Comparing Approaches to Mobile Depression Assessment for Measurement-Based Care: Prospective Study

Negative self-referent cognition predicts future depression symptom change: an intensive sampling approach

Cognitive theories of depression assert that negative self-referent cognition has a causal role in the development and maintenance of depression symptoms, but few studies have examined temporal associations between these constructs using intensive, longitudinal sampling strategies. In three samples of undergraduate students, we examined associations between change in self-referent processing and depression across 5 daily assessments (Sample 1, N = 303, 1,194 measurements, 79% adherence), 7 daily assessments (Sample 2, N = 313, 1,784 measurements, 81% adherence), and 7 weekly assessments (Sample 3; N = 155, 833 measurements, 81% adherence). Random intercept cross-lagged panel models indicated large cross-lagged effects in two of the three samples (Samples 1 and 3 but not Sample 2), such that more negative self-referent thinking than usual was significantly associated with a subsequent increase in depression symptoms at the next time lag. Notably, change in depression from usual was not associated with increases in negative self-referent processing at the next time point in any sample. These findings suggest that change in negative self-referent processing may be causally linked to future increases in depression on a day-to-day and week-to-week basis, although confidence in this conclusion is tempered somewhat by a lack of replication in Sample 2.

EMPOWERED trial: protocol for a randomised control trial of digitally supported, highly personalised and measurement-based care to improve functional outcomes in young people with mood disorders

OBJECTIVES

Many adolescents and young adults with emerging mood disorders do not achieve substantial improvements in education, employment, or social function after receiving standard youth mental health care. We have developed a new model of care referred to as 'highly personalised and measurement-based care' (HP&MBC). HP&MBC involves repeated assessment of multidimensional domains of morbidity to enable continuous and personalised clinical decision-making. Although measurement-based care is common in medical disease management, it is not a standard practice in mental health. This clinical effectiveness trial tests whether HP&MBC, supported by continuous digital feedback, delivers better functional improvements than standard care and digital support.

METHOD AND ANALYSIS

This controlled implementation trial is a PROBE study (Prospective, Randomised, Open, Blinded End-point) that comprises a multisite 24-month, assessor-blinded, follow-up study of 1500 individuals aged 15-25 years who present for mental health treatment. Eligible participants will be individually randomised (1:1) to 12 months of HP&MBC or standardised clinical care. The primary outcome measure is social and occupational functioning 12 months after trial entry, assessed by the Social and Occupational Functioning Assessment Scale. Clinical and social outcomes for all participants will be monitored for a further 12 months after cessation of active care.

ETHICS AND DISSEMINATION

This clinical trial has been reviewed and approved by the Human Research Ethics Committee of the Sydney Local Health District (HREC Approval Number: X22-0042 & 2022/ETH00725, Protocol ID: BMC-YMH-003-2018, protocol version: V.3, 03/08/2022). Research findings will be disseminated through peer-reviewed journals, presentations at scientific conferences, and to user and advocacy groups. Participant data will be deidentified.

TRIAL REGISTRATION NUMBER

ACTRN12622000882729.

The mediating role of loneliness on relations between face-to-face and virtual interactions and psychological well-being across age: A 21-day diary study

Lack of social interaction is associated with a heightened sense of loneliness and, in turn, poorer psychological well-being. Despite the prevalence of communicating with others virtually even when physically alone, whether the social interaction–loneliness–well-being relationship is different between face-to-face and virtual interactions and between younger and older adults is relatively understudied. This 21-day diary study examined this question among younger ( n = 91; Mage = 22.87) and older ( n = 107; Mage = 64.53) Hong Kong participants during the early stage of the COVID-19 pandemic (March–May 2020). We found significant indirect effects of shorter face-to-face interaction time on poorer psychological well-being via a heightened sense of loneliness at the within-person level only among younger adults and at the between-person level only among older adults. Independent of loneliness, spending more time with others on virtual interactions was associated with better psychological well-being only among older adults. Taken together, while the mechanisms may be different across age groups, face-to-face interaction remains an effective way to reduce loneliness and enhance psychological well-being even at times when it is discouraged (e.g., pandemic). Although virtual interaction does not reduce loneliness, its positive impact on older adults’ well-being sheds light on the utility of promoting technological acceptance in late adulthood.

Which Variant of Anxiety Is Associated with Smartphone Expertise in Community Dwelling Older Adults?

OBJECTIVES

Older adults vary greatly in their mastery of state-of-the-art smartphones. Anxiety may function as a barrier to technological expertise. This study characterizes an older community-dwelling sample (n = 71) in terms of their levels of demonstrated smartphone expertise relative to variants of anxiety (e.g., trait, social, tech-related).

METHODS

A 20-step behavioral smartphone challenge task, the Smartphone Task for Older Adults (STOA), was used to evaluate older adults' knowledge of a range of smartphone functions. Self-report measures of anxiety symptoms and perceived digital proficiency were also administered.

RESULTS

STOA scores were relatively low (x = 8.26, s.d. = 5.65) and showed negative relations with tech-anxiety and in-vivo frustration, but not social or trait anxiety. A hierarchical regression model indicated that tech-related anxiety and in-vivo frustration contributed significantly to STOA scores, above and beyond established predictors such as education.

CONCLUSIONS

Tech-anxiety and frustration while learning new smartphone functions may characterize the next cohort of older adults who have not effectively mastered the use of smartphones.

CLINICAL IMPLICATIONS

Anxiety management skills derived from cognitive behavior therapy and other self-regulation tools could help those who experience tech-anxiety or frustration during smartphone training, facilitating the development of expertise.

Behavioral Activation through Virtual Reality for Depression: A Single Case Experimental Design with Multiple Baselines

Behavioral activation (BA) is a structured psychotherapeutic approach for the treatment of major depressive disorder (MDD), which aims at increasing the engagement in activities that might bring enjoyment and meaning to patients' lives. Although a growing body of evidence supports the effectiveness of BA, enhancing the motivation and activity level of depressed patients is often challenging. In the present study, we explored the effectiveness of a brief BA treatment supported by virtual reality (VR) to facilitate the visualization and anticipation of four pleasurable activities that we tried to re-introduce in the patients' daily routine. To do so, we conducted a single-case experimental design with multiple baselines in a sample of patients with moderate to severe depressive symptoms. Three overlap analyses across participants and across behaviors were conducted to calculate the rate of improvement of each patient after the delivery of the intervention. Across the three overlap indices, the participants generally showed moderate-to-large improvements in the level of daily activity, as well as in the time spent planning and/or engaging in one or more activities scheduled during the intervention. Furthermore, most patients also reported a moderate-to-large reduction in daily depressive symptoms and improved mood. Overall, the promising results of the present study suggest that the proposed VR-based BA intervention might represent a valid approach to behaviorally activate depressed patients. The barriers and future lines of research of this innovative field are discussed.

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

BACKGROUND

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

OBJECTIVE

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

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

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

Professional legislation knowledge of dentists and psychological effects of negligence

INTRODUCTION

The aim of the present study was to evaluate the extent to which a group of general dentists and specialists had knowledge of the professional laws and psychological effects of negligence on them.

MATERIALS AND METHODS

The sample in this cross-sectional study consisted of 400 dentists (General dentists and specialists) in Isfahan city, Iran. Having designed the questionnaire and confirmed its validity and reliability, we published online to be completed by the dentists. The obtained data were analyzed using descriptive statistics, t-test, and ANOVA test. Optimal knowledge was determined to be 75%, and P-value<0.05 was considered to be statistically significant.

RESULTS

The majority of the dentists (75%) had poor and very poor knowledge. The mean score of knowledge (range: 0-21, maximum obtainable: 24) was 9.58 ± 4.5. Sixty dentists (15%) reported they had experienced negligence. Further, 278 (69.5%) reported they had somehow experienced the occurrence of malpractice during their practical experience. Legal negligence was more prevalent among the general dentists than specialists (17.8 VS 8%, p < 0.001). Regarding the legal complaint history, a significant difference was observed between the males and females (P = 0.015) and among different categories of work experience years (P = 0.000). Moreover, among those who had a history of a legal complaint, 96.7% showed psychological symptoms, 70% had physical symptoms, and 80% displayed social symptoms related to the stress following legal complaints.

CONCLUSION

Findings of this study indicated that refining the knowledge of the rules and regulations of the dental profession should be enhanced by considering appropriate training courses in the curricula and continuous education programs. More than half of the participants considered themselves guilty of negligence in this regard.

Using virtual reality to target positive autobiographical memory in individuals with moderate-to-moderately severe depressive symptoms: A single case experimental design

So far, several aspects of autobiographical memory (AM) have been found to be impaired in depression. Among others, depressed patients show the tendency to recall more negative than positive events (i.e., negative bias) and usually retrieve memories that lack of specificity and details (i.e., overgeneral memories). Based on this, we designed an AM task enhanced by the use of virtual reality (VR) to specifically train the recall of positive memories. Using a single-case, multiple baseline experimental design, we explored the effects of a brief intervention consisting of two sessions of this training in a sample of 18 individuals with moderate-to-moderately severe depressive symptoms. According to the results, changes occurred at the short term only. In particular, almost all participants reported a significant improvement in at least one outcome measure 0-3 days after the intervention. However, these clinical gains were not maintained in the mid-term (from day 4 to 10). The present findings do not support the efficacy of our VR-based AM recall treatment as a standalone intervention. Nevertheless, it might represent a suitable procedure to obtain immediate and/or short-term improvements. It might also serve as a valid component to be integrated in broader protocols for patients with moderate-to-moderately severe depressive symptoms.

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

For some youth, pathologic Internet use can cause significant distress and dysfunction, a phenomenon known as Problematic Internet Use (PIU). PIU has been associated with poorer health outcomes in adolescents with existing psychiatric illness but understanding PIU has been challenging due to research methodologies using cross-sectional, self-report data. This study assessed the feasibility of using app-based ecological momentary assessment (EMA) to provide more ecologically-valid data to identify and characterize the relationship between mood symptoms and PIU in adolescents in active mental health treatment. 25 youth (aged 12-23) were recruited to use an EMA app for 6 weeks. 96% of participants completed the study and the majority of participants completed surveys at least once weekly. Youth with anxiety disorders endorsed significantly greater benefit from using the app to monitor PIU. While PIU severity was positively correlated with worsened anxiety and depression, analyses of the temporal relationships between PIU and mood symptoms showed that anxiety symptoms were significantly improved after episodes of PIU. Overall results suggest that app-based EMA may be both acceptable and feasible to understand PIU in this population. Follow-up studies should consider personalization of study protocols and use of digital phenotyping methodology to collect more objective measurements of behavior.

A Combined Digital and Biomarker Diagnostic Aid for Mood Disorders (the Delta Trial): Protocol for an Observational Study

Background

Mood disorders affect hundreds of millions of people worldwide, imposing a substantial medical and economic burden. Existing diagnostic methods for mood disorders often result in a delay until accurate diagnosis, exacerbating the challenges of these disorders. Advances in digital tools for psychiatry and understanding the biological basis of mood disorders offer the potential for novel diagnostic methods that facilitate early and accurate diagnosis of patients.

Objective

The Delta Trial was launched to develop an algorithm-based diagnostic aid combining symptom data and proteomic biomarkers to reduce the misdiagnosis of bipolar disorder (BD) as a major depressive disorder (MDD) and achieve more accurate and earlier MDD diagnosis.

Methods

Participants for this ethically approved trial were recruited through the internet, mainly through Facebook advertising. Participants were then screened for eligibility, consented to participate, and completed an adaptive digital questionnaire that was designed and created for the trial on a purpose-built digital platform. A subset of these participants was selected to provide dried blood spot (DBS) samples and undertake a World Health Organization World Mental Health Composite International Diagnostic Interview (CIDI). Inclusion and exclusion criteria were chosen to maximize the safety of a trial population that was both relevant to the trial objectives and generalizable. To provide statistical power and validation sets for the primary and secondary objectives, 840 participants were required to complete the digital questionnaire, submit DBS samples, and undertake a CIDI.

Results

The Delta Trial is now complete. More than 3200 participants completed the digital questionnaire, 924 of whom also submitted DBS samples and a CIDI, whereas a total of 1780 participants completed a 6-month follow-up questionnaire and 1542 completed a 12-month follow-up questionnaire. The analysis of the trial data is now underway.

Conclusions

If a diagnostic aid is able to improve the diagnosis of BD and MDD, it may enable earlier treatment for patients with mood disorders.

International Registered Report Identifier (IRRID)

DERR1-10.2196/18453

Internet-Based Management for Depressive Disorder

The advances in the Internet and related technologies may lead to changes in professional roles of psychiatrists and psychotherapists. The application of artificial intelligence (AI) and electronic measurement-based care (eMBC) in the treatment of depressive disorder has addressed more interest. AI could play a role in population health management and patient administration as well as assist physicians to make a decision in the real-world clinical practice. The eMBC strengthens MBC through web/mobile devices and telephone consulting services, to monitor disease progression, and customizes the MBC interface in electronic medical record systems (EMRs).

Design feasibility of an automated, machine-learning based feedback system for motivational interviewing

Direct observation of psychotherapy and providing performance-based feedback is the gold-standard approach for training psychotherapists. At present, this requires experts and training human coding teams, which is slow, expensive, and labor intensive. Machine learning and speech signal processing technologies provide a way to scale up feedback in psychotherapy. We evaluated an initial proof of concept automated feedback system that generates motivational interviewing quality metrics and provides easy access to other session data (e.g., transcripts). The system automatically provides a report of session-level metrics (e.g., therapist empathy) and therapist behavior codes at the talk-turn level (e.g., reflections). We assessed usability, therapist satisfaction, perceived accuracy, and intentions to adopt. A sample of 21 novice (n = 10) or experienced (n = 11) therapists each completed a 10-min session with a standardized patient. The system received the audio from the session as input and then automatically generated feedback that therapists accessed via a web portal. All participants found the system easy to use and were satisfied with their feedback, 83% found the feedback consistent with their own perceptions of their clinical performance, and 90% reported they were likely to use the feedback in their practice. We discuss the implications of applying new technologies to evaluation of psychotherapy. (PsycINFO Database Record (c) 2019 APA, all rights reserved).