DynAMo: A Modular Platform for Monitoring Process, Outcome, and Algorithm-Based Treatment Planning in Psychotherapy

How to personalise cognitive-behavioural therapy for chronic primary pain using network analysis: study protocol for a single-case experimental design with multiple baselines

INTRODUCTION

Cognitive-behavioural therapy (CBT) is an effective treatment for chronic primary pain (CPP), but effect sizes are small to moderate. Process orientation, personalisation, and data-driven clinical decision-making might address the heterogeneity among persons with CPP and are thus promising pathways to enhance the effectiveness of CBT for CPP. This study protocol describes one approach to personalise CBT for CPP using network analysis.

METHODS AND ANALYSIS

A single-case experimental design with multiple baselines will be combined with ecological momentary assessment (EMA). Feasibility and acceptance of the study procedure will be demonstrated on a sample of n=12 adults with CPP in an outpatient clinic. In phase A, participants complete 21 days of EMA, followed by the standard diagnostic phase of routine clinical care (phase B). Person-specific, process-based networks are estimated based on EMA data. Treatment targets are selected using mean ratings, strength and out-strength centrality. After a second, randomised baseline (phase A'), participants will receive 1 out of 10 CBT interventions, selected by an algorithm matching targets to interventions, in up to 10 sessions (phase C). Finally, another EMA phase of 21 days will be completed to estimate a post-therapy network. Tau-U and Hedges' g are used to indicate individual treatment effects. Additionally, conventional pain disability measures (Pain Disability Index and the adapted Quebec Back Pain Disability Scale) are assessed prior, post, and 3 months after phase C.

ETHICS AND DISSEMINATION

Ethical considerations were made with regard to the assessment-induced burden on the participants. This proof-of-concept study may guide future studies aiming at personalisation of CBT for CPP as it outlines methodological decisions that need to be considered step by step. The project was approved by the local ethics committee of the psychology department of University Kaiserslautern-Landau (#LEK-457). Participants gave their written informed consent prior to any data assessment and app installation. The results of the project will be published, presented at congresses, and relevant data will be made openly accessible via the Open Science Framework (OSF).

TRIAL REGISTRATION NUMBER

NCT06179784.

Integrating theory-based and data-driven methods to case conceptualization: A functional analysis approach with ecological momentary assessment

Objective Ecological momentary assessment (EMA) and network analysis are promising empirical developments for psychotherapy research and practice, but they lack a therapeutic rationale that could guide case conceptualization and treatment planning. We developed an assessment strategy that aims to assess functional analysis with EMA. Method: The assessment strategy was applied to a series of three N-of-1 assessments in a proof-of-concept study. After selecting a personalized set of items, EMA was implemented with three measurement time points per day for a period of 30 days. The participants evaluated feasibility and acceptance. Practicing psychotherapists discussed clinical implications in a focus group. Results: The implementation of the assessment strategy seemed feasible and accepted; participants did not report any side effects. Principal component and network analyses indicated interpretable components (e.g., participant 1: hopelessness, procrastination, coping, avoidance). The focus group pointed out potentials (e.g., efficient profit of the waiting time, empowering patients) and challenges (e.g., prioritize and interpret all the information). Conclusion: The presented assessment strategy may enhance the scientific quality of case conceptualization empowering therapists' decision-making regarding treatment planning. At the same time, it is a concrete demonstration of the challenges that need to be addressed in future research.

Feasibility and utility of idiographic models in the clinic: A pilot study

AbstractIntroduction: Idiographic, or individual-level, methodology has been touted for its potential clinical utility. Empirically modeling relationships between symptoms for a single individual may offer both the client and therapist information that is useful for case conceptualization and treatment planning. However, few studies have investigated the feasibility and utility of integrating idiographic models in a clinical setting.Methods: Clients (n = 12) completed ecological momentary assessment regarding psychological symptoms five times per day for three weeks. Clients also generated predictions about the associative and directed relationships in their networks. Graphical vector autoregression was used to generate contemporaneous and directed networks from each client's data, and both clients and therapists completed self-report questionnaires regarding the feasibility and utility of these methods.Results: Results indicated that the idiographic model structures varied widely across participants and differed markedly from the client's own predictions. Clients found the models useful, whereas their therapists demonstrated a more tempered response.Discussion: These results echo previous findings suggesting that clients are willing to complete intensive data collection and are interested in the output, whereas therapists may be less open to idiographic methods. We provide recommendations for future implementation of personalized models in clinical settings.

Cystic Fibrosis Point of Personalized Detection (CFPOPD): An Interactive Web Application

Background

Despite steady gains in life expectancy, individuals with cystic fibrosis (CF) lung disease still experience rapid pulmonary decline throughout their clinical course, which can ultimately end in respiratory failure. Point-of-care tools for accurate and timely information regarding the risk of rapid decline is essential for clinical decision support.

Objective

This study aims to translate a novel algorithm for earlier, more accurate prediction of rapid lung function decline in patients with CF into an interactive web-based application that can be integrated within electronic health record systems, via collaborative development with clinicians.

Methods

Longitudinal clinical history, lung function measurements, and time-invariant characteristics were obtained for 30,879 patients with CF who were followed in the US Cystic Fibrosis Foundation Patient Registry (2003-2015). We iteratively developed the application using the R Shiny framework and by conducting a qualitative study with care provider focus groups (N=17).

Results

A clinical conceptual model and 4 themes were identified through coded feedback from application users: (1) ambiguity in rapid decline, (2) clinical utility, (3) clinical significance, and (4) specific suggested revisions. These themes were used to revise our application to the currently released version, available online for exploration. This study has advanced the application’s potential prognostic utility for monitoring individuals with CF lung disease. Further application development will incorporate additional clinical characteristics requested by the users and also a more modular layout that can be useful for care provider and family interactions.

Conclusions

Our framework for creating an interactive and visual analytics platform enables generalized development of applications to synthesize, model, and translate electronic health data, thereby enhancing clinical decision support and improving care and health outcomes for chronic diseases and disorders. A prospective implementation study is necessary to evaluate this tool’s effectiveness regarding increased communication, enhanced shared decision-making, and improved clinical outcomes for patients with CF.

Advantages and disadvantages of online and blended therapy: Replication and extension of findings on psychotherapists' appraisals

Therapists hold a key role for the uptake of digital mental health interventions (DMHI) within regular care services but have demonstrated cautious attitudes towards such interventions. It is relevant to explore in detail what factors may positively influence therapists' perception when considering DMHI implementation within routine care. We recently assessed therapist views towards Internet-based and blended treatment in Austria (low implementation level). The present study aims at testing the reliability of previous findings, and moreover, it compares therapists' appraisals to a country with advanced DMHI implementation (Sweden). An online survey was conducted February through June of 2019. Respondents were recruited via email and social media. The survey assessed first-hand experience with Internet-based treatment (IT) and blended treatment (BT). To start, the survey presented a short informational video to half of the respondents, then assessed therapists' views on 17 advantages and 13 disadvantages of IT and BT on 6-point Likert scales. In total N = 300 therapists responded to the invitation, of which N = 165 provided full survey data (Germany 114/220, 52%; Sweden 51/80, 64%). German therapists rated the advantages of IT and BT as neutral (IT, M = 3.6; BT, M = 3.8) and to some extent agreed with disadvantages of IT (IT, M = 4.5; BT, M = 3.5). In comparison, Swedish therapists rated significantly greater advantages (IT, M = 4.6; BT, M = 4.5) and less disadvantages (IT, M = 3.2; BT, M = 2.8). Effect sizes ranged from d = 0.89 to d = 1.83; all P's < .001. Those with first-hand experience with DMHI reported more positive appraisals in both countries. No significant effect was found for exposure to the short informational video. The German sample represented essential characteristics of current German therapists; in comparison Swedish respondents skewed towards younger less experienced therapists (P's < .001). Those confounders accounted for a small non-significant proportion of variance (0.1-4.7%). We found that therapists considered blended treatment to have less disadvantages than Internet treatment, and that first-hand experience with DMHI, but not exposure to an acceptance facilitating video clip, predicted greater acceptability on individual level. The responses among German therapists closely resembled findings from our preceding study in Austria, indicating that reliable results can be achieved in small survey studies if sample and population parameters correspond. Swedish therapists held significantly more favorable attitudes towards both interventions. The comparison between countries, however, is limited by a number of potential confounding variables.

How Are Information and Communication Technologies Supporting Routine Outcome Monitoring and Measurement-Based Care in Psychotherapy? A Systematic Review

Psychotherapy has proven to be effective for a wide range of mental health problems. However, not all patients respond to the treatment as expected (not-on-track patients). Routine outcome monitoring (ROM) and measurement-based care (MBC), which consist of monitoring patients between appointments and using this data to guide the intervention, have been shown to be particularly useful for these not-on-track patients. Traditionally, though, ROM and MBC have been challenging, due to the difficulties associated with repeated monitoring of patients and providing real-time feedback to therapists. The use of information and communication technologies (ICTs) might help reduce these challenges. Therefore, we systematically reviewed evidence regarding the use of ICTs for ROM and MBC in face-to-face psychological interventions for mental health problems. The search included published and unpublished studies indexed in the electronic databases PubMed, PsycINFO, and SCOPUS. Main search terms were variations of the terms “psychological treatment”, “progress monitoring or measurement-based care”, and “technology”. Eighteen studies met eligibility criteria. In these, ICTs were frequently handheld technologies, such as smartphone apps, tablets, or laptops, which were involved in the whole process (assessment and feedback). Overall, the use of technology for ROM and MBC during psychological interventions was feasible and acceptable. In addition, the use of ICTs was found to be effective, particularly for not-on-track patients, which is consistent with similar non-ICT research. Given the heterogeneity of reviewed studies, more research and replication is needed to obtain robust findings with different technological solutions and to facilitate the generalization of findings to different mental health populations.

Applied ambulatory assessment: Integrating idiographic and nomothetic principles of measurement

Ambulatory assessment (AA; also known as ecological momentary assessment) has enjoyed enthusiastic implementation in psychological research. The ability to assess thoughts, feelings, behavior, physiology, and context intensively and repeatedly in the moment in an individual's natural ecology affords access to data that can answer exciting questions about sequences of events and dynamic processes in daily life. AA also holds unique promise for developing personalized models of individuals (i.e., precision or person-specific assessment) that might be transformative for applied settings such as clinical practice. However, successfully translating AA from bench to bedside is challenging because of the inherent tension between idiographic and nomothetic principles of measurement. We argue that the value of applied AA will be most fully realized by balancing the ability to develop personalized models with ensuring comparability among individuals. (PsycINFO Database Record (c) 2019 APA, all rights reserved).

Process-symptom-bridges in psychotherapy: An idiographic network approach

AIM

real-time monitoring of psychotherapeutic processes was recently described as a promising, new way of tracking periods of change in ongoing treatments. This approach generates complex, multivariate datasets that have to be presented in an intuitive way for clinicians to aid their clinical decision-making. Using network modeling and new approaches in centrality analyses, we examine "bridge nodes" between symptom stress and aspects of the psychotherapeutic process between therapy session (intersession processes, ISP). Method:we recorded intersession processes as well as depressive and anxiety symptoms using daily questionnaires in ten cases. Regularized, thresholded intraindividual dynamic networks were estimated. We applied bridge centrality analysis to identify individual bridges between psychotherapeutic processes and symptoms in the resulting models. Case-wise interpretations of bridge centrality values are offered.

RESULTS

bridge centrality analysis revealed individual bridge nodes between intersession processes and symptom severity. Strength and direction of bridges varied substantially across individuals.

CONCLUSION

given current methodological challenges, idiographic network studies are feasible and offer important insights for psychotherapy process research. In this case, we demonstrated how patients deal with periods of increased symptom stress. In this case we have described how patients deal with their therapy under increased symptom load. Bridges between psychotherapeutic processes and symptom stress are a promising target for monitoring systems based on ISP. Future studies should examine the clinical utility of network-based monitoring and feedback in ongoing therapies. In the near future, process feedback systems based on idiographic models could serve clinicians to improve treatments.

Daily dynamic assessment and modelling of intersession processes in ambulatory psychotherapy: A proof of concept study

Background: the typical mode of assessment in studies on intersession processes (ISP) in psychotherapy is using cross-sectional or weekly measurements. Daily dynamics of intersession processes have not yet been studied. Method: intersession process data from 22 ambulatory psychotherapy cases were collected in a naturalistic study with high temporal resolution, resulting in a total of 1026 daily measurements. Multilevel vector autoregressive (VAR) modelling was applied to discover the temporal course and causal influences among intersession processes. Centrality analysis was applied to discover unique functions of various intersession process variables. Results: a group-level network structure was discovered, offering first insights on the role of different intersession processes during psychotherapy. Centrality analysis revealed unique roles for various aspects of the intersession process. Temporal distance from the last session had only weak influence on the ISP. Conclusions: using short, daily measures, the unique role of various aspects of the ISP were uncovered. Some aspects of the ISP, like recalling session contents or reflection on future session contents, are facilitators of overall ISP intensity. Other aspects like thoughts on payment or appointments or negative treatment-related emotions are likely to suppress ISP.

Feasibility of a blended group treatment (bGT) for major depression: uncontrolled interventional study in a university setting

OBJECTIVE

This study investigated the feasibility of a novel blended (face-to-face and computer-based) group intervention for the reduction of depressive symptoms in major depression.

DESIGN

Patient-centred uncontrolled interventional study.

SETTING

University setting in a general community sample. A multimodal recruitment strategy (public health centres and public areas) was applied.

PARTICIPANTS

Based on independent interviews, 26 participants, diagnosed with major depressive disorder (81% female; 23% comorbidity >1 and 23% comorbidity >2), entered treatment.

INTERVENTION

Acceptance and mindfulness based, as well as self-management and resource-oriented psychotherapy principles served as the theoretical basis for the low-threshold intervention. The blended format included face-to-face sessions, complemented with multimedia presentations and a platform featuring videos, online work sheets, an unguided group chat and remote therapist-patient communication.

MAIN OUTCOME MEASURES

The Center for Epidemiological Studies-Depression scale and the 12-item General Health Questionnaire.

RESULTS

Large to very large within group effect sizes were found on self-reported depression (F_{(2, 46.37)}=25.69, p<0.001; d=1.80), general health (F_(2,46.73)=11.47, p<0.001; d=1.32), personal resources (F_(2,43.36)=21.17, p<0.001; d=0.90) and mindfulness (F_(2,46.22)=9.40, p<0.001; d=1.12) after a follow-up period of 3 months. Treatment satisfaction was high, and 69% ranked computer and multimedia use as a therapeutic factor. Furthermore, participants described treatment intensification as important advantage of the blended format. Half of the patients (48%) would have preferred more time for personal exchange.

CONCLUSION

The investigated blended group format seems feasible for the reduction of depressive symptoms in major depression. The development of blended interventions can benefit from assuring that highly structured treatments actually meet patients' needs. As a next step, the intervention should be tested in comparative trials in routine care.

TRIAL REGISTRATION NUMBER

DRKS00010894; Pre-results.

Attitudes of Austrian Psychotherapists Towards Process and Outcome Monitoring

While monitoring systems in psychotherapy have become more common, little is known about the attitudes that mental health practitioners have towards these systems. In an online survey among 111 Austrian psychotherapists and trainees, attitudes towards therapy monitoring were measured. A well-validated questionnaire measuring attitudes towards outcome monitoring, the Outcome Measurement Questionnaire, was used. Clinicians' theoretical orientations as well as previous knowledge and experience with monitoring systems were associated with positive attitudes towards monitoring. Possible factors that may have led to these findings, like the views of different theoretical orientations or obstacles in Austrian public health care, are discussed.

Toward Impactful Collaborations on Computing and Mental Health

We describe an initiative to bring mental health researchers, computer scientists, human-computer interaction researchers, and other communities together to address the challenges of the global mental ill health epidemic. Two face-to-face events and one special issue of the Journal of Medical Internet Research were organized. The works presented in these events and publication reflect key state-of-the-art research in this interdisciplinary collaboration. We summarize the special issue articles and contextualize them to present a picture of the most recent research. In addition, we describe a series of collaborative activities held during the second symposium and where the community identified 5 challenges and their possible solutions.