Is a brief mindfulness ecological momentary intervention more efficacious than a self-monitoring app for social anxiety disorder? A randomized controlled trial

Prescriptive Predictors of Mindfulness Ecological Momentary Intervention for Social Anxiety Disorder: Machine Learning Analysis of Randomized Controlled Trial Data

BACKGROUND

Shame and stigma often prevent individuals with social anxiety disorder (SAD) from seeking and attending costly and time-intensive psychotherapies, highlighting the importance of brief, low-cost, and scalable treatments. Creating prescriptive outcome prediction models is thus crucial for identifying which clients with SAD might gain the most from a unique scalable treatment option. Nevertheless, widely used classical regression methods might not optimally capture complex nonlinear associations and interactions.

OBJECTIVE

Precision medicine approaches were thus harnessed to examine prescriptive predictors of optimization to a 14-day fully self-guided mindfulness ecological momentary intervention (MEMI) over a self-monitoring app (SM).

METHODS

This study involved 191 participants who had probable SAD. Participants were randomly assigned to MEMI (n=96) or SM (n=95). They completed self-reports of symptoms, risk factors, treatment, and sociodemographics at baseline, posttreatment, and 1-month follow-up (1MFU). Machine learning (ML) models with 17 predictors of optimization to MEMI over SM, defined as a higher probability of SAD remission from MEMI at posttreatment and 1MFU, were evaluated. The Social Phobia Diagnostic Questionnaire, structurally equivalent to the Diagnostic and Statistical Manual SAD criteria, was used to define remission. These ML models included random forest and support vector machines (radial basis function kernel) and 10-fold nested cross-validation that separated model training, minimal tuning in inner folds, and model testing in outer folds.

RESULTS

ML models outperformed logistic regression. The multivariable ML models using the 10 most important predictors achieved good performance, with the area under the receiver operating characteristic curve (AU-ROC) values ranging from .71 to .72 at posttreatment and 1MFU. These prerandomization and early-stage prescriptive predictors consistently identified which participants had the highest probability of optimization of MEMI over SM after 14 days and 6 weeks from baseline. Significant predictors included 4 strengths (higher trait mindfulness, lower SAD severity, presence of university education, no current psychotropic medication use), 2 weaknesses (higher generalized anxiety severity and clinician-diagnosed depression or anxiety disorder), and 1 sociodemographic variable (Chinese ethnicity). Emotion dysregulation and current psychotherapy predicted remission with inconsistent signs across time points.

CONCLUSIONS

The AU-ROC values indicated moderately meaningful effect sizes in identifying prescriptive predictors within multivariable models for clients with SAD. Focusing on the identified notable client strengths, weaknesses, and Chinese ethnicity may enhance our ability to predict future responses to scalable treatments. Estimating the likelihood of SAD remission with a "prescriptive predictor calculator" for each client may help clinicians and policymakers allocate scarce treatment resources effectively. Clients with high remission probability may benefit from receiving the MEMI as a vigilant waitlist strategy before intensive therapist-led psychotherapy. These efforts may aid in creating actionable treatment selection tools to optimize care for clients with SAD in routine health care settings that use stratified care principles.

TRIAL REGISTRATION

OSF Registries 10.17605/OSF.IO/M3KXZ; https://osf.io/m3kxz.

Systematic review and meta-analysis of adverse events in clinical trials of mental health apps

Mental health apps are efficacious, yet they may pose risks in some. This review (CRD42024506486) examined adverse events (AEs) from mental health apps. We searched (May 2024) the Medline, PsycINFO, Web of Science, and ProQuest databases to identify clinical trials of mental health apps. The risk of bias was assessed using the Cochrane Risk of Bias tool. Only 55 of 171 identified clinical trials reported AEs. AEs were more likely to be reported in trials sampling schizophrenia and delivering apps with symptom monitoring technology. The meta-analytic deterioration rate from 13 app conditions was 6.7% (95% CI = 4.3, 10.1, I2 = 75%). Deterioration rates did not differ between app and control groups (OR = 0.79, 95% CI = 0.62-1.01, I2 = 0%). Reporting of AEs was heterogeneous, in terms of assessments used, events recorded, and detail provided. Overall, few clinical trials of mental health apps report AEs. Those that do often provide insufficient information to properly judge risks related to app use.

Dating in social anxiety disorder: A daily diary study

Romantic relationships are vital for health, well-being and quality of life, and an increasing percentage of romantic relations begin via use of dating apps and subsequently progress to dates. In the present study we examined dating application use and dates among individuals with SAD (n = 54) and without SAD (n = 54). Our sample included young adults (age range 18 to 33) who were not in a romantic relationship at the time of the study. For both individuals with SAD and without SAD, half of the participants were men, and half were women. We used a daily diary measurement in which participants reported on their dating application use and dates, as well as on concomitant emotions and perceptions for 21 consecutive days. We found that individuals with and without SAD did not differ in the frequency/duration of application use nor in the number of dates attended. However, individuals with SAD experienced dates as more negative compared to individuals without SAD (Cohen's d = 0.65). Interestingly, individuals with SAD did not significantly differ in their experience of dates as positive compared to individuals without SAD. Moreover, use of dating applications/going on dates were associated with increases in shame (Cohen's d = 0.59) and embarrassment (Cohen's d = 0.45) and this was found to a greater extent among individuals with SAD compared to individuals without SAD (Cohen's d = 0.50, 0.39 for shame and embarrassment respectively). Findings are discussed in the context of cognitive behavioral models of SAD and implications for treatment are considered.

Temporal dynamics and long-term effects of a mindfulness-based intervention for young adults with adverse childhood experiences

Objectives

Mindfulness-based interventions (MBIs) have been shown to be beneficial for young adults with adverse childhood experiences (ACE), but the temporal course of the therapeutic effects is still not well understood. This study aimed to investigate MBI-induced weekly changes and long-term effects in trait mindfulness and psychological symptoms.

Method

This study analyzed longitudinal data from a mechanistic clinical trial in which young adults (aged 21-35) with ACE were randomized to an 8-week MBI or an active control condition of Stress Management Education (SME), with 21 and 19 completers respectively. Mindful Attention Awareness Scale (MAAS), Perceived Stress Scale (PSS), and Kellner's Symptom Questionnaire (KSQ) were administered before, after, and weekly during the 8-week interventions, and at 6-, 12-, and 18-months follow-up. Data analyses were conducted with linear mixed effects models, Granger causality and Dynamic Structural Equation Modeling (DSEM).

Results

Group by time interaction effects were observed with PSS, MAAS, KSQ-depression, KSQ-hostility, and KSQ-anxiety with small effect sizes. Only in the MBI group, increases of MAAS scores predicted reductions of PSS, KSQ-somatization, and KSQ-hostility scores. MAAS score reached significant increase at the end of MBI, and most MBI-induced symptom reduction lasted 12 months without refresher courses.

Conclusions

MBI demonstrated unique effects of trait mindfulness improvement leading to psychological symptom reductions. At least 8 weeks of MBI program duration and refreshment at 12 months may be necessary for ACE survivors.

Preregistration

This study is not preregistered.

Testing the Efficacy of a Brief, Self-Guided Mindfulness Ecological Momentary Intervention on Emotion Regulation and Self-Compassion in Social Anxiety Disorder: Randomized Controlled Trial

BACKGROUND

Theories propose that brief, mobile, self-guided mindfulness ecological momentary interventions (MEMIs) could enhance emotion regulation (ER) and self-compassion. Such changes are posited to be mechanisms of change. However, rigorous tests of these theories have not been conducted.

OBJECTIVE

In this assessor-blinded, parallel-group randomized controlled trial, we aimed to test these theories in social anxiety disorder (SAD).

METHODS

Participants with SAD (defined as having a prerandomization cut-off score ≥20 on the Social Phobia Inventory self-report) were randomized to a 14-day fully self-guided MEMI (96/191, 50.3%) or self-monitoring app (95/191, 49.7%) arm. They completed web-based self-reports of 6 clinical outcome measures at prerandomization, 15-day postintervention (administered the day after the intervention ended), and 1-month follow-up time points. ER and self-compassion were assessed at preintervention and 7-day midintervention time points. Multilevel modeling determined the efficacy of MEMI on ER and self-compassion domains from pretrial to midintervention time points. Bootstrapped parallel multilevel mediation analysis examined the mediating role of pretrial to midintervention ER and self-compassion domains on the efficacy of MEMI on 6 clinical outcomes.

RESULTS

Participants demonstrated strong compliance, with 78% (149/191) engaging in at least 80% of the MEMI and self-monitoring prompts. MEMI was more efficacious than the self-monitoring app in decreasing ER goal-directed behavior difficulties (between-group Cohen d=-0.24) and lack of emotional clarity (Cohen d=0.16) and increasing self-compassion social connectedness (Cohen d=0.19), nonidentification with emotions (Cohen d=0.16), and self-kindness (Cohen d=0.19) from pretrial to midintervention time points. The within-group effect sizes from pretrial to midintervention were larger in the MEMI arm than in the self-monitoring app arm (ER goal-directed behavior difficulties: Cohen d=-0.73 vs -0.29, lack of emotional clarity: Cohen d=-0.39 vs -0.21, self-compassion domains of social connectedness: Cohen d=0.45 vs 0.19, nonidentification with emotions: Cohen d=0.63 vs 0.48, and self-kindness: Cohen d=0.36 vs 0.10). Self-monitoring, but not MEMI, alleviated ER emotional awareness issues (between-group Cohen d=0.11 and within-group: Cohen d=-0.29 vs -0.13) and reduced self-compassion acknowledging shared human struggles (between-group Cohen d=0.26 and within-group: Cohen d=-0.23 vs 0.13). No ER and self-compassion domains were mediators of the effect of MEMI on SAD symptoms (P=.07-<.99), generalized anxiety symptoms (P=.16-.98), depression severity (P=.20-.94), repetitive negative thinking (P=.12-.96), and trait mindfulness (P=.18-.99) from pretrial to postintervention time points. Similar nonsignificant mediation effects emerged for all of these clinical outcomes from pretrial to 1-month follow-up time points (P=.11-.98).

CONCLUSIONS

Brief, fully self-guided, mobile MEMIs efficaciously increased specific self-compassion domains and decreased ER difficulties associated with goal pursuit and clarity of emotions from pretrial to midintervention time points. Higher-intensity MEMIs may be required to pinpoint the specific change mechanisms in ER and self-compassion domains of SAD.

TRIAL REGISTRATION

Open Science Framework (OSF) Registries; osf.io/m3kxz https://osf.io/m3kxz.