Rising early warning signals in affect associated with future changes in depression: a dynamical systems approach

BACKGROUND

Predicting future states of psychopathology such as depressive episodes has been a hallmark initiative in mental health research. Dynamical systems theory has proposed that rises in certain 'early warning signals' (EWSs) in time-series data (e.g. auto-correlation, temporal variance, network connectivity) may precede impending changes in disorder severity. The current study investigates whether rises in these EWSs over time are associated with future changes in disorder severity among a group of patients with major depressive disorder (MDD).

METHODS

Thirty-one patients with MDD completed the study, which consisted of daily smartphone-delivered surveys over 8 weeks. Daily positive and negative affect were collected for the time-series analyses. A rolling window approach was used to determine whether rises in auto-correlation of total affect, temporal standard deviation of total affect, and overall network connectivity in individual affect items were predictive of increases in depression symptoms.

RESULTS

Results suggested that rises in auto-correlation were significantly associated with worsening in depression symptoms (r = 0.41, p = 0.02). Results indicated that neither rises in temporal standard deviation (r = -0.23, p = 0.23) nor in network connectivity (r = -0.12, p = 0.59) were associated with changes in depression symptoms.

CONCLUSIONS

This study more rigorously examines whether rises in EWSs were associated with future depression symptoms in a larger group of patients with MDD. Results indicated that rises in auto-correlation were the only EWS that was associated with worsening future changes in depression.

Real-time digital monitoring of a suicide attempt by a hospital patient

Suicide is among the most devastating problems facing clinicians, who currently have limited tools to predict and prevent suicidal behavior. Here we report on real-time, continuous smartphone and sensor data collected before, during, and after a suicide attempt made by a patient during a psychiatric inpatient hospitalization. We observed elevated and persistent sympathetic nervous system arousal and suicidal thinking leading up to the suicide attempt. This case provides the highest resolution data to date on the psychological, psychophysiological, and behavioral markers of imminent suicidal behavior and highlights new directions for prediction and prevention efforts.

A-13 A Description of Patient Characteristics and Predictors for Vestibular Therapy Referral Following Concussion

Purpose: To describe patient characteristics and predictors for vestibular therapy referral among concussion patients with vestibular and ocular motor dysfunction. Methods: Medical records from 1083 patients (12-50 yrs) seeking care for concussion within 30 days of injury were extracted. Demographics and clinical outcomes (symptoms, vestibular/oculomotor change scores, and state anxiety) were described and associations between referral and these variables were explored with chi-square analyses and a logistic regression. Results: Twenty-one percent (229/1083, Mage = 22.34, SD = 10.26 yrs, 64% female) of patients received vestibular therapy referral. The most frequent risk factors included symptom burden (94%), vestibular/ocular motor symptom provocation (88%), convergence insufficiency (73%), state anxiety (66%), and post-traumatic migraine (PTM) (52%). The LR (χ2(13, 1083) = 142.24, p < 0.001) revealed vestibular/ocular motor provocation (adjusted OR = 3.88, p < 0.001) showed the greatest likelihood for referral followed by symptom burden (adjusted OR = 2.78, p < 0.001), convergence insufficiency (adjusted OR = 2.77, p < 0.001), first clinical visit longer than one week (adjusted OR = 1.90, p < 0.001), and on-field dizziness (adjusted OR = 1.51, p = 0.03). Conclusions: Approximately 25% of concussed patients receive vestibular therapy. These patients have more vestibular/ocular motor impairment, dizziness, and overall symptom burden.

Measuring Health-Related Quality of Life With Multimodal Data: Viewpoint

The ability to objectively measure aspects of performance and behavior is a fundamental pillar of digital health, enabling digital wellness products, decentralized trial concepts, evidence generation, digital therapeutics, and more. Emerging multimodal technologies capable of measuring several modalities simultaneously and efforts to integrate inputs across several sources are further expanding the limits of what digital measures can assess. Experts from the field of digital health were convened as part of a multi-stakeholder workshop to examine the progress of multimodal digital measures in two key areas: detection of disease and the measurement of meaningful aspects of health relevant to the quality of life. Here we present a meeting report, summarizing key discussion points, relevant literature, and finally a vision for the immediate future, including how multimodal measures can provide value to stakeholders across drug development and care delivery, as well as three key areas where headway will need to be made if we are to continue to build on the encouraging progress so far: collaboration and data sharing, removal of barriers to data integration, and alignment around robust modular evaluation of new measurement capabilities.

Monitoring Changes in Depression Severity Using Wearable and Mobile Sensors

Background: While preliminary evidence suggests that sensors may be employed to detect presence of low mood it is still unclear whether they can be leveraged for measuring depression symptom severity. This study evaluates the feasibility and performance of assessing depressive symptom severity by using behavioral and physiological features obtained from wristband and smartphone sensors. Method: Participants were thirty-one individuals with Major Depressive Disorder (MDD). The protocol included 8 weeks of behavioral and physiological monitoring through smartphone and wristband sensors and six in-person clinical interviews during which depression was assessed with the 17-item Hamilton Depression Rating Scale (HDRS-17). Results: Participants wore the right and left wrist sensors 92 and 94% of the time respectively. Three machine-learning models estimating depressive symptom severity were developed-one combining features from smartphone and wearable sensors, one including only features from the smartphones, and one including features from wrist sensors-and evaluated in two different scenarios. Correlations between the models' estimate of HDRS scores and clinician-rated HDRS ranged from moderate to high (0.46 [CI: 0.42, 0.74] to 0.7 [CI: 0.66, 0.74]) and had moderate accuracy with Mean Absolute Error ranging between 3.88 ± 0.18 and 4.74 ± 1.24. The time-split scenario of the model including only features from the smartphones performed the best. The ten most predictive features in the model combining physiological and mobile features were related to mobile phone engagement, activity level, skin conductance, and heart rate variability. Conclusion: Monitoring of MDD patients through smartphones and wrist sensors following a clinician-rated HDRS assessment is feasible and may provide an estimate of changes in depressive symptom severity. Future studies should further examine the best features to estimate depressive symptoms and strategies to further enhance accuracy.

Vomit Comet Physiology: Autonomic Changes in Novice Flyers

This exploratory study examined the effects of varying g-forces, including feelings of weightlessness, on an individual's physiology during parabolic flight. Specifically, we collected heart rate, accelerometer, and skin conductance measurements from 16 flyers aboard a parabolic flight using wearable, wireless sensors. The biosignals were then correlated to participant reports of nausea, anxiety, and excitement during periods of altered g-forces. Using linear mixed-effects models, we found that (1) heart rate was positively correlated to individuals' self-reported highest/lowest periods of both anxiety and excitement, and (2) bilateral skin conductance asymmetry was positively correlated to individuals' self-reported highest/lowest periods of nausea.

Negative affect is more strongly associated with suicidal thinking among suicidal patients with borderline personality disorder than those without

Patients suffering from borderline personality disorder (BPD) are at elevated risk for suicidal thoughts and behaviors (STBs), but this well-described and clinically important association is not well-understood. Prior research suggests that STBs often function as an attempt to escape aversive affect, and that people with BPD experience stronger emotion reactivity and greater discomfort with emotion than those without BPD. Here, we tested whether negative affective states are more likely to predict suicidal thoughts among those with BPD than those without this disorder. Data on affective states and suicidal thoughts were collected several times per day from 35 psychiatric inpatients using their smartphones to capture real-time associations between negative affect and suicidal thoughts. Results revealed that the association between negative affective states (e.g., abandonment, desperation, guilt, hopelessness, loneliness, rage, self-hatred, and upset), and severity of suicidal thinking was stronger among those with BPD than among those without BPD. This finding has implications for risk assessment and intervention in the clinical setting: for a given degree of reported negative affect, patients with BPD experience more suicidal ideation than those without. Further research needs to be done to elucidate the mechanism of this effect.

Digital phenotyping of suicidal thoughts

BACKGROUND

To examine whether there are subtypes of suicidal thinking using real-time digital monitoring, which allows for the measurement of such thoughts with greater temporal granularity than ever before possible.

METHODS

We used smartphone-based real-time monitoring to assess suicidal thoughts four times per day in two samples: Adults who attempted suicide in the past year recruited from online forums (n = 51 participants with a total of 2,889 responses, surveyed over 28 days; ages ranged from 18 to 38 years) and psychiatric inpatients with recent suicidal ideation or attempts (n = 32 participants with a total of 640 responses, surveyed over the duration of inpatient treatment [mean stay = 8.79 days], ages ranged 23-68 years). Latent profile analyses were used to identify distinct phenotypes of suicidal thinking based on the frequency, intensity, and variability of such thoughts.

RESULTS

Across both samples, five distinct phenotypes of suicidal thinking emerged that differed primarily on the intensity and variability of suicidal thoughts. Participants whose profile was characterized by more severe, persistent suicidal thoughts (i.e., higher mean and lower variability around the mean) were most likely to have made a recent suicide attempt.

CONCLUSIONS

Suicidal thinking has historically been studied as a homogeneous construct, but using newly available monitoring technology we discovered five profiles of suicidal thinking. Key questions for future research include how these phenotypes prospectively relate to future suicidal behaviors, and whether they represent remain stable or trait-like over longer periods.

Examination of real-time fluctuations in suicidal ideation and its risk factors: Results from two ecological momentary assessment studies

Two studies examined 2 important but previously unanswered questions about the experience of suicidal ideation: (a) How does suicidal ideation vary over short periods of time?, and (b) To what degree do risk factors for suicidal ideation vary over short periods and are such changes associated with changes in suicidal ideation? Participants in Study 1 were 54 adults who had attempted suicide in the previous year and completed 28 days of ecological momentary assessment (EMA; average of 2.51 assessments per day; 2,891 unique assessments). Participants in Study 2 were 36 adult psychiatric inpatients admitted for suicide risk who completed EMA throughout their time in the hospital (average stay of 10.32 days; average 2.48 assessments per day; 649 unique assessments). These studies revealed 2 key findings: (a) For nearly all participants, suicidal ideation varied dramatically over the course of most days: more than 1-quarter (Study 1 = 29%; Study 2 = 28%) of all ratings of suicidal ideation were a standard deviation above or below the previous response from a few hours earlier and nearly all (Study 1 = 94.1%; Study 2 = 100%) participants had at least 1 instance of intensity of suicidal ideation changing by a standard deviation or more from 1 response to the next. (b) Across both studies, well-known risk factors for suicidal ideation such as hopelessness, burdensomeness, and loneliness also varied considerably over just a few hours and correlated with suicidal ideation, but were limited in predicting short-term change in suicidal ideation. These studies represent the most fine-grained examination of suicidal ideation ever conducted. The results advance the understanding of how suicidal ideation changes over short periods and provide a novel method of improving the short-term prediction of suicidal ideation. (PsycINFO Database Record

Wavelet-based motion artifact removal for electrodermal activity

Electrodermal activity (EDA) recording is a powerful, widely used tool for monitoring psychological or physiological arousal. However, analysis of EDA is hampered by its sensitivity to motion artifacts. We propose a method for removing motion artifacts from EDA, measured as skin conductance (SC), using a stationary wavelet transform (SWT). We modeled the wavelet coefficients as a Gaussian mixture distribution corresponding to the underlying skin conductance level (SCL) and skin conductance responses (SCRs). The goodness-of-fit of the model was validated on ambulatory SC data. We evaluated the proposed method in comparison with three previous approaches. Our method achieved a greater reduction of artifacts while retaining motion-artifact-free data.

Automatic identification of artifacts in electrodermal activity data

Recently, wearable devices have allowed for long term, ambulatory measurement of electrodermal activity (EDA). Despite the fact that ambulatory recording can be noisy, and recording artifacts can easily be mistaken for a physiological response during analysis, to date there is no automatic method for detecting artifacts. This paper describes the development of a machine learning algorithm for automatically detecting EDA artifacts, and provides an empirical evaluation of classification performance. We have encoded our results into a freely available web-based tool for artifact and peak detection.

Response to Commentaries on “Multiple Arousal Theory and Daily-Life Electrodermal Activity Asymmetry”

We respond to the commentaries of Critchley and Nagai, Mendes, Norman, Sabatinelli, and Richter. We agree that a theory needs to make predictions and we elaborate on the predictions we made so far. We do not agree that arousal has to have a precise definition in order to present theory about it; however, we do provide concrete answers to questions raised about multiple arousal theory.

Multiple Arousal Theory and Daily-Life Electrodermal Activity Asymmetry

Using “big data” from sensors worn continuously outside the lab, researchers have observed patterns of objective physiology that challenge some of the long-standing theoretical concepts of emotion and its measurement. One challenge is that emotional arousal, when measured as sympathetic nervous system activation through electrodermal activity, can sometimes differ significantly across the two halves of the upper body. We show that traditional measures on only one side may lead to misjudgment of arousal. This article presents daily life and controlled study data, as well as existing evidence from neuroscience, supporting the influence of multiple emotional substrates in the brain causing innervation on different sides of the body. We describe how a theory of multiple arousals explains the asymmetric EDA findings.