Based mHealth Approaches for Psychiatric Disorders and Symptoms: Systematic Review

BACKGROUND

Mobile Therapeutic Attention for Patients with Treatment-Resistant Schizophrenia (m-RESIST) is an EU Horizon 2020-funded project aimed at designing and validating an innovative therapeutic program for treatment-resistant schizophrenia. The program exploits information from mobile phones and wearable sensors for behavioral tracking to support intervention administration.

OBJECTIVE

To systematically review original studies on sensor-based mHealth apps aimed at uncovering associations between sensor data and symptoms of psychiatric disorders in order to support the m-RESIST approach to assess effectiveness of behavioral monitoring in therapy.

METHODS

A systematic review of the English-language literature, according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines, was performed through Scopus, PubMed, Web of Science, and the Cochrane Central Register of Controlled Trials databases. Studies published between September 1, 2009, and September 30, 2018, were selected. Boolean search operators with an iterative combination of search terms were applied.

RESULTS

Studies reporting quantitative information on data collected from mobile use and/or wearable sensors, and where that information was associated with clinical outcomes, were included. A total of 35 studies were identified; most of them investigated bipolar disorders, depression, depression symptoms, stress, and symptoms of stress, while only a few studies addressed persons with schizophrenia. The data from sensors were associated with symptoms of schizophrenia, bipolar disorders, and depression.

CONCLUSIONS

Although the data from sensors demonstrated an association with the symptoms of schizophrenia, bipolar disorders, and depression, their usability in clinical settings to support therapeutic intervention is not yet fully assessed and needs to be scrutinized more thoroughly.

OpenSIMPLe: A real-world implementation feasibility study of a smartphone-based psychoeducation programme for bipolar disorder

BACKGROUND

Few evidence-based mental health apps are widely available to patients and, conversely, many of the available apps have not been appropriately evaluated. Given that the ultimate goal is to scale-up and open internet-based platforms (IBP), it is crucial to appropriately evaluate their real-world feasibility beforehand. We aimed to evaluate the implementation feasibility of a smartphone-based psychoeducational programme for bipolar disorder, exploring its long-term retention, usability, perceived helpfulness and satisfaction, alongside its impact on secondary health outcomes.

METHODS

Participants were recruited via the project website after completing an online screening questionnaire. They were requested to complete web-based questionnaires before using the app and after 6 months of use which included sociodemographic, illness and treatment variables, the world health organisation-five well-being index (WHO-5) and the short form health survey (SF-36). The follow-up questionnaires also contained satisfaction and usefulness questions.

RESULTS

201 participants took part in the study. According to their retention, 66.2% of the participants were classified as noncompleters and 33.8% as completers. The only predictor significantly associated with higher odds of retention was older age (OR = 1.021, p < 0.001). 62% of the users reported they were satisfied with the programme with a higher percentage among completers. Who-5 baseline and follow-up scores showed a significant improvement as well as 6 out of 8 domains of the SF-36.

LIMITATIONS

Screening and outcome measures were administered using exclusively self-reported online methods.

CONCLUSION

The 6-month attrition rate of the programme was high. Positive outcomes regarding satisfaction were found predominantly among completers. The optimal dosage and retention of IBP mental health programmes remain challenging issues that need further research.

Effectiveness of smartphone-based ambulatory assessment (SBAA-BD) including a predicting system for upcoming episodes in the long-term treatment of patients with bipolar disorders: study protocol for a randomized controlled single-blind trial

BACKGROUND

The detection of early warning signs is essential in the long-term treatment of bipolar disorders. However, in bipolar patients' daily life and outpatient treatment the assessment of upcoming state changes faces several difficulties. In this trial, we examine the effectiveness of a smartphone based automated feedback about ambulatory assessed early warning signs in prolonging states of euthymia and therefore preventing hospitalization. This study aims to assess, whether patients experience longer episodes of euthymia, when their treating psychiatrists receive automated feedback about changes in communication and activity. With this additional information an intervention at an earlier stage in the development of mania or depression could be facilitated. We expect that the amount of time will be longer between affective episodes in the intervention group.

METHODS/DESIGN

The current study is designed as a randomized, multi-center, observer-blind, active-control, parallel group trial within a nationwide research project on the topic of innovative methods for diagnostics, prevention and interventions of bipolar disorders. One hundred and twenty patients with bipolar disorder will be randomly assigned to (1) the experimental group with included automated feedback or (2) the control group without feedback. During the intervention phase, the psychopathologic state of all participants is assessed every four weeks over 18 months. Kaplan-Meier estimators will be used for estimating the survival functions, a Log-Rank test will be used to formally compare time to a new episode across treatment groups. An intention-to-treat analysis will include data from all randomized patients.

DISCUSSION

This article describes the design of a clinical trial investigating the effectiveness of a smartphone-based feedback loop. This feedback loop is meant to elicit early interventions at the detection of warning signs for the prevention of affective episodes in bipolar patients. This approach will hopefully improve the chances of a timely intervention helping patients to keep a balanced mood for longer periods of time. In detail, if our hypothesis can be confirmed, clinical practice treating psychiatrists will be enabled to react quickly when changes are automatically detected. Therefore, outpatients would receive an even more individually tailored treatment concerning time and frequency of doctor's appointments.

TRIAL REGISTRATION

ClinicalTrials.gov : NCT02782910 : Title: "Smartphone-based Ambulatory Assessment of Early Warning Signs (BipoLife_A3)". Registered May 25 2016. Protocol Amendment Number: 03. Issue Date: 26 March 2018. Author(s): ES.

Recent developments in the use of smartphone interventions for mental health

PURPOSE OF REVIEW

The purpose of this update is to provide an overview of the breadth of research studies published from April 2017 to April 2018 on mobile-based interventions for mental health, with a special emphasis on smartphone-based interventions.

RECENT FINDINGS

Several studies during the review period have described the process of applying user-centred design in the development of mental health apps and novel approaches to enhance user-engagement. Studies on consumer perspectives indicate largely positive findings about open-ness to utilize mental health apps. There is a scarcity of similar studies on health providers. Efficacy studies have provided evidence for apps for a variety of psychiatric disorders. There are fewer studies on preventive and promotive interventions. Although a plethora of mental health apps is available for public, most have not undergone scientific evaluation. Many well researched apps are not accessible to public. The potential of smartphone technology in enhancing healthcare service delivery in low-resource settings has also been examined in a few studies.

SUMMARY

Evidence for acceptability, feasibility and efficacy of mobile-based mental health interventions for facilitating recovery is on the rise. More research is needed on implementation and integration of these interventions in diverse real-world clinical and community contexts.

Review of Use of Asynchronous Technologies Incorporated in Mental Health Care

PURPOSE OF REVIEW

Mental health clinicians should understand how technologies augment, enhance, and provide alternate means for the delivery of mental healthcare. These technologies can be used asynchronously, in which the patient and the clinician need not be communicating at the same time. This contrasts with synchronous technologies, in which patient and clinician must communicate at the same time.

RECENT FINDINGS

The review is based on research literature and the authors' clinical and healthcare administration experiences. Asynchronous technologies can exist between a single clinician and a single patient, such as patient portal e-mail and messaging, in-app messaging, asynchronous telepsychiatry via store-and-forward video, and specialty patient-to-provider mobile apps. Asynchronous technologies have already been used in different countries with success, and can alleviate the psychiatric workforce shortage and improve barriers to access. Multiple studies referred to in this review demonstrate good retention and acceptability of asynchronous psychotherapy interventions by patients. Asynchronous technologies can alleviate access barriers, such as geographical, scheduling, administrative, and financial issues. It is important for clinicians to understand the efficacy, assess the ethics, and manage privacy and legal concerns that may arise from using asynchronous technologies.

Predicting Social Anxiety From Global Positioning System Traces of College Students: Feasibility Study

BACKGROUND

Social anxiety is highly prevalent among college students. Current methodologies for detecting symptoms are based on client self-report in traditional clinical settings. Self-report is subject to recall bias, while visiting a clinic requires a high level of motivation. Assessment methods that use passively collected data hold promise for detecting social anxiety symptoms and supplementing self-report measures. Continuously collected location data may provide a fine-grained and ecologically valid way to assess social anxiety in situ.

OBJECTIVE

The objective of our study was to examine the feasibility of leveraging noninvasive mobile sensing technology to passively assess college students' social anxiety levels. Specifically, we explored the different relationships between mobility and social anxiety to build a predictive model that assessed social anxiety from passively generated Global Positioning System (GPS) data.

METHODS

We recruited 228 undergraduate participants from a Southeast American university. Social anxiety symptoms were assessed using self-report instruments at a baseline laboratory session. An app installed on participants' personal mobile phones passively sensed data from the GPS sensor for 2 weeks. The proposed framework supports longitudinal, dynamic tracking of college students to evaluate the relationship between their social anxiety and movement patterns in the college campus environment. We first extracted the following mobility features: (1) cumulative staying time at each different location, (2) the distribution of visits over time, (3) the entropy of locations, and (4) the frequency of transitions between locations. Next, we studied the correlation between these features and participants' social anxiety scores to enhance the understanding of how students' social anxiety levels are associated with their mobility. Finally, we used a neural network-based prediction method to predict social anxiety symptoms from the extracted daily mobility features.

RESULTS

Several mobility features correlated with social anxiety levels. Location entropy was negatively associated with social anxiety (during weekdays, r=-0.67; and during weekends, r=-0.51). More (vs less) socially anxious students were found to avoid public areas and engage in less leisure activities during evenings and weekends, choosing instead to spend more time at home after school (4 pm-12 am). Our prediction method based on extracted mobility features from GPS trajectories successfully classified participants as high or low socially anxious with an accuracy of 85% and predicted their social anxiety score (on a scale of 0-80) with a root-mean-square error of 7.06.

CONCLUSIONS

Results indicate that extracting and analyzing mobility features may help to reveal how social anxiety symptoms manifest in the daily lives of college students. Given the ubiquity of mobile phones in our society, understanding how to leverage passively sensed data has strong potential to address the growing needs for mental health monitoring and treatment.

Smartphones, Sensors, and Machine Learning to Advance Real-Time Prediction and Interventions for Suicide Prevention: a Review of Current Progress and Next Steps

PURPOSE OF REVIEW

As rates of suicide continue to rise, there is urgent need for innovative approaches to better understand, predict, and care for those at high risk of suicide. Numerous mobile and sensor technology solutions have already been proposed, are in development, or are already available today. This review seeks to assess their clinical evidence and help the reader understand the current state of the field.

RECENT FINDINGS

Advances in smartphone sensing, machine learning methods, and mobile apps directed towards reducing suicide offer promising evidence; however, most of these innovative approaches are still nascent. Further replication and validation of preliminary results is needed. Whereas numerous promising mobile and sensor technology based solutions for real time understanding, predicting, and caring for those at highest risk of suicide are being studied today, their clinical utility remains largely unproven. However, given both the rapid pace and vast scale of current research efforts, we expect clinicians will soon see useful and impactful digital tools for this space within the next 2 to 5 years.