Momentary assessment technology as a tool to help patients with depression help themselves

The experience sampling method as an mHealth tool to support self-monitoring, self-insight, and personalized health care in clinical practice

BACKGROUND

The experience sampling method (ESM) builds an intensive time series of experiences and contexts in the flow of daily life, typically consisting of around 70 reports, collected at 8-10 random time points per day over a period of up to 10 days.

METHODS

With the advent of widespread smartphone use, ESM can be used in routine clinical practice. Multiple examples of ESM data collections across different patient groups and settings are shown and discussed, varying from an ESM evaluation of a 6-week randomized trial of mindfulness, to a twin study on emotion dynamics in daily life.

RESULTS

Research shows that ESM-based self-monitoring and feedback can enhance resilience by strengthening the capacity to use natural rewards. Personalized trajectories of starting or stopping medication can be more easily initiated and predicted if sensitive feedback data are available in real time. In addition, personalized trajectories of symptoms, cognitive abilities, symptoms impacting on other symptoms, the capacity of the dynamic system of mental health to "bounce back" from disturbance, and patterns of environmental reactivity yield uniquely personal data to support shared decision making and prediction in clinical practice. Finally, ESM makes it possible to develop insight into previous implicit patterns of thought, experience, and behavior, particularly if rapid personalized feedback is available.

CONCLUSIONS

ESM enhances clinical practice and research. It is empowering, providing co-ownership of the process of diagnosis, treatment evaluation, and routine outcome measurement. Blended care, based on a mix of face-to-face and ESM-based outside-the-office treatment, may reduce costs and improve outcomes.

Exploring the feasibility and usability of the experience sampling method to examine the daily lives of patients with acquired brain injury

The experience sampling method (ESM) is a structured diary method with high ecological validity, in that it accurately captures the everyday context of individuals through repeated measurements in naturalistic environments. Our main objective was to investigate the feasibility of using ESM in individuals with acquired brain injury (ABI). A second goal was to explore the usability of ESM data on a clinical level, by illustrating the interactions between person, environment, and affect. The PsyMate device provided ABI patients (N = 17) with ten signals (beeps) per day during six consecutive days. Each beep was followed by a digital questionnaire assessing mood, location, activities, social context, and physical well-being. Results demonstrated high feasibility with a 71% response rate and a 99% completion rate of the questionnaires. There were no dropouts and the method was experienced as user-friendly. Time-lagged multilevel analysis showed that higher levels of physical activity and fatigue predicted higher levels of negative affect at the same point in time, but not at later time points. This study illustrates the potential of ESM to identify complex person-environment dynamics after ABI, while generating understandable and easy to use graphical feedback.

Treating major depression with yoga: A prospective, randomized, controlled pilot trial

Background

Conventional pharmacotherapies and psychotherapies for major depression are associated with limited adherence to care and relatively low remission rates. Yoga may offer an alternative treatment option, but rigorous studies are few. This randomized controlled trial with blinded outcome assessors examined an 8-week hatha yoga intervention as mono-therapy for mild-to-moderate major depression.

Methods

Investigators recruited 38 adults in San Francisco meeting criteria for major depression of mild-to-moderate severity, per structured psychiatric interview and scores of 14–28 on Beck Depression Inventory-II (BDI). At screening, individuals engaged in psychotherapy, antidepressant pharmacotherapy, herbal or nutraceutical mood therapies, or mind-body practices were excluded. Participants were 68% female, with mean age 43.4 years (SD = 14.8, range = 22–72), and mean BDI score 22.4 (SD = 4.5). Twenty participants were randomized to 90-minute hatha yoga practice groups twice weekly for 8 weeks. Eighteen participants were randomized to 90-minute attention control education groups twice weekly for 8 weeks. Certified yoga instructors delivered both interventions at a university clinic. Primary outcome was depression severity, measured by BDI scores every 2 weeks from baseline to 8 weeks. Secondary outcomes were self-efficacy and self-esteem, measured by scores on the General Self-Efficacy Scale (GSES) and Rosenberg Self-Esteem Scale (RSES) at baseline and at 8 weeks.

Results

In intent-to-treat analysis, yoga participants exhibited significantly greater 8-week decline in BDI scores than controls (p-value = 0.034). In sub-analyses of participants completing final 8-week measures, yoga participants were more likely to achieve remission, defined per final BDI score ≤ 9 (p-value = 0.018). Effect size of yoga in reducing BDI scores was large, per Cohen’s d = -0.96 [95%CI, -1.81 to -0.12]. Intervention groups did not differ significantly in 8-week change scores for either the GSES or RSES.

Conclusion

In adults with mild-to-moderate major depression, an 8-week hatha yoga intervention resulted in statistically and clinically significant reductions in depression severity.

Trial registration

ClinicalTrials.gov NCT01210651

An Exploratory Randomized Controlled Trial of Personalized Lifestyle Advice and Tandem Skydives as a Means to Reduce Anhedonia

Anhedonia is a major public health concern and has proven particularly difficult to counteract. It has been hypothesized that anhedonia can be deterred by engagement in rewarding social and physical events. The aims of the present study were to examine (1) the effects of personalized lifestyle advice based on observed individual patterns of lifestyle factors and experienced pleasure in anhedonic young adults; and (2) whether a tandem skydive can enhance the motivation to carry out the recommended lifestyle changes. Participants (N = 69; M_age = 21.5, SD = 2.0; 79.7% female) were selected through an online screening survey among young adults. Inclusion criteria were persistent anhedonia and willingness to perform a tandem skydive. Participants filled out questionnaires on their smartphones for 2 consecutive months (3 times per day). After the first month, they were randomly assigned to one of three groups: (1) no intervention, (2) lifestyle advice, and (3) lifestyle advice and tandem skydive. The momentary questionnaire data were analyzed using interrupted time series analyses (ITSA) in a multilevel model and monthly pleasure and depression questionnaires by repeated measures ANOVA. No group differences were found in monthly depression and pleasure scores, but the momentary data showed higher positive affect (PA) and pleasure ratings in the month following the intervention in the two intervention groups than in the control group. The tandem skydive did not have any effects above the effects of the lifestyle advice. Our results indicate that providing personalized lifestyle advice to anhedonic young adults can be an effective way to increase PA and pleasure.

Reactivity to smartphone-based ecological momentary assessment of depressive symptoms (MoodMonitor): protocol of a randomised controlled trial

BACKGROUND

Ecological momentary assessment (EMA) of mental health symptoms may influence the symptoms that it measures, i.e. assessment reactivity. In the field of depression, EMA reactivity has received little attention. We aim to investigate whether EMA of depressive symptoms induces assessment reactivity. Reactivity will be operationalised as an effect of EMA on depressive symptoms measured by a retrospective questionnaire, and, secondly, as a change in response rate and variance of the EMA ratings.

METHODS

This study is a 12-week randomised controlled trial comprising three groups: group 1 carries out EMA of mood and completes a retrospective questionnaire, group 2 carries out EMA of how energetic they feel and completes a retrospective questionnaire, group 3 is the control group, which completes only the retrospective questionnaire. The retrospective questionnaire (Centre for Epidemiologic Studies Depression scale; CES-D) assesses depressive symptoms and is administered at baseline, 6 weeks after baseline and 12 weeks after baseline. We aim to recruit 160 participants who experience mild to moderate depressive symptoms, defined as a Patient Health Questionnaire (PHQ-9) score of 5 to 15. This study is powered to detect a small between-groups effect, where no clinically relevant effect is defined as the effect size margin -0.25< d <0.25.

DISCUSSION

To our knowledge, this is the first study to investigate whether self-rated EMA of depressive symptoms could induce assessment reactivity among mildly depressed individuals.

TRIAL REGISTRATION

Netherlands Trial Register NTR5803. Registered 12 April 2016. http://www.trialregister.nl/trialreg/admin/rctview.asp?TC=5803 .

Piloting the use of experience sampling method to investigate the everyday social experiences of children with Asperger syndrome/high functioning autism

OBJECTIVE

This pilot study explored the nature and quality of social experiences of children with Asperger Syndrome/High Functioning Autism (AS/HFA) through experience sampling method (ESM) while participating in everyday activities.

METHODS

ESM was used to identify the contexts and content of daily life experiences. Six children with AS/HFA (aged 8-12) wore an iPod Touch on seven consecutive days, while being signalled to complete a short survey.

RESULTS

Participants were in the company of others 88.3% of their waking time, spent 69.0% of their time with family and 3.8% with friends, but only conversed with others 26.8% of the time. Participants had more positive experiences and emotions when they were with friends compared with other company. Participating in leisure activities was associated with enjoyment, interest in the occasion, and having positive emotions.

CONCLUSIONS

ESM was found to be helpful in identifying the nature and quality of social experiences of children with AS/HFA from their perspective.

An n=1 Clinical Network Analysis of Symptoms and Treatment in Psychosis

INTRODUCTION

Dynamic relationships between the symptoms of psychosis can be shown in individual networks of psychopathology. In a single patient, data collected with the Experience Sampling Method (ESM-a method to construct intensive time series of experience and context) can be used to study lagged associations between symptoms in relation to illness severity and pharmacological treatment.

METHOD

The patient completed, over the course of 1 year, for 4 days per week, 10 daily assessments scheduled randomly between 10 minutes and 3 hours apart. Five a priori selected symptoms were analysed: 'hearing voices', 'down', 'relaxed', 'paranoia' and 'loss of control'. Regression analysis was performed including current level of one symptom as the dependent variable and all symptoms at the previous assessment (lag) as the independent variables. Resulting regression coefficients were printed in graphs representing a network of symptoms. Network graphs were generated for different levels of severity: stable, impending relapse and full relapse.

RESULTS

ESM data showed that symptoms varied intensely from moment to moment. Network representations showed meaningful relations between symptoms, e.g. 'down' and 'paranoia' fuelling each other, and 'paranoia' negatively impacting 'relaxed'. During relapse, symptom levels as well as the level of clustering between symptoms markedly increased, indicating qualitative changes in the network. While 'hearing voices' was the most prominent symptom subjectively, the data suggested that a strategic focus on 'paranoia', as the most central symptom, had the potential to bring about changes affecting the whole network.

CONCLUSION

Construction of intensive ESM time series in a single patient is feasible and informative, particularly if represented as a network, showing both quantitative and qualitative changes as a function of relapse.

Testing the fading affect bias for healthy coping in the context of death

Affect fades faster for unpleasant events than for pleasant events (e.g., Walker, Vogl, & Thompson, 1997 ), which is referred to as the fading affect bias (FAB; Walker, Skowronski, Gibbons, Vogl, & Thompson, 2003 ). Although research has generally shown that the FAB is a healthy coping mechanism, this same finding has not been demonstrated at a specific level of analysis accounting for particular event types and related individual differences (e.g., Gibbons et al., 2013 ). Given the strong unpleasant emotions associated with death (Rask, Kaunonen, & Paunonen-Ilmonen, 2002 ), the current study examined FAB in the context of death events and participant attitudes toward death. General healthy coping was shown by robust FAB across death and control (i.e., everyday) events and by a negative correlation between negative religious coping and FAB. Although healthy coping at a specific level of analysis was supported by increased FAB for participants who held accepting attitudes toward death when they recalled everyday events, it was not supported by decreased FAB for the same participants when they recalled death events. This effect was mediated by rehearsal ratings, not depression. Implications are discussed.

Development and Evaluation of a Smartphone-Based Measure of Social Rhythms for Bipolar Disorder

Dynamic psychological processes are most often assessed using self-report instruments. This places a constraint on how often and for how long data can be collected due to the burden placed on human participants. Smartphones are ubiquitous and highly personal devices, equipped with sensors that offer an opportunity to measure and understand psychological processes in real-world contexts over the long term. In this article, we present a novel smartphone approach to address the limitations of self-report in bipolar disorder where mood and activity are key constructs. We describe the development of MoodRhythm, a smartphone application that incorporates existing self-report elements from interpersonal and social rhythm therapy, a clinically validated treatment, and combines them with novel inputs from smartphone sensors. We reflect on lessons learned in transitioning from an existing self-report instrument to one that involves smartphone sensors and discuss the potential impact of these changes on the future of psychological assessment.

Study protocol for a randomized controlled trial to explore the effects of personalized lifestyle advices and tandem skydives on pleasure in anhedonic young adults

BACKGROUND

Anhedonia is generally defined as the inability to feel pleasure in response to experiences that are usually enjoyable. Anhedonia is one of the two core symptoms of depression and is a major public health concern. Anhedonia has proven particularly difficult to counteract and predicts poor treatment response generally. It has often been hypothesized that anhedonia can be deterred by a healthy lifestyle. However, it is quite unlikely that a one-size-fits-all approach will be effective for everyone. In this study the effects of personalized lifestyle advice based on observed individual patterns of lifestyle behaviors and experienced pleasure will be examined. Further, we will explore whether a tandem skydive following the personalized lifestyle advice positively influences anhedonic young adults' abilities to carry out the recommended lifestyle changes, and whether this ultimately improves their self-reported pleasure.

METHODS

Our study design is an exploratory intervention study, preceded by a cross-sectional survey as a screening instrument. For the survey, 2000 young adults (18-24 years old) will be selected from the general population. Based on survey outcomes, 72 individuals (36 males and 36 females) with persistent anhedonia (i.e., more than two months) and 60 individuals (30 males and 30 females) without anhedonia (non-anhedonic control group) will be selected for the intervention study. The non-anhedonic control group will fill out momentary assessments of pleasure and lifestyle behaviors three times a day, for one month. The anhedonic individuals will fill out momentary assessments for three consecutive months. After the first month, the anhedonic individuals will be randomly assigned to (1) no intervention, (2) lifestyle advice only, (3) lifestyle advice plus tandem skydive. The personalized lifestyle advice is based on patterns observed in the first month.

DISCUSSION

The present study is the first to examine the effects of a personalized lifestyle advice and tandem skydive on pleasure in anhedonic young adults. Results of the present study may improve treatment for anhedonia, if the interventions are found to be effective.

TRIAL REGISTRATION

Dutch Trial Register, NTR5498 , registered September 22, 2015 (retrospectively registered).

Dealing with daily challenges in dementia (deal-id study): effectiveness of the experience sampling method intervention 'Partner in Sight' for spousal caregivers of people with dementia: design of a randomized controlled trial

BACKGROUND

There is an urgent need for psychosocial interventions that effectively support dementia caregivers in daily life. The Experience Sampling Methodology (ESM) offers the possibility to provide a more dynamic view of caregiver functioning. ESM-derived feedback may help to redirect caregivers' behavior towards situations that elicit positive emotions and to increase their feelings of competence in the caretaking process. This paper presents the design of a study that evaluates the process characteristics and effects of the ESM-based intervention 'Partner in Sight'.

METHODS/DESIGN

A randomized controlled trial with 90 spousal caregivers of people with dementia will be conducted. Participants will be randomly assigned to the experimental (6-week ESM intervention including feedback), pseudo-experimental (6-week ESM intervention without feedback), or control group (care as usual). Assessments will be performed pre- and post-intervention and at 2-, and 6-month follow-up. Main outcomes will be sense of competence, perceived control, momentary positive affect, and psychological complaints (depressive symptoms, perceived stress, anxiety, momentary negative affect). In addition to the effect evaluation, a process and economic evaluation will be conducted to investigate the credibility and generalizability of the intervention, and its cost-effectiveness.

DISCUSSION

The potential effects of the ESM intervention may help caregivers to endure their care responsibilities and prevent them from becoming overburdened. This is the first ESM intervention for caregivers of people with dementia. The results of this study, therefore, provide a valuable contribution to the growing knowledge on m-health interventions for dementia caregivers.

TRIAL REGISTRATION

Dutch Trial Register NTR4847 ; date registered Oct 9, 2014.

Effectiveness of blended depression treatment for adults in specialised mental healthcare: study protocol for a randomised controlled trial

BACKGROUND

Internet-based interventions are seen as an important potential strategy to improve accessibility and affordability of high quality treatments in mental healthcare. A growing number of studies have demonstrated the clinical efficacy of internet-based treatment for mood disorders, but scientific evidence for the application in routine specialised mental healthcare settings is limited. Also, little is known about the clinical and health-economic benefits of blended treatment, where online interventions are integrated with face-to-face treatment of depression in one treatment protocol. The primary aim of this study is to investigate the clinical and cost-effectiveness of blended Cognitive Behavioural Therapy (bCBT) for depression, as compared to treatment as usual (TAU) in specialised routine mental healthcare in the Netherlands. This trial is part of the E-COMPARED project which has a broader perspective, focussing on primary and specialised care in eight European countries.

METHODS/DESIGN

The study is a randomised controlled non-inferiority trial with two parallel conditions: bCBT and TAU. The blended treatment combines individual face-to-face CBT with CBT delivered through an Internet-based treatment platform (Moodbuster). This platform includes a mobile phone application, used for ecological momentary assessments, automated feedback and motivational messages. Weekly alternating face-to-face (10) and online (9) sessions will be delivered over a period of 19-20 weeks. TAU is defined as the routine care that subjects receive when they are diagnosed with depression in specialised mental healthcare. Adult patients ≥ 18 years old meeting DSM-IV diagnostic criteria for major depressive disorder will be recruited within participating outpatient specialised mental healthcare clinics in the Netherlands. Measurements will be taken at baseline and at 3, 6 and 12 months follow-up. The primary outcome will be depressive symptoms, measured with the PHQ-9 and QIDS. Secondary outcomes include health-related quality of life, mastery, treatment preference, working alliance, system usability, treatment satisfaction and possible negative side-effects. Moreover, a cost-effectiveness analysis will be conducted from a societal perspective and will include both direct and indirect healthcare costs.

DISCUSSION

The results of this study will provide insight into the health and economical outcomes of blended treatment for depression and give an indication of the value of implementing blended treatment in specialised clinical settings.

TRIAL REGISTRATION

Netherlands Trial Register NTR4962 . Registered 05-01-2015.

Unraveling the Relationship between Motor Symptoms, Affective States and Contextual Factors in Parkinson's Disease: A Feasibility Study of the Experience Sampling Method

Background

In Parkinson's disease (PD), the complex relationship between motor symptoms, affective states, and contextual factors remains to be elucidated. The Experience Sampling Method provides (ESM) a novel approach to this issue. Using a mobile device with a special purpose application (app), motor symptoms, affective states and contextual factors are assessed repeatedly at random moments in the flow of daily life, yielding an intensive time series of symptoms and experience. The aim of this study was to study the feasibility of this method.

Method

We studied the feasibility of a five-day period of ESM in PD and its ability to objectify diurnal fluctuations in motor symptom severity and their relation with affect and contextual factors in five PD patients with motor fluctuations.

Results

Participants achieved a high compliance, with 84% of assessment moments completed without disturbance of daily activities. The utility of the device was rated 8 on a 10-point scale. We were able to capture extensive diurnal fluctuations that were not revealed by routine clinical assessment. In addition, we were able to detect clinically relevant associations between motor symptoms, emotional fluctuations and contextual factors at an intra-individual level.

Conclusions

ESM represents a viable and novel approach to elucidate relationships between motor symptoms, affective states and contextual factors at the level of individual subjects. ESM holds promise for clinical practice and scientific research.

Real-Time Monitoring of Non-linear Suicidal Dynamics: Methodology and a Demonstrative Case Report

In recent years, a number of different authors have stressed the usefulness of non-linear dynamic systems approach in suicide research and suicide prevention. This approach applies specific methods of time series analysis and, consequently, it requires a continuous and fine-meshed assessment of the processes under consideration. The technical means for this kind of process assessment and process analysis are now available. This paper outlines how suicidal dynamics can be monitored in high-risk patients by an Internet-based application for continuous self-assessment with integrated tools of non-linear time series analysis: the Synergetic Navigation System. This procedure is illustrated by data from a patient who attempted suicide at the end of a 90-day monitoring period. Additionally, future research topics and clinical applications of a non-linear dynamic systems approach in suicidology are discussed.

Is the Divide a Chasm?: Bridging Affective Science with Clinical Practice

This special section endeavors to facilitate the integration of biologically-based assessments of emotion into the clinical setting. This goal is consistent with the Research Domain Criteria (RDoC) initiative, which aims to identify transdiagnostic biobehavioral mechanisms that underlie mental disorders. We focus on four challenges to applying biologically-informed research on emotion and emotion regulation to clinical contexts: (1) How do we assess emotion in an RDoC framework? (2) How do we integrate measures of emotion with other systems in a wider context? (3) What do physiological indices of emotion tell us about clinical phenomena? and (4) How do we integrate physiological assessments into clinical practice? Throughout this comment, we refer to the articles in this special section to make our points, and, when possible, offer suggestions for future work to continue to address these challenges.

Network destabilization and transition in depression: New methods for studying the dynamics of therapeutic change

The science of dynamic systems is the study of pattern formation and system change. Dynamic systems theory can provide a useful framework for understanding the chronicity of depression and its treatment. We propose a working model of therapeutic change with potential to organize findings from psychopathology and treatment research, suggest new ways to study change, facilitate comparisons across studies, and stimulate treatment innovation. We describe a treatment for depression that we developed to apply principles from dynamic systems theory and then present a program of research to examine the utility of this application. Recent methodological and technological developments are also discussed to further advance the search for mechanisms of therapeutic change.

Experience sampling and ecological momentary assessment studies in psychopharmacology: A systematic review

Experience sampling methods (ESM) and ecological momentary assessment (EMA) offer insight into daily life experiences, including symptoms of mental disorders. The application of ESM/EMA in psychopharmacology can be a valuable addition to more traditional measures such as retrospective self-report questionnaires because they may help reveal the impact of psychotropic medication on patients' actual experiences. In this paper we systematically review the existing literature on the use of ESM/EMA in psychopharmacology research. To this end, we searched the PsycInfo and Medline databases for all available ESM/EMA studies on the use of psychotropic medication in patients with DSM-III-R and DSM-IV disorders. Dissertations were excluded. We included 18 studies that applied ESM/EMA to study the effects of medication on patients with major depressive disorder, substance use disorder, attention-deficit hyperactivity disorder, psychotic disorder, and anxiety disorder. We found that ESM/EMA may allow researchers and clinicians to track patients during different phases of treatment: before treatment to predict outcome, during treatment to examine the effects of treatment on symptoms and different aspects of daily life experience, and after treatment to detect vulnerability for relapse. Moreover, ESM/EMA can potentially help determine how long and in what contexts medications are effective. Thus, ESM/EMA may benefit both researchers and clinicians and might prove to be an effective tool for improving the treatment of psychiatric patients.

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

Background

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

Methods

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

Results

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

Conclusions

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

The application of mHealth to mental health: opportunities and challenges

Advances in smartphones and wearable biosensors enable real-time psychological, behavioural, and physiological data to be gathered in increasingly precise and unobtrusive ways. Thus, moment-to-moment information about an individual's moods, cognitions, and activities can be collected, in addition to automated data about their whereabouts, behaviour, and physiological states. In this report, we discuss the potential of these new mobile digital technologies to transform mental health research and clinical practice. By drawing on results from the INSIGHT research project, we show how traditional boundaries between research and clinical practice are becoming increasingly blurred and how, in turn, this is leading to exciting new developments in the assessment and management of common mental disorders. Furthermore, we discuss the potential risks and key challenges associated with applying mobile technology to mental health.

The Diagnostic Validity and Reliability of an Internet-Based Clinical Assessment Program for Mental Disorders

Background

Internet-based assessment has the potential to assist with the diagnosis of mental health disorders and overcome the barriers associated with traditional services (eg, cost, stigma, distance). Further to existing online screening programs available, there is an opportunity to deliver more comprehensive and accurate diagnostic tools to supplement the assessment and treatment of mental health disorders.

Objective

The aim was to evaluate the diagnostic criterion validity and test-retest reliability of the electronic Psychological Assessment System (e-PASS), an online, self-report, multidisorder, clinical assessment and referral system.

Methods

Participants were 616 adults residing in Australia, recruited online, and representing prospective e-PASS users. Following e-PASS completion, 158 participants underwent a telephone-administered structured clinical interview and 39 participants repeated the e-PASS within 25 days of initial completion.

Results

With structured clinical interview results serving as the gold standard, diagnostic agreement with the e-PASS varied considerably from fair (eg, generalized anxiety disorder: κ=.37) to strong (eg, panic disorder: κ=.62). Although the e-PASS’ sensitivity also varied (0.43-0.86) the specificity was generally high (0.68-1.00). The e-PASS sensitivity generally improved when reducing the e-PASS threshold to a subclinical result. Test-retest reliability ranged from moderate (eg, specific phobia: κ=.54) to substantial (eg, bulimia nervosa: κ=.87).

Conclusions

The e-PASS produces reliable diagnostic results and performs generally well in excluding mental disorders, although at the expense of sensitivity. For screening purposes, the e-PASS subclinical result generally appears better than a clinical result as a diagnostic indicator. Further development and evaluation is needed to support the use of online diagnostic assessment programs for mental disorders.

Trial Registration

Australian and New Zealand Clinical Trials Registry ACTRN121611000704998; http://www.anzctr.org.au/trial_view.aspx?ID=336143 (Archived by WebCite at http://www.webcitation.org/618r3wvOG).

From Affective Experience to Motivated Action: Tracking Reward-Seeking and Punishment-Avoidant Behaviour in Real-Life

Many of the decisions and actions in everyday life result from implicit learning processes. Important to psychopathology are, for example, implicit reward-seeking and punishment-avoidant learning processes. It is known that when specific actions get associated with a rewarding experience, such as positive emotions, that this will increase the likelihood that an organism will engage in similar actions in the future. Similarly, when actions get associated with punishing experiences, such as negative emotions, this may reduce the likelihood that the organism will engage in similar actions in the future. This study examines whether we can observe these implicit processes prospectively in the flow of daily life. If such processes take place then we expect that current behaviour can be predicted by how similar behaviour was experienced (in terms of positive and negative affect) at previous measurement moments. This was examined in a sample of 621 female individuals that had participated in an Experience Sampling data collection. Measures of affect and behaviour were collected at 10 semi-random moments of the day for 5 consecutive days. It was examined whether affective experience that was paired with certain behaviours (physical activity and social context) at previous measurements modified the likelihood to show similar behaviours at next measurement moments. Analyses were performed both at the level of observations (a time scale with units of ± 90 min) and at day level (a time scale with units of 24 h). As expected, we found that affect indeed moderated the extent to which previous behaviour predicted similar behaviour later in time, at both beep- and day-level. This study showed that it is feasible to track reward-seeking and punishment-avoidant behaviour prospectively in humans in the flow of daily life. This opens up a new toolbox to examine processes determining goal-oriented behaviour in relation to psychopathology in humans.

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

OBJECTIVES

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

DESIGN

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

SETTINGS

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

PARTICIPANTS

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

INTERVENTION

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

MAIN OUTCOME

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

RESULTS

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

CONCLUSION

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

TRIAL REGISTRATION

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

Improving motor activity assessment in depression: which sensor placement, analytic strategy and diurnal time frame are most powerful in distinguishing patients from controls and monitoring treatment effects

BACKGROUND

Abnormalities in motor activity represent a central feature in major depressive disorder. However, measurement issues are poorly understood, limiting the use of objective measurement of motor activity for diagnostics and treatment monitoring.

METHODS

To improve measurement issues, especially sensor placement, analytic strategies and diurnal effects, we assessed motor activity in depressed patients at the beginning (MD; n=27) and after anti-depressive treatment (MD-post; n=18) as well as in healthy controls (HC; n=16) using wrist- and chest-worn accelerometers. We performed multiple analyses regarding sensor placements, extracted features, diurnal variation, motion patterns and posture to clarify which parameters are most powerful in distinguishing patients from controls and monitoring treatment effects.

RESULTS

Whereas most feature-placement combinations revealed significant differences between groups, acceleration (wrist) distinguished MD from HC (d=1.39) best. Frequency (vertical axis chest) additionally differentiated groups in a logistic regression model (R2=0.54). Accordingly, both amplitude (d=1.16) and frequency (d=1.04) showed alterations, indicating reduced and decelerated motor activity. Differences between MD and HC in gestures (d=0.97) and walking (d=1.53) were found by data analysis from the wrist sensor. Comparison of motor activity at the beginning and after MD-treatment largely confirms our findings.

LIMITATIONS

Sample size was small, but sufficient for the given effect sizes. Comparison of depressed in-patients with non-hospitalized controls might have limited motor activity differences between groups.

CONCLUSIONS

Measurement of wrist-acceleration can be recommended as a basic technique to capture motor activity in depressed patients as it records whole body movement and gestures. Detailed analyses showed differences in amplitude and frequency denoting that depressed patients walked less and slower.

Investigating dynamics and predictors of suicidal behaviors using ambulatory assessment

Ambulatory assessment studies may provide important insights in the etiology of suicidal behaviors, because suicidal behaviors and their risk factors fluctuate over time.The review aims at (1) evaluating the current state of research and (2) summarizing main findings in this field. Reviewed studies (N = 4) were heterogeneous. Up to 74% of participants reported suicidal ideation during ambulatory assessment sampling. Suicidal ideation was predicted by intensity and instability of negative affective states (e.g., worry, sadness). Ambulatory assessment studies seem a promising approach to uncover the dynamic course of suicidal ideation and its risk factors in clinically relevant time frames (i.e., real-time).

Is it possible to use highly realistic virtual reality in the elderly? A feasibility study with image-based rendering

BACKGROUND

Virtual reality (VR) opens up a vast number of possibilities in many domains of therapy. The primary objective of the present study was to evaluate the acceptability for elderly subjects of a VR experience using the image-based rendering virtual environment (IBVE) approach and secondly to test the hypothesis that visual cues using VR may enhance the generation of autobiographical memories.

METHODS

Eighteen healthy volunteers (mean age 68.2 years) presenting memory complaints with a Mini-Mental State Examination score higher than 27 and no history of neuropsychiatric disease were included. Participants were asked to perform an autobiographical fluency task in four conditions. The first condition was a baseline grey screen, the second was a photograph of a well-known location in the participant's home city (FamPhoto), and the last two conditions displayed VR, ie, a familiar image-based virtual environment (FamIBVE) consisting of an image-based representation of a known landmark square in the center of the city of experimentation (Nice) and an unknown image-based virtual environment (UnknoIBVE), which was captured in a public housing neighborhood containing unrecognizable building fronts. After each of the four experimental conditions, participants filled in self-report questionnaires to assess the task acceptability (levels of emotion, motivation, security, fatigue, and familiarity). CyberSickness and Presence questionnaires were also assessed after the two VR conditions. Autobiographical memory was assessed using a verbal fluency task and quality of the recollection was assessed using the "remember/know" procedure.

RESULTS

All subjects completed the experiment. Sense of security and fatigue were not significantly different between the conditions with and without VR. The FamPhoto condition yielded a higher emotion score than the other conditions (P<0.05). The CyberSickness questionnaire showed that participants did not experience sickness during the experiment across the VR conditions. VR stimulates autobiographical memory, as demonstrated by the increased total number of responses on the autobiographical fluency task and the increased number of conscious recollections of memories for familiar versus unknown scenes (P<0.01).

CONCLUSION

The study indicates that VR using the FamIBVE system is well tolerated by the elderly. VR can also stimulate recollections of autobiographical memory and convey familiarity of a given scene, which is an essential requirement for use of VR during reminiscence therapy.

Testing an mHealth momentary assessment Routine Outcome Monitoring application: a focus on restoration of daily life positive mood states

BACKGROUND

Routine Outcome Monitoring (ROM) is used as a means to enrich the process of treatment with feedback on patient outcomes, facilitating patient involvement and shared decision making. While traditional ROM measures focus on retrospective accounts of symptoms, novel mHealth technology makes it possible to collect real life, in-the-moment ambulatory data that allow for an ecologically valid assessment of personalized and contextualized emotional and behavioural adjustment in the flow daily life (mROM).

METHOD

In a sample of 34 patients with major depressive disorder, treated with antidepressants, the combined effect of treatment and natural course was examined over a period of 18 weeks with Ecological Momentary Assessment (EMA). EMA consisted of repeated, within-subject, mini-measurements of experience (eg positive affect, negative affect, medication side effects) and context (eg stressors, situations, activities) at 10 unselected semi-random moments per day, for a period of six days, repeated three times over the 18-week period (baseline, week 6 and week 18).

RESULTS

EMA measures of emotional and behavioural adjustment were sensitive to the effects of treatment and natural course over the 18-week period, particularly EMA measures focussing on positive mood states and the ability to use natural rewards (impact of positive events on positive mood states), with standardized effect sizes of 0.4-0.5. EMA measures of activities, social interaction, stress-sensitivity and negative mood states were also sensitive to change over time.

CONCLUSION

This study supports the use of mROM as a means to involve the patient in the process of needs assessment and treatment. EMA data are meaningful to the patient, as they reflect daily life circumstances. Assessment of treatment response with mROM data allows for an interpretation of the effect of treatment at the level of daily life emotional and social adjustment--as an index of health, obviating the need for an exclusive focus on traditional measures of 'sickness'.

A Rehabilomics framework for personalized and translational rehabilitation research and care for individuals with disabilities: Perspectives and considerations for spinal cord injury

Despite many people having similar clinical presentation, demographic factors, and clinical care, outcome can differ for those sustaining significant injury such as spinal cord injury (SCI) and traumatic brain injury (TBI). In addition to traditional demographic, social, and clinical factors, variability also may be attributable to innate (including genetic, transcriptomic proteomic, epigenetic) biological variation that individuals bring to recovery and their unique response to their care and environment. Technologies collectively called "-omics" enable simultaneous measurement of an enormous number of biomolecules that can capture many potential biological contributors to heterogeneity of injury/disease course and outcome. Due to the nature of injury and complex disease, and its associations with impairment, disability, and recovery, rehabilitation does not lend itself to a singular "protocolized" plan of therapy. Yet, by nature and by necessity, rehabilitation medicine operates as a functional model of "Personalized Care". Thus, the challenge for successful programs of translational rehabilitation care and research is to identify viable approaches to examine broad populations, with varied impairments and functional limitations, and to identify effective treatment responses that incorporate personalized protocols to optimize functional recovery. The Rehabilomics framework is a translational model that provides an "-omics" overlay to the scientific study of rehabilitation processes and multidimensional outcomes. Rehabilomics research provides novel opportunities to evaluate the neurobiology of complex injury or chronic disease and can be used to examine methods and treatments for person-centered care among populations with disabilities. Exemplars for application in SCI and other neurorehabilitation populations are discussed.

Analysing psychosocial difficulties in depression: a content comparison between systematic literature review and patient perspective

Despite all the knowledge on depression, it is still unclear whether current literature covers all the psychosocial difficulties (PSDs) important for depressed patients. The aim of the present study was to identify the gaps in the recent literature concerning PSDs and their related variables. Psychosocial difficulties were defined according to the World Health Organization International Classification of Functioning, Disability and Health (ICF). A comparative approach between a systematic literature review, a focus group, and individual interviews with depressed patients was used. Literature reported the main psychosocial difficulties almost fully, but not in the same degree of importance as patients' reports. Furthermore, the covered areas were very general and related to symptomatology. Regarding the related variables, literature focused on clinical variables and treatments above all but did not report that many psychosocial difficulties influence other PSDs. This study identified many existing research gaps in recent literature mainly in the area of related variables of PSDs. Future steps in this direction are needed. Moreover, we suggest that clinicians select interventions covering not only symptoms, but also PSDs and their modifiable related variables. Furthermore, identification of interventions for particular psychosocial difficulties and personalisation of therapies according to individuals' PSDs are necessary.

How to boost positive interpretations? A meta-analysis of the effectiveness of cognitive bias modification for interpretation

The current meta-analysis explores the strength of effects of cognitive bias modification training for interpretation bias (CBM-I) on positive (i.e., adaptive) interpretations and mood as well as the training and sample characteristics influencing these effects. Data-bases were searched with the key words “interpret* bias AND training” and “interpret* bias AND modif*”. Reference lists of identified articles were checked and authors of identified articles were contacted for further relevant articles and unpublished data. Studies were reviewed for inclusion with eligibility criteria being that the study (a) aimed to target interpretation biases through any kind of training, (b) assessed mood and/or interpretation bias as outcome measures, (c) allocated individuals to training conditions at random, and (d) recruited adult samples. A meta-analytic multilevel mixed-effects model was employed to assess standardized mean changes in interpretation bias, negative mood, and emotional reactivity. In addition, several training and sample characteristics were explored for their potential to enhance benign training effectiveness. On average, benign CBM-I resulted in an increase in positive interpretation bias (p<.01) and a decrease in negative mood state (p<.001), but did not affect emotional reactivity. These effects were not consistently different from control conditions with no or neutral training. However, within benign training conditions imagery instructions and more training sessions were related to larger cognitive and mood effects, whereas feedback about training performance and inclusion of non-benign training items (instead of including benign items only) boosted cognitive effects only. Finally, training was more effective in women (cognitive and mood effects) and presumably samples with symptomatic emotional dysregulation (cognitive effects). Although the effects of emotional dysregulation and number of training sessions could not well be distinguished, there is an indication that when used with imagery instructions and more training sessions, benign CBM-I can be employed as a useful complementary treatment to usual psychotherapies.

Telemonitoring with respect to mood disorders and information and communication technologies: overview and presentation of the PSYCHE project

This paper reviews what we know about prediction in relation to mood disorders from the perspective of clinical, biological, and physiological markers. It then also presents how information and communication technologies have developed in the field of mood disorders, from the first steps, for example, the transition from paper and pencil to more sophisticated methods, to the development of ecological momentary assessment methods and, more recently, wearable systems. These recent developments have paved the way for the use of integrative approaches capable of assessing multiple variables. The PSYCHE project stands for Personalised monitoring SYstems for Care in mental HEalth.

The dynamic nature of depression: a new micro-level perspective of mental disorder that meets current challenges

The examination of moment-to-moment, 'micro-level' patterns of experience and behaviour using experience sampling methodology has contributed to our understanding of the 'macro-level' development of full-blown symptoms and disorders. This paper argues that the micro-level perspective can be used to identify the smallest building blocks underlying the onset and course of mental ill-health. Psychopathology may be the result of the continuous dynamic interplay between micro-level moment-to-moment experiences and behavioural patterns over time. Reinforcing loops between momentary states may alter the course of mental health towards either a more or less healthy state. An example with observed data, from a population of individuals with depressive symptoms, supports the validity of a dynamic network model of psychopathology and shows that together and over time, this continuous interplay between momentary states may result in the cluster of symptoms we call major depressive disorder. This approach may help conceptualize the nature of mental disorders, and generate individualized insights useful for diagnosis and treatment in psychiatry.

Recommendations for the use of Serious Games in people with Alzheimer's Disease, related disorders and frailty

Alzheimer's disease and other related disorders (ADRD) represent a major challenge for health care systems within the aging population. It is therefore important to develop better instruments to assess the disease severity and progression, as well as to improve its treatment, stimulation, and rehabilitation. This is the underlying idea for the development of Serious Games (SG). These are digital applications specially adapted for purposes other than entertaining; such as rehabilitation, training and education. Recently, there has been an increase of interest in the use of SG targeting patients with ADRD. However, this field is completely uncharted, and the clinical, ethical, economic and research impact of the employment of SG in these target populations has never been systematically addressed. The aim of this paper is to systematically analyze the Strengths, Weaknesses, Opportunities, and Threats (SWOT) of employing SG with patients with ADRD in order to provide practical recommendations for the development and use of SG in these populations. These analyses and recommendations were gathered, commented on and validated during a 2-round workshop in the context of the 2013 Clinical Trial of Alzheimer's Disease (CTAD) conference, and endorsed by stakeholders in the field. The results revealed that SG may offer very useful tools for professionals involved in the care of patients suffering from ADRD. However, more interdisciplinary work should be done in order to create SG specifically targeting these populations. Furthermore, in order to acquire more academic and professional credibility and acceptance, it will be necessary to invest more in research targeting efficacy and feasibility. Finally, the emerging ethical challenges should be considered a priority.

Time-lagged moment-to-moment interplay between negative affect and paranoia: new insights in the affective pathway to psychosis

Evidence suggests that affect plays a role in the development of psychosis but the underlying mechanism requires further investigation. This study examines the moment-to-moment dynamics between negative affect (NA) and paranoia prospectively in daily life. A female general population sample (n = 515) participated in an experience sampling study. Time-lagged analyses between increases in momentary NA and subsequent momentary paranoia were examined. The impact of childhood adversity, stress sensitivity (impact of momentary stress on momentary NA), and depressive symptoms on these time-lagged associations, as well as associations with follow-up self-reported psychotic symptoms (Community Assessment of Psychic Experiences and the Symptom Checklist-90-Revised) were investigated. Moments of NA increase resulted in a significant increase in paranoia over 180 subsequent minutes. Both stress sensitivity and depressive symptoms impacted on the transfer of NA to paranoia. Stress sensitivity moderated the level of increase in paranoia during the initial NA increase, while depressive symptoms increased persistence of paranoid feelings from moment to moment. Momentary paranoia responses to NA increases were associated with follow-up psychotic symptoms. Examination of microlevel momentary experience may thus yield new insights into the mechanism underlying co-occurrence of altered mood states and psychosis. Knowledge of the underlying mechanism is required in order to determine source and place where remediation should occur.

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

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

Evidence that a psychopathology interactome has diagnostic value, predicting clinical needs: an experience sampling study

BACKGROUND

For the purpose of diagnosis, psychopathology can be represented as categories of mental disorder, symptom dimensions or symptom networks. Also, psychopathology can be assessed at different levels of temporal resolution (monthly episodes, daily fluctuating symptoms, momentary fluctuating mental states). We tested the diagnostic value, in terms of prediction of treatment needs, of the combination of symptom networks and momentary assessment level.

METHOD

Fifty-seven patients with a psychotic disorder participated in an ESM study, capturing psychotic experiences, emotions and circumstances at 10 semi-random moments in the flow of daily life over a period of 6 days. Symptoms were assessed by interview with the Positive and Negative Syndrome Scale (PANSS); treatment needs were assessed using the Camberwell Assessment of Need (CAN).

RESULTS

Psychotic symptoms assessed with the PANSS (Clinical Psychotic Symptoms) were strongly associated with psychotic experiences assessed with ESM (Momentary Psychotic Experiences). However, the degree to which Momentary Psychotic Experiences manifested as Clinical Psychotic Symptoms was determined by level of momentary negative affect (higher levels increasing probability of Momentary Psychotic Experiences manifesting as Clinical Psychotic Symptoms), momentary positive affect (higher levels decreasing probability of Clinical Psychotic Symptoms), greater persistence of Momentary Psychotic Experiences (persistence predicting increased probability of Clinical Psychotic Symptoms) and momentary environmental stress associated with events and activities (higher levels increasing probability of Clinical Psychotic Symptoms). Similarly, the degree to which momentary visual or auditory hallucinations manifested as Clinical Psychotic Symptoms was strongly contingent on the level of accompanying momentary paranoid delusional ideation. Momentary Psychotic Experiences were associated with CAN unmet treatment needs, over and above PANSS measures of psychopathology, similarly moderated by momentary interactions with emotions and context.

CONCLUSION

The results suggest that psychopathology, represented as an interactome at the momentary level of temporal resolution, is informative in diagnosing clinical needs, over and above traditional symptom measures.

Deconstructing the familiality of variability in momentary negative and positive affect

OBJECTIVE

The daily life, affective phenotypes of momentary negative affect (NA), positive affect (PA) variability and NA variability are associated with future depressive symptomatology. This study investigates the extent to which genetic and environmental factors contribute to the inter-individual differences in these daily life, affective phenotypes.

METHOD

Two hundred and seventy-nine female twins from the Flemish (Belgium) general population participated in an experience sampling study measuring affect in daily life. Structural equation modelling was used to fit univariate and bivariate models.

RESULTS

Genetic factors explained, respectively, 18%, 18% and 35% of the inter-individual differences in momentary NA, PA variability and NA variability. Non-shared environmental factors were found to explain the remaining inter-individual variation. In addition, 41% of the association between positive and NA variability was attributed to shared genetic factors.

CONCLUSION

Results of this study show that daily life patterns of affective expression are subject to substantial environmental influence. Prospective assessments of the effect of interventions on these expressions may therefore represent a powerful tool to prevent transition from subclinical depressive symptomatology to a clinical outcome or to reduce symptomatology in those with clinical depression.

Altered transfer of momentary mental states (ATOMS) as the basic unit of psychosis liability in interaction with environment and emotions

Psychotic disorders are thought to represent altered neural function. However, research has failed to map diagnostic categories to alterations in neural networks. It is proposed that the basic unit of psychotic psychopathology is the moment-to-moment expression of subtle anomalous experiences of subclinical psychosis, and particularly its tendency to persist from moment-to-moment in daily life, under the influence of familial, environmental, emotional and cognitive factors.

In a general population twin sample (n = 579) and in a study of patients with psychotic disorder (n = 57), their non-psychotic siblings (n = 59) and unrelated controls (n = 75), the experience sampling paradigm (ESM; repetitive, random sampling of momentary mental states and context) was applied. We analysed, in a within-person prospective design, (i) transfer of momentary anomalous experience at time point (t–1) to time point (t) in daily life, and (ii) moderating effects of negative affect, positive affect, daily stressors, IQ and childhood trauma. Additionally, (iii) familial associations between persistence of momentary anomalous experience and psychotic symptomatology were investigated. Higher level of schizotypy in the twins (but not higher level of psychotic symptoms in patients) predicted more persistence of momentary anomalous experience in daily life, both within subjects and across relatives. Persistence of momentary anomalous experience was highest in patients, intermediate in their siblings and lowest in controls. In both studies, persistence of momentary anomalous experience was moderated by higher levels of negative affect, daily stressors and childhood trauma (only in twins), and by lower levels of positive affect. The study of alterations in the moment-to-moment transfer of subtle anomalous experience of psychosis, resulting in their persistence, helps to explain why psychotic and emotional dysregulation tend to cluster in a single phenotype such as schizophrenia, and how familial and environmental risks increase the risk of expression of psychosis from, first, subtle momentary anomalous experience to, second, observable clinical symptoms.

Recommendations for ICT use in Alzheimer's disease assessment: Monaco CTAD Expert Meeting

Alzheimer disease (AD) and other related dementia represent a major challenge for health care systems within the aging population. It is therefore important to develop better instruments for assessing disease severity and disease progression to optimize patient's care and support to care providers, and also provide better tools for clinical research. In this area, Information and Communication Technologies (ICT) are of particular interest. Such techniques enable accurate and standardized assessments of patients' performance and actions in real time and real life situations. The aim of this article is to provide basic recommendation concerning the development and the use of ICT for Alzheimer's disease and related disorders. During he ICT and Mental Health workshop (CTAD meeting held in Monaco on the 30th October 2012) an expert panel was set up to prepare the first recommendations for the use of ICT in dementia research. The expert panel included geriatrician, epidemiologist, neurologist, psychiatrist, psychologist, ICT engineers, representatives from the industry and patient association. The recommendations are divided into three sections corresponding to 1/ the clinical targets of interest for the use of ICT, 2/ the conditions, the type of sensors and the outputs (scores) that could be used and obtained, 3/ finally the last section concerns specifically the use of ICT within clinical trials.

Does unstable mood increase risk of suicide? Theory, research and practice

BACKGROUND

Suicide represents a substantial problem, with significant societal and personal impact. The identification of factors influencing suicide risk is an important step in preventing self-harming behaviour. In this article the authors explore whether emotional instability increases risk of suicide, beyond that of mood intensity.

METHOD

This article provides a summary of existing theory and indirect evidence in support of an association between emotional instability and suicidality. A systematic literature search (Embase, Medline, PsychInfo) was carried out on literature conducted up to October, 2011. Meta-analysis was used to assess the strength of the proposed association.

RESULTS

The systematic search identified 20 journal articles meeting the inclusion criteria, including retrospective questionnaire design studies and research conducted across several time-points. Meta-analysis revealed a moderate association, which remained statistically significant even when only including studies conducted over multiple time-points. This effect was attenuated, but remained significant, when controlling for study selection bias.

LIMITATIONS

Retrospective questionnaire studies failed to adequately control for mood level. Little is still currently understood about the types of emotional instability (e.g., dysoria, anxiety) most associated with suicidality.

CONCLUSIONS

Future avenues of investigation include micro- to macro-longitudinal research and the differentiation of emotion subtypes and instability metrics. Momentary assessment techniques may help to detect subtle fluctuations in mood leading to more effective and immediate intervention. Psychosocial intervention strategies for treating unstable emotions are discussed.

The feasibility and validity of ambulatory self-report of psychotic symptoms using a smartphone software application

BACKGROUND

Semi-structured interview scales for psychosis are the gold standard approach to assessing psychotic and other symptoms. However, such assessments have limitations such as recall bias, averaging, insensitivity to change and variable interrater reliability. Ambulant, real-time self-report assessment devices may hold advantages over interview measures, but it needs to be shown that the data thus collected are valid, and the collection method is acceptable, feasible and safe. We report on a monitoring system for the assessment of psychosis using smartphone technology. The primary aims were to: i) assess validity through correlations of item responses with those on widely accepted interview assessments of psychosis, and ii) examine compliance to the procedure in individuals with psychosis of varying severity.

METHODS

A total of 44 participants (acute or remitted DSM-4 schizophrenia and related disorders, and prodromal) completed 14 branching self-report items concerning key psychotic symptoms on a touch-screen mobile phone when prompted by an alarm at six pseudo-random times, each day, for one week. Face to face PANSS and CDS interviews were conducted before and after the assessment period blind to the ambulant data.

RESULTS

Compliance as defined by completion of at least 33% of all possible data-points over seven days was 82%. In the 36 compliant participants, 5 items (delusions, hallucinations, suspiciousness, anxiety, hopelessness) showed moderate to strong (rho 0.6-0.8) associations with corresponding items from interview rating scales. Four items showed no significant correlation with rating scales: each was an item based on observable behaviour. Ambulant ratings showed excellent test-retest reliability and sensitivity to change.

CONCLUSIONS

Ambulatory monitoring of symptoms several times daily using smartphone software applications represents a feasible and valid way of assessing psychotic phenomena for research and clinical management purposes. Further evaluation required over longer assessment periods, in clinical trials and service settings.