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Effects of a Novel, Transdiagnostic Ecological Momentary Intervention for Prevention, and Early Intervention of Severe Mental Disorder in Youth (EMIcompass): Findings From an Exploratory Randomized Controlled Trial
Abstract
Background/hypothesis:
Digital interventions targeting transdiagnostic mechanisms in daily life may be a promising translational strategy for prevention and early intervention of psychotic and other severe mental disorders. We aimed to investigate the feasibility and initial signals of efficacy of a transdiagnostic, compassion-focused, hybrid ecological momentary intervention for improving resilience (ie, EMIcompass) in youth with early mental health problems.
Study design:
In an exploratory, assessor-blind randomized controlled trial, youth aged 14-25 with current distress, broad at-risk mental state, or first episode of severe mental disorder were randomly allocated to experimental (EMIcompass+treatment as usual [TAU]) or control condition (TAU). Data on primary (stress reactivity) and secondary candidate mechanisms as well as candidate primary (psychological distress) and secondary outcomes were collected.
Study results:
Criteria for the feasibility of trial methodology and intervention delivery were met (n = 92 randomized participants). No serious adverse events were observed. Initial outcome signals were evident for reduced momentary stress reactivity (stress×time×condition, B = -0.10 95%CI -0.16--0.03, d = -0.10), aberrant salience (condition, B = -0.38, 95%CI -0.57--0.18, d = -0.56) as well as enhanced momentary resilience (condition, B = 0.55, 95%CI 0.18-0.92, d = 0.33) and quality of life (condition, B = 0.82, 95%CI 0.10-1.55, d = 0.60) across post-intervention and 4-week follow-up. No outcome signals were observed for self-reported psychological distress (condition, B = 0.57, 95%CI -1.59-2.72, d = 0.09), but there was suggestive evidence of reduced observer-rated symptoms at the 4-week follow-up (B = -1.41, 95%CI -2.85-0.02, d = -0.41).
Conclusions:
Our findings provide evidence of feasibility and initial signals that EMIcompass may reduce stress reactivity and improve quality of life. A definitive trial is now warranted.
... EMIs were developed for different mental health problems such as mood [15,16], anxiety [17,18], and substance use disorders [19][20][21]. In addition, EMIs can focus on transdiagnostic intervention elements [22,23]. Unfortunately, still a limited number of studies rigorously research the effect of EMIs and several major (transdiagnostic) psychological domains remain unaddressed [24][25][26]. ...
... To enhance the field of EMI research an important challenge is the need for high-quality trials [25,30,31]. The SELFIE trial targeting self-esteem, and the EMI compass trial targeting resilience through a compassion-focused intervention, are particular examples for targeting mechanisms that may confer the development of mental disorders at a later age [23,29,31]. Research moves from knowing that psychological interventions work to understanding how they work [32]. ...
... The current realist evaluation was set in the context of the SELFIE trial [23,29], and follows a previously undertaken realist evaluation of the SELFIE intervention [50]. This previously undertaken realist evaluation was a result of the known relevance of interventions aimed at low self-esteem in youth, and due to the complex nature of self-esteem and its targeting by an intervention, it was considered important to focus the analysis of the available qualitative data solely on characteristics and delivery of self-esteem interventions. ...
Background
Technology improves accessibility of psychological interventions for youth. An ecological momentary intervention (EMI) is a digital intervention geared toward intervening in daily life to enhance the generalizability and ecological validity, and to be able to intervene in moments most needed. Identifying working mechanisms of the use of ecological momentary interventions might generate insights to improve interventions.
Methods
The present study investigates the working mechanisms of the use and acceptability of an ecological momentary intervention, named SELFIE, targeting self-esteem in youth exposed to childhood trauma, and evaluates under what circumstances these mechanisms of use and acceptability do or do not come into play. A realist evaluation approach was used for developing initial program theories (data: expert interviews and a stakeholders focus group), and subsequently testing (data: 15 interviews with participants, a focus group with therapists, debriefing questionnaire), and refining them.
Results
The SELFIE intervention is offered through a smartphone application enabling constant availability of the intervention and thereby increasing accessibility and feasibility. When the intervention was offered on their personal smartphone, this enhanced a sense of privacy and less hesitance in engaging with the app, leading to increased disclosure and active participation. Further, the smartphone application facilitates the practice of skills in daily life, supporting the repeated practice of exercises in different situations leading to the generalizability of the effect. Buffering against technical malfunction seemed important to decrease its possible negative effects.
Conclusions
This study enhanced our understanding of possible working mechanisms in EMIs, such as the constant availability supporting increased accessibility and feasibility, for which the use of the personal smartphone was experienced as a facilitating context. Hereby, the current study contributes to relatively limited research in this field. For the field to move forward, mechanisms of use, and acceptability of EMIs need to be understood. It is strongly recommended that alongside efficacy trials of an EMI on specific target mechanisms, a process evaluation is conducted investigating the working mechanisms of use.
Trial registration
The current paper reports on a realist evaluation within the SELFIE trial (Netherlands Trial Register NL7129 (NTR7475)).
... As for feasibility studies that also examined (preliminary) effectiveness, 71% of these used an observational one-group cohort study design without a control group. The other four studies conducted a randomized controlled trial, with two studies comparing results with a wait list control group (63,70), one study using treatment as usual (72) and one study including an attention control group (65). Sample sizes ranged from three to 248, with a total of 774 participants across the 14 studies. ...
... Intervention periods lasted between 2 and 12 weeks, with two studies requiring daily app usage (60,62) and three studies requiring app use frequency of at least once a week (63,64,68). Of the 14 included feasibility studies with preliminary effectiveness outcomes, three studies registered their clinical trial (63,65,72) and one also published a study protocol (72). ...
... Intervention periods lasted between 2 and 12 weeks, with two studies requiring daily app usage (60,62) and three studies requiring app use frequency of at least once a week (63,64,68). Of the 14 included feasibility studies with preliminary effectiveness outcomes, three studies registered their clinical trial (63,65,72) and one also published a study protocol (72). ...
Background
To bridge the gap in adolescent psychotherapy created by the increasing need for mental health interventions and the limited possibilities of in-person treatment during the pandemic, many health care providers opted to offer online mental health care programs. As a result, the number of mental health apps available in app stores experienced a sharp increase during the COVID-19 pandemic.
Objective
The aim of the current review is to provide an overview of feasibility and effectiveness studies testing mobile applications in adolescent psychotherapy during the peak phase of the COVID-19 pandemic.
Methods
We conducted a literature search in Pubmed, PsychInfo, Google Scholar, OpenSIGLE and OpenGREY for papers published from June 2020 to June 2023. Studies were included if they evaluated app-based interventions intended for psychotherapeutic treatment and targeted adolescents between 12 and 27 years of age with symptoms of psychological disorders. The quality of each study was assessed using the Systematic Assessment of Quality in Observational Research (SAQOR). Effectiveness outcomes were analyzed by vote counting and calculating a binomial probability test.
Results
The search yielded 31 relevant studies that examined 27 different apps with a total of 1,578 adolescent participants. Nine articles were primary effectiveness studies and 22 focused on feasibility measures as primary outcome. There was evidence that mental health apps influenced adolescents' psychotherapy, with 83% of the studies with effectiveness outcomes favoring the intervention (p = 0.002). Sixty-one percent of the included studies were rated at low or very low quality.
Conclusions
The pandemic has given apps a firm and important role in healthcare that will probably continue to expand in the future. To ensure that mental health apps are truly effective and beneficial for adolescents' psychotherapy, we need a standardized measurement of quality features of mental health apps and higher quality app evaluation studies.
Systematic review registration
https://www.crd.york.ac.uk/PROSPERO/display_record.php?RecordID=406455, PROSPERO International Prospective Register of Systematic Reviews [CRD42023406455].
... Of the 17 studies, seven were of fair quality ( >60% (Harpøth et al., 2020;Heininga & Oldehinkel, 2024;Hoorelbeke et al., 2019;Jennings et al., 2023;LoSavio et al., 2011;Martinez-Corts et al., 2015;Reininghaus et al., 2023)). The other 10 studies showed poor quality (36%-56%), resulting in an average rating of 54.4% (SD = 10.6%). ...
... Four studies focused on momentary ability to recover (e.g., "Right now, I feel like I can deal with whatever comes"; Mertens et al., 2023). Finally, three studies assessed self-reported ability to recover in response to a stressful or negative event (e.g., "I had difficulties to recover" (Reininghaus et al., 2023). Most studies investigated the selfreported ability to recover from daily stressors in relation to general daily stressors, whereas Jennings et al. (2023) and Martinez-Corts et al. (2015) examined resilience in the context of work conflicts. ...
Resilience is the dynamic process of adapting to or recovering from stressors, maintaining positive mental health. While most studies have investigated resilience after major life events, less is known about resilience in everyday life. To understand how individuals recover from everyday stressors, and associations with other psychosocial variables, well-being and mental health, we conducted a systematic review of studies to daily resilience, i.e., recovery from daily stressors, using the experience sampling method (ESM). Out of 36 included studies, 11 studies investigated daily resilience in youth (10.9–24.7 years) and 25 in adult samples. Daily resilience was operationalized either with self-report items adapted from trait measures (17 studies) or in terms of affective recovery from daily stressors (20 studies). The self-reported ability to recover from daily stressors reflects subjective experiences of coping with stressors, whereas daily resilience as recovery from daily stressors captures the dynamic process, but is understudied in youth. Daily resilience was associated with psychosocial variables, including better sleep quality and greater optimism. Furthermore, individuals with mental health problems consistently showed longer recovery times after daily stressors. Overall, ESM studies highlight that daily resilience could help to identify individuals at-risk for mental health problems. The findings may facilitate timely interventions.
... So far, one EMI including SC called "EMIcompass" has been reported (Paetzold et al., 2022;Reininghaus et al., 2023). The research team incorporated the EMI into the usual face-to-face treatment for young patients with mental health problems. ...
... Even though increasing the number of words in each SC writing may be a promising approach, it is not hard to imagine that participants face difficulty in coming up with long SC messages immediately after experiencing a negative event. Thus, combining other short SC exercises may be another method for improvement (Dong et al., 2022;Paetzold et al., 2022;Reininghaus et al., 2023). For example, reading compassionate messages from others, engaging in short meditations, and conducting soothing touch exercises could be effective momentary interventions. ...
Objectives
Numerous studies have focused on the ways to cultivate self-compassion (SC). Most of the SC interventions were typically lengthy and did not capture momentary fluctuations in SC after each exercise in the intervention. Therefore, we explored the impact of repeated self-compassionate writing as an ecological momentary intervention (EMI).
Method
Seventy-five participants completed a 3-week study with signals sent twice daily, resulting in 1,980 observations collected. During the 1-week control period, participants were asked to report their experiences of negative events, momentary SC, and momentary stress. In the subsequent 1-week intervention period, they engaged in SC writing whenever they experienced negative events. Trait SC and weekly stress were also evaluated before and after the intervention, including a 1-week follow-up period.
Results
Multilevel modeling showed a slight significant increase in momentary SC and a reduction in momentary stress. However, the slope did not differ significantly between the intervention and control periods. Moreover, there were no significant changes in trait SC nor in weekly stress, although the weekly stress levels showed a decreasing trend with a small effect size from pre to post intervention.
Conclusions
This study provided preliminary evidence of the feasibility and utility of EMI in cultivating SC using repeated self-compassionate writing. Although the effect sizes were small, the study highlighted possible approaches to increase the effectiveness of the intervention.
Preregistration
This study is not preregistered.
... An optional function offers participants CFIs in moments of high stress or negative affect based on brief ecological momentary assessments. The intervention and the exploratory RCT are presented in detail elsewhere (Paetzold et al., 2022;Reininghaus et al., 2023). ...
... Extending evidence from quantitative analyses Reininghaus et al., 2023) and replicating findings from a recent meta-analysis (Ferrari et al., 2019) with qualitative results, the incorporation of compassion-focused principles and the activation of participants' soothing systems were key elements of the intervention's content and the interpersonal contact in the current analyses. Qualitative findings showing improved understanding of the affective process, emotional resilience, and emotion regulation skills provide evidence for emotion regulation as a putative link between CFIs and clinical outcomes (Ferrari et al., 2019;Finlay-Jones, 2017;Paetzold et al., 2023). ...
Objectives
Previous research indicates that the hybrid compassion‐focused intervention EMIcompass may reduce stress reactivity and improve quality of life. Our aim was to investigate what components of the intervention work for whom, how, and under which circumstances to contribute to the enhancement of resilience.
Methods
We conducted a process evaluation using a realist framework. First, we developed initial programme theories using compassion‐focused interventions and ecological momentary intervention documents, in addition to conducting a focus group and an interview with an individual expert. Second, we tested the initial programme theories based on qualitative data from 20 participants. Third, we refined the programme theories by analysing and interpreting the data.
Results
We identified four programme components experienced as enhancing the activation of the soothing system and the application of compassion‐focused principles. EMIcompass was perceived as lowering the burden of and barriers to treatment and facilitating the translation into daily life. Intra‐ and interpersonal context factors interacted with the mechanisms, leading to improvement in well‐being, which was identified as a main outcome.
Discussion
The intervention worked by strengthening participants' soothing system and facilitating ecological translation leading to improved well‐being. Adaptions to improve the intervention may allow for more flexibility in individual intervention trajectories acknowledging different needs and preferences.
... EMI are administered via smartphone devices and are designed to intervene in an individual's natural environment, precisely targeting moments when mental health is at risk (Heron & Smyth, 2010;Myin-Germeys et al., 2016;Schulte-Strathaus et al., 2022). For instance, EMI have been employed to enhance resilience in response to stress in youth at risk to develop, or with first episodes of, severe mental disorders Reininghaus et al., 2023;Schick et al., 2021), and to reduce depression and anxiety (Schueller et al., 2017;Seppälä et al., 2019). ...
... For instance, empirical EMI resulted in an overall pattern of improvement across predicted psychological variables, and exerted a stronger degree of system control than the mere passive indication of social presence and absence. This aligns well with previous observations of immediate EMI-driven mental health improvements , as well as the general motivation behind delivering these specific EMI (Paetzold et al., 2022;Reininghaus et al., 2023). However, the observed interindividual differences in dynamical systems and responses also imply personalized intervention approaches are necessary. ...
Objectives
Ecological momentary interventions (EMI) are digital mobile health interventions administered in an individual's daily life to improve mental health by tailoring intervention components to person and context. Experience sampling via ecological momentary assessments (EMA) furthermore provides dynamic contextual information on an individual's mental health state. We propose a personalized data‐driven generic framework to select and evaluate EMI based on EMA.
Methods
We analyze EMA/EMI time‐series from 10 individuals, published in a previous study. The EMA consist of multivariate psychological Likert scales. The EMI are mental health trainings presented on a smartphone. We model EMA as linear dynamical systems (DS) and EMI as perturbations. Using concepts from network control theory, we propose and evaluate three personalized data‐driven intervention delivery strategies. Moreover, we study putative change mechanisms in response to interventions.
Results
We identify promising intervention delivery strategies that outperform empirical strategies in simulation. We pinpoint interventions with a high positive impact on the network, at low energetic costs. Although mechanisms differ between individuals ‐ demanding personalized solutions ‐ the proposed strategies are generic and applicable to various real‐world settings.
Conclusions
Combined with knowledge from mental health experts, DS and control algorithms may provide powerful data‐driven and personalized intervention delivery and evaluation strategies.
... Sixth, developing transdiagnostic interventions is a growing clinical and research need (Reininghaus et al., 2023). ...
Aims
To map studies assessing both clinical high risk for psychosis (CHR-P) and borderline personality disorder (BPD) in clinical samples, focusing on clinical/research/preventive paradigms and proposing informed research recommendations.
Methods
We conducted a PRISMA-ScR/JBI-compliant scoping review (protocol: https://osf.io/8mz7a) of primary research studies (cross-sectional/longitudinal designs) using valid measures/criteria to assess CHR-P and BPD (threshold/subthreshold) in clinical samples, reporting on CHR-P/psychotic symptoms and personality disorder(s) in the title/abstract/keywords, identified in Web of Science/PubMed/(EBSCO)PsycINFO until 23/08/2023.
Results
33 studies were included and categorized into four themes reflecting their respective clinical/research/preventive paradigm: (i) BPD as a comorbidity in CHR-P youth (k = 20), emphasizing early detection and intervention in psychosis; (ii) attenuated psychosis syndrome (APS) as a comorbidity among BPD inpatients (k = 2), with a focus on hospitalized adolescents/young adults admitted for non-psychotic mental disorders; (iii) mixed samples (k = 7), including descriptions of early intervention services and referral pathways; (iv) transdiagnostic approaches (k = 4) highlighting “clinical high at risk mental state” (CHARMS) criteria to identify a pluripotent risk state for severe mental disorders.
Conclusion
The scoping review reveals diverse approaches to clinical care for CHR-P and BPD, with no unified treatment strategies. Recommendations for future research should focus on: (i) exploring referral pathways across early intervention clinics to promote timely intervention; (ii) enhancing early detection strategies in innovative settings such as emergency departments; (iii) improving mental health literacy to facilitate help-seeking behaviors; (iv) analysing comorbid disorders as complex systems to better understand and target early psychopathology; (v) investigating prospective risk for BPD; (vi) developing transdiagnostic interventions; (vii) engaging youth with lived experience of comorbidity to gain insight on their subjective experience; (viii) understanding caregiver burden to craft family-focused interventions; (ix) expanding research in underrepresented regions such as Africa and Asia, and; (x) evaluating the cost-effectiveness of early interventions to determine scalability across different countries.
Systematic Review Registration
https://osf.io/8mz7a.
... There is increasing interest for interventions targeting paranoia and other outcomes in schizophrenia, bipolar disorder, and related conditions through digital media. 17,18,50,51 The correlates of media use identified here point to potential barriers to the accessibility of such interventions in some individuals, especially since the same systemic inequities that hamper media access may also act as risk factors for more severe clinical outcomes in these populations 52 . ...
Paranoia is a spectrum of fear-related experiences that spans diagnostic categories and is influenced by the environment. The extent to which traditional and digital media use is associated with paranoia remains unknown. We aimed to examine associations between media use and paranoia at the within-and between-person levels. Participants were 409 individuals diagnosed with schizophrenia spectrum or bipolar disorder. Measures included sociodemographic and clinical characteristics at baseline, followed by ecological momentary assessments (EMA) collected three times daily over 30 days. EMA evaluated paranoia and five types of media use: TV, social media, music, reading or writing, and other internet or computer use. Generalized linear mixed models were used to examine paranoia as a function of each type of media use and vice-versa. Characteristics associated with lower likelihood of media use included minority ethnoracial status, lower educational attainment, and diagnosis of schizophrenia vs. bipolar disorder. There were within-person associations between social media use and subsequently reduced paranoia in the schizophrenia group: fold-change=0.900; 95% CI: 0.840, 0.965; and between listening to music and subsequently decreased paranoia in the bipolar disorder group: fold-change=0.949; 95% CI: 0.906, 0.995. Associations of other media with paranoia were not significant. The associations of social media use and listening to music with reductions in paranoia may reflect clinical benefits of social interaction and distraction. However, systemic inequities and individual factors may hamper the accessibility of certain types of media.
... models offering telehealth visits combined with a smartphone app, mindLAMP, involving both digital phenotyping for personalizing care and digital interventions for practicing skills, also show promise for rapidly reducing anxiety and depression-related symptoms [127]. Furthermore, a new generation of apps, such as EMIcompass, capture digital signals related to daily life (eg sleep patterns, mood) and use that data to respond with personalized and just-in-time support, thereby offering scalable and customized support for youth [128]. Digital technologies can also be used to detect emerging mental disorders outside established clinical pathways, an important prerequisite for population-based preventive approaches. ...
Most mental disorders have a typical onset between 12 and 25 years of age, highlighting the importance of this period for the pathogenesis, diagnosis, and treatment of mental ill-health. This perspective addresses interactions between risk and protective factors and brain development as key pillars accounting for the emergence of psychopathology in youth. Moreover, we propose that novel approaches towards early diagnosis and interventions are required that reflect the evolution of emerging psychopathology, the importance of novel service models, and knowledge exchange between science and practitioners. Taken together, we propose a transformative early intervention paradigm for research and clinical care that could significantly enhance mental health in young people and initiate a shift towards the prevention of severe mental disorders.
Background
Considering the high prevalence of mental health conditions among young people and the technological advancements of artificial intelligence (AI)–based approaches in health services, mobile health (mHealth) apps for mental health are a promising way for low-threshold and large-scale mental health promotion, prevention, and intervention strategies, especially for young people. However, insufficient evidence on health-promoting effects and deficient user-centric designs emphasize the necessity for participatory methods in the interventions’ development processes.
Objective
This study aimed to explore young people’s everyday experiences using an AI-based mHealth app for mental health promotion based on ecological momentary assessments and ecological momentary interventions. Our analysis of qualitative data focused on exploring young people’s use patterns in daily life and mental health–promoting effects.
Methods
We conducted problem-centered interviews and focus groups with a subsample of 27 young people aged 14 to 25 years, who were among the participants of 2 microrandomized trials testing and evaluating an AI-based mHealth app (AI4U training). Our study used a participatory approach, with “co- and peer researchers” from the dialogue population actively engaged in research processes and data analysis. Structural content analysis guided the qualitative analysis.
Results
Participants reported enhanced emotional self-awareness and regulation in daily life through the ecological momentary assessments and ecological momentary interventions. Young people appreciated the AI4U training for managing emotions and stress. They had no trust issues regarding disclosing their mental health via the AI4U training in daily life. Some faced challenges integrating it into their daily routines and highlighted the value of autonomy in use decision-making processes.
Conclusions
Our findings reveal that young people benefited from enhanced emotional awareness and management through the use of the AI4U training, appreciating its anonymity for facilitating emotional disclosure. The results suggest that enhanced self-directed use may improve daily life integration, although participants noted that they sometimes avoided using the AI4U training during distress despite recognizing its potential benefits. These findings indicate the importance of balancing directed use and autonomy in digital interventions to harmonize compliance with effectiveness in daily life. We highlight the importance of participatory research for tailored digital mental health solutions.
Background and Hypothesis
Consistent with diathesis-stress models, psychosis research has focused on genetic moderation of adverse environmental exposures. In contrast, the Differential Susceptibility (DS) model suggests that the same genetic variants that increase risk-inducing effects of adverse experiences also enhance beneficial effects from positive experiences. This study examined whether individuals with high genetic susceptibility to the environment showed differential psychotic-like and affective reactivity in response to positive and negative events in daily life.
Study Design
Experience sampling methodology assessed context (positive and stressful) and momentary levels of paranoia, psychotic-like experiences (PLE), and positive (PA) and negative affect (NA) in 217 non-clinical adults oversampled for schizotypy. Linear mixed models examined whether Polygenic Risk Scores of Environmental Sensitivity (PRS-ES) moderated the impact of current context on subsequent experiences.
Study Results
PRS-ES moderated positive, but not stressful, context on subsequent levels of momentary paranoia, NA, and PA, but not PLE. Genetic and environmental (G × E) interactions indicated diathesis-stress at lower thresholds of PRS-ES, but a DS model at the highest threshold of the PRS-ES. Participants with elevated PRS-ES showed increased paranoia and NA and decreased PA in subsequent assessments when reporting low levels of positive situations, but also decreased paranoia and NA and increased PA when rating contexts as positive.
Conclusions
Findings support the influence of genetic sensitivity to the environment on psychotic-like and affective reactivity in daily life, particularly in response to positive contexts. This highlights the transdiagnostic protective role of positive experiences and informs ecological momentary interventions.
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.
Background
Mental health problems among children and adolescents increased in recent years, while mental health services are overburdened with long waiting lists. eHealth interventions, that is, interventions delivered digitally via apps or websites, offer a promising approach to prevent and efficiently treat emerging mental health problems in youth. Over the past years, rapid technological progress has led to diverse eHealth interventions for youth mental health. However, a structured overview of effective eHealth elements and mechanisms through which interventions aim to improve mental health is lacking. The aim of this pre-registered systematic review is to identify elements of eHealth interventions that improve mental health and well-being in children and adolescents aged 10–25 from both clinical and general populations.
Methods
This systematic review conducted in April 2023 in accordance with the Preferred Reporting Items for Systematic Review and Meta-Analysis guidelines identified 108 studies and 103 distinct interventions between 2011–2023. The overall sample size was 33,435 participants (30.7% male, mean age = 18.4 years, SD = 2.5). Most studies (64.8%) were randomized controlled trials (RCTs) to test the interventions. The remaining studies utilized a pre-post or group-comparison design (non-RCTs).
Results
The interventions were heterogeneous in design, method of delivery, target group and outcome measures. Overall, 77.7% of the studies showed a positive significant association between eHealth intervention and mental health or well-being. Elements that were often related to improved mental health and well-being were cognitive behavioural therapy (CBT) or self-monitoring as therapeutic principles, blended approaches combining eHealth with traditional therapy, peer/parental involvement and technological gamification elements, such as rewards.
Conclusions
Elements of youth eHealth interventions that appear to positively impact mental health or well-being are (a) CBT-based, (b) self-monitoring (c) blended interventions, (d) peer or parental involvement or (e) gamification. Future directions for the development and implementation of eHealth interventions for youth are discussed.
The experience sampling method (ESM) is a structured diary technique, which is used to assess thoughts, mood and appraise subjective experiences in daily life. It has been recognized as a useful tool for understanding the characteristics, dynamics, and underlying mechanisms of prodromal symptoms of psychosis. The present systematic review aimed to provide a qualitative synthesis of findings provided by the ESM studies conducted in people with psychosis risk states. A systematic review of the MEDLINE, ERIC, Academic Search Ultimate, and Health Source: Nursing/Academic Edition databases, utilizing search terms related to the ESM and the risk of psychosis was conducted. Out of 1069 publication records identified, 77 studies met the inclusion criteria for the review. Data were synthesized around the following topics: 1) assessment of symptoms dynamics and social functioning; 2) assessment mechanisms contributing to the emergence of psychotic experiences 3) assessment of stress sensitivity. The studies have shown that negative emotions are associated with subsequent development of paranoia. The tendency to draw hasty conclusions, aberrant salience, self-esteem, and emotion regulation were the most frequently reported mechanisms associated with the emergence of psychotic experiences. Studies using the ESM also provided evidence for the role of stress sensitivity, in the development of psychotic symptoms. The ESM has widely been applied to studies investigating psychosis risk states, using a variety of protocols. Findings from this systematic review might inform future studies and indicate potential targets for interventions.
Importance
Targeting low self-esteem in youth exposed to childhood adversity is a promising strategy for preventing adult mental disorders. Ecological momentary interventions (EMIs) allow for the delivery of youth-friendly, adaptive interventions for improving self-esteem, but robust trial-based evidence is pending.
Objective
To examine the efficacy of SELFIE, a novel transdiagnostic, blended EMI for improving self-esteem plus care as usual (CAU) compared with CAU only.
Design, Setting, and Participants
This was a 2-arm, parallel-group, assessor-blinded, randomized clinical trial conducted from December 2018 to December 2022. The study took place at Dutch secondary mental health services and within the general population and included youth (aged 12-26 years) with low self-esteem (Rosenberg Self-Esteem Scale [RSES] <26) exposed to childhood adversity.
Interventions
A novel blended EMI (3 face-to-face sessions, email contacts, app-based, adaptive EMI) plus CAU or CAU only.
Main Outcomes and Measures
The primary outcome was RSES self-esteem at postintervention and 6-month follow-up. Secondary outcomes included positive and negative self-esteem, schematic self-beliefs, momentary self-esteem and affect, general psychopathology, quality of life, observer-rated symptoms, and functioning.
Results
A total of 174 participants (mean [SD] age, 20.7 [3.1] years; 154 female [89%]) were included in the intention-to-treat sample, who were primarily exposed to childhood emotional abuse or neglect, verbal or indirect bullying, and/or parental conflict. At postintervention, 153 participants (87.9%) and, at follow-up, 140 participants (80.5%), provided primary outcome data. RSES self-esteem was, on average, higher in the experimental condition (blended EMI + CAU) than in the control condition (CAU) across both postintervention and follow-up as a primary outcome (B = 2.32; 95% CI, 1.14-3.50; P < .001; Cohen d -type effect size [hereafter, Cohen d ] = 0.54). Small to moderate effect sizes were observed suggestive of beneficial effects on positive (B = 3.85; 95% CI, 1.83-5.88; P < .001; Cohen d = 0.53) and negative (B = −3.78; 95% CI, −6.59 to −0.98; P = .008; Cohen d = −0.38) self-esteem, positive (B = 1.58; 95% CI, 0.41-2.75; P = .008; Cohen d = 0.38) and negative (B = −1.71; 95% CI, −2.93 to −0.48; P = .006; Cohen d = −0.39) schematic self-beliefs, momentary self-esteem (B = 0.29; 95% CI, 0.01-0.57; P = .04; Cohen d = 0.24), momentary positive affect (B = 0.23; 95% CI, 0.01-0.45; P = .04; Cohen d = 0.20), momentary negative affect (B = −0.33; 95% CI, −0.59 to −0.03, P = .01, Cohen d = −0.27), general psychopathology (B = −17.62; 95% CI, −33.03 to −2.21; P = .03; Cohen d = −0.34), and quality of life (B = 1.16; 95% CI, 0.18-2.13; P = .02; Cohen d = 0.33) across postintervention and follow-up. No beneficial effects on symptoms and functioning were observed.
Conclusions and Relevance
A transdiagnostic, blended EMI demonstrated efficacy on the primary outcome of self-esteem and signaled beneficial effects on several secondary outcomes. Further work should focus on implementing this novel EMI in routine public mental health provision.
Trial Registration
Dutch Trial Register Identifier: NL7129(NTR7475)
Zusammenfassung
Dieser Artikel hat zum Ziel, einen Überblick über drei zentrale Strategien populationsbasierter Interventionen der Public Mental Health darzustellen: (1) Hochrisikostrategie, (2) Populationsstrategie und der (3) vulnerable Populationsansatz. Dabei werden zentrale Herausforderungen beleuchtet und die Bedeutung inter- und transdisziplinärer Zusammenarbeit hervorgehoben. Zukünftige Maßnahmen der Public Mental Health erfordern die Integration dieser Strategien unter Beteiligung von Betroffenen und Stakeholdern.
Objectives
Previous research indicates that the hybrid compassion‐focused intervention EMIcompass may reduce stress reactivity and improve quality of life. Our aim was to investigate what components of the intervention work for whom, how, and under which circumstances to contribute to the enhancement of resilience.
Methods
We conducted a process evaluation using a realist framework. First, we developed initial programme theories using compassion‐focused interventions and ecological momentary intervention documents, in addition to conducting a focus group and an interview with an individual expert. Second, we tested the initial programme theories based on qualitative data from 20 participants. Third, we refined the programme theories by analysing and interpreting the data.
Results
We identified four programme components experienced as enhancing the activation of the soothing system and the application of compassion‐focused principles. EMIcompass was perceived as lowering the burden of and barriers to treatment and facilitating the translation into daily life. Intra‐ and interpersonal context factors interacted with the mechanisms, leading to improvement in well‐being, which was identified as a main outcome.
Discussion
The intervention worked by strengthening participants' soothing system and facilitating ecological translation leading to improved well‐being. Adaptions to improve the intervention may allow for more flexibility in individual intervention trajectories acknowledging different needs and preferences.
Background
Young people are a target population for mental health–related early intervention and prevention. Although evidence for early intervention is promising, availability of and access to youth mental health services remain limited. Therefore, the development of an evidence-based hybrid intervention is urgently needed.
Objective
This study aimed to present a manual for a hybrid intervention, combining an ecological momentary intervention and face-to-face sessions aimed for enhancing resilience in help-seeking young people based on compassion-focused interventions, and explore whether participants’ baseline characteristics are associated with putative mechanisms and outcomes of the EMIcompass intervention. Specifically, we aimed to explore initial signals as to whether participants’ sociodemographic, clinical, and functional characteristics at baseline are associated with putative mechanisms (ie, change in self-compassion, change in emotion regulation, working alliance, training frequency); and whether participants’ sociodemographic, clinical, and functional characteristics, self-compassion, and emotion regulation at baseline are associated with clinical outcomes (ie, psychological distress and general psychopathology at postintervention and 4-week follow-ups) in the experimental condition and obtain first parameter estimates.
Methods
We recruited young people aged 14 to 25 years, with psychological distress, Clinical High At-Risk Mental State, or first episodes of severe mental disorder for an exploratory randomized controlled trial with assessments at baseline and postintervention and 4-week follow-ups. A structured manual was developed and optimized based on a pilot study’s manual, a scoping review of existing literature and manuals, exchange with experts, the team’s clinical experience of working with compassion-focused interventions, and the principles of ecological momentary interventions. This analysis focuses on the experimental condition receiving the EMIcompass intervention.
Results
A total of 46 young individuals were randomized to the experimental condition. There was evidence for initial signals of effects of age (B=0.11, 95% CI 0.00-0.22), general psychopathology (B=0.08, 95% CI −0.01 to 0.16), and clinical stage (B=1.50, 95% CI 0.06-2.93) on change in momentary self-compassion and change in emotion regulation from baseline to postintervention assessments. There was no evidence for associations of other baseline characteristics (eg, gender, minority status, and level of functioning) and putative mechanisms (eg, overall self-compassion, working alliance, and training frequency). In addition, except for an initial signal for an association of momentary self-compassion at baseline and psychological distress (B=−2.83, 95% CI −5.66 to 0.00), we found no evidence that baseline characteristics related to clinical outcomes.
Conclusions
The findings indicated the reach of participants by the intervention largely independent of sociodemographic, clinical, and functional baseline characteristics. The findings need to be confirmed in a definitive trial.
Trial Registration
German Clinical Trials Register NDRKS00017265; https://www.drks.de/drks_web/navigate.do?navigationId=trial.HTML&TRIAL_ID=DRKS00017265
International Registered Report Identifier (IRRID)
RR2-10.2196/27462
Background
Most mental disorders first emerge in youth and, in their early stages, surface as subthreshold expressions of symptoms comprising a transdiagnostic phenotype of psychosis, mania, depression, and anxiety. Elevated stress reactivity is one of the most widely studied mechanisms underlying psychotic and affective mental health problems. Thus, targeting stress reactivity in youth is a promising indicated and translational preventive strategy for adverse mental health outcomes that could develop later in life and for improving resilience. Compassion-focused interventions offer a wide range of innovative therapeutic techniques that are particularly amenable to being implemented as ecological momentary interventions (EMIs), a specific type of mobile health intervention, to enable youth to access interventions in a given moment and context in daily life. This approach may bridge the current gap in youth mental health care.
Objective
This study aims to investigate the clinical feasibility, candidate underlying mechanisms, and initial signals of the efficacy of a novel, transdiagnostic, hybrid EMI for improving resilience to stress in youth—EMIcompass.
Methods
In an exploratory randomized controlled trial, youth aged between 14 and 25 years with current distress, a broad Clinical High At-Risk Mental State, or the first episode of a severe mental disorder will be randomly allocated to the EMIcompass intervention (ie, EMI plus face-to-face training sessions) in addition to treatment as usual or a control condition of treatment as usual only. Primary (stress reactivity) and secondary candidate mechanisms (resilience, interpersonal sensitivity, threat anticipation, negative affective appraisals, and momentary physiological markers of stress reactivity), as well as primary (psychological distress) and secondary outcomes (primary psychiatric symptoms and general psychopathology), will be assessed at baseline, postintervention, and at the 4-week follow-up.
Results
The first enrollment was in August 2019, and as of May 2021, enrollment and randomization was completed (N=92). We expect data collection to be completed by August 2021.
Conclusions
This study is the first to establish feasibility, evidence on underlying mechanisms, and preliminary signals of the efficacy of a compassion-focused EMI in youth. If successful, a confirmatory randomized controlled trial will be warranted. Overall, our approach has the potential to significantly advance preventive interventions in youth mental health provision.
Trial Registration
German Clinical Trials Register DRKS00017265; https://www.drks.de/drks_web/navigate.do?navigationId=trial.HTML&TRIAL_ID=DRKS00017265
International Registered Report Identifier (IRRID)
DERR1-10.2196/27462
Background: Digital interventions offer new avenues for low-threshold prevention and treatment in young people. Ecological momentary interventions (EMIs) represent a powerful approach that allows for adaptive, real-time, and real-world delivery of intervention components in daily life by real-time processing of ecological momentary assessment (EMA) data. Compassion-focused interventions (CFIs) may be particularly amenable to translation into an EMI to strengthen emotional resilience and modify putative risk mechanisms, such as stress sensitivity, in the daily lives of young help-seeking individuals.
Objective: This study aims to investigate the feasibility, safety, and initial therapeutic effects of a novel, accessible, transdiagnostic, ecological momentary CFI for improving emotional resilience to stress (EMIcompass).
Methods: In this uncontrolled pilot study, help-seeking youth with psychotic, depressive, or anxiety symptoms were offered the EMIcompass intervention in addition to treatment as usual. The EMIcompass intervention consisted of a 3-week EMI (including enhancing, consolidating, and EMA-informed interactive tasks) administered through a mobile health app and three face-to-face sessions with a trained psychologist intended to provide guidance and training on the CFI exercises presented in the app (ie, training session, follow-up booster session, and review session).
Results: In total, 10 individuals (mean age 20.3 years, SD 3.8; range 14-25) were included in the study. Most (8/10, 80%) participants were satisfied and reported a low burden of app usage. No adverse events were observed. In approximately one-third of all EMAs, individuals scored high on stress, negative affect, or threat anticipation during the intervention period, resulting in real-time, interactive delivery of the CFI intervention components in addition to weekly enhancing and daily consolidating tasks. Although the findings should be interpreted with caution because of the small sample size, reduced stress sensitivity, momentary negative affect, and psychotic experiences, along with increased positive affect, were found at postintervention and the 4-week follow-up. Furthermore, reductions in psychotic, anxiety, and depressive symptoms were found (r=0.30-0.65). Conclusions: Our findings provide evidence on the feasibility and safety of the EMIcompass intervention for help-seeking youth and lend initial support to beneficial effects on stress sensitivity and mental health outcomes. An exploratory randomized controlled trial is warranted to establish the feasibility and preliminary evidence of its efficacy.
Background: Public health measures to curb SARS-CoV-2 transmission rates may have negative psychosocial consequences in youth. Digital interventions may help to mitigate these effects. We investigated the associations between social isolation, COVID-19-related cognitive preoccupation, worries, and anxiety, objective social risk indicators, and psychological distress, as well as use of, and attitude toward, mobile health (mHealth) interventions in youth. Methods:
Data were collected as part of the “Mental Health And Innovation During COVID-19 Survey”—a cross-sectional panel study including a representative sample of individuals aged 16–25 years (N = 666; Mage = 21.3; assessment period: May 5, 2020 to May 16, 2020). Results:
Overall, 38% of youth met criteria for moderate or severe psychological distress. Social isolation worries and anxiety, and objective risk indicators were associated with psychological distress, with evidence of dose–response relationships for some of these associations. For instance, psychological distress was progressively more likely to occur as levels of social isolation increased (reporting “never” as reference group: “occasionally”: adjusted odds ratio [aOR] 9.1, 95% confidence interval [CI] 4.3–19.1, p < 0.001; “often”: aOR 22.2, CI 9.8–50.2, p < 0.001; “very often”: aOR 42.3, CI 14.1–126.8, p < 0.001). There was evidence that psychological distress, worries, and anxiety were associated with a positive attitude toward using mHealth interventions, whereas psychological distress, worries, and anxiety were associated with actual use. Conclusions: Public health measures during pandemics may be associated with poor mental health outcomes in youth. Evidence-based digital interventions may help mitigate the negative psychosocial impact without risk of viral infection given there is an objective need and subjective demand.
Background:
Accumulating evidence suggests the COVID-19 pandemic has negative effects on public mental health. Digital interventions that have been developed and evaluated in recent years may be used to mitigate the negative consequences of the pandemic. However, evidence-based recommendations on the use of existing telemedicine and internet-based (eHealth) and app-based mobile health (mHealth) interventions are lacking.
Objective:
The aim of this study was to investigate the theoretical and empirical base, user perspective, safety, effectiveness, and cost-effectiveness of digital interventions related to public mental health provision (ie, mental health promotion, prevention, and treatment of mental disorders) that may help to reduce the consequences of the COVID-19 pandemic.
Methods:
A rapid meta-review was conducted. The MEDLINE, PsycINFO, and CENTRAL databases were searched on May 11, 2020. Study inclusion criteria were broad and considered systematic reviews and meta-analyses that investigated digital tools for health promotion, prevention, or treatment of mental health conditions and determinants likely affected by the COVID-19 pandemic.
Results:
Overall, 815 peer-reviewed systematic reviews and meta-analyses were identified, of which 83 met the inclusion criteria. Our findings suggest that there is good evidence on the usability, safety, acceptance/satisfaction, and effectiveness of eHealth interventions. Evidence on mHealth apps is promising, especially if social components (eg, blended care) and strategies to promote adherence are incorporated. Although most digital interventions focus on the prevention or treatment of mental disorders, there is some evidence on mental health promotion. However, evidence on process quality, cost-effectiveness, and long-term effects is very limited.
Conclusions:
There is evidence that digital interventions are particularly suited to mitigating psychosocial consequences at the population level. In times of physical distancing, quarantine, and restrictions on social contacts, decision makers should develop digital strategies for continued mental health care and invest time and efforts in the development and implementation of mental health promotion and prevention programs.
Importance
The large contribution of psychiatric disorders to premature death and persistent disability among young people means that earlier identification and enhanced long-term care for those who are most at risk of developing life-threatening or chronic disorders is critical. Clinical staging as an adjunct to diagnosis to address emerging psychiatric disorders has been proposed for young people presenting for care; however, the longer-term utility of this system has not been established.
Objectives
To determine the rates of transition from earlier to later stages of anxiety, mood, psychotic, or comorbid disorders and to identify the demographic and clinical characteristics that are associated with the time course of these transitions.
Design, Setting, and Participants
A longitudinal, observational study of 2254 persons aged 12 to 25 years who obtained mental health care at 2 early intervention mental health services in Sydney, Australia, and were recruited to a research register between June 18, 2008, and July 24, 2018 (the Brain and Mind Centre Optymise Cohort).
Main Outcomes and Measures
The primary outcome of this study was transition from earlier to later clinical stages. A multistate Markov model was used to examine demographic (ie, age, sex, engagement in education, employment, or both) and clinical (ie, social and occupational function, clinical presentation, personal history of mental illness, physical health comorbidities, treatment use, self-harm, suicidal thoughts and behaviors) factors associated with these transitions.
Results
Of the 2254 individuals included in the study, mean (SD) age at baseline was 18.18 (3.33) years and 1330 (59.0%) were female. Data on race/ethnicity were not available. Median (interquartile range) follow-up was 14 (5-33) months. Of 685 participants at stage 1a (nonspecific symptoms), 253 (36.9%) transitioned to stage 1b (attenuated syndromes). Transition was associated with lower social functioning (hazard ratio [HR], 0.77; 95% CI, 0.66-0.90), engagement with education, employment, or both (HR, 0.47; 95% CI, 0.25-0.91), manic-like experiences (HR, 2.12; 95% CI, 1.19-3.78), psychotic-like experiences (HR, 2.13; 95% CI, 1.38-3.28), self-harm (HR, 1.42; 95% CI, 1.01-1.99), and older age (HR, 1.27; 95% CI, 1.11-1.45). Of 1370 stage 1b participants, 176 (12.8%) transitioned to stage 2 (full-threshold) disorders. Transition was associated with psychotic-like experiences (HR, 2.31; 95% CI, 1.65-3.23), circadian disturbance (HR, 1.66; 95% CI, 1.17-2.35), psychiatric medication (HR, 1.43; 95% CI, 1.03-1.99), childhood psychiatric disorder (HR, 1.62; 95% CI, 1.03-2.54), and older age (HR, 1.24; 95% CI, 1.05-1.45).
Conclusions and Relevance
Differential rates of progression from earlier to later stages of anxiety, mood, psychotic, or comorbid disorders were observed in young persons who presented for care at various stages. Understanding the rate and factors associated with transition assists planning of stage-specific clinical interventions and secondary prevention trials.
Background
Despite increasing interest in research on how to translate knowledge into practice and improve healthcare, the accumulation of scientific knowledge in this field is slow. Few substantial new insights have become available in the last decade.
Main body
Various problems hinder development in this field. There is a frequent misfit between problems and approaches to implementation, resulting in the use of implementation strategies that do not match with the targeted problems. The proliferation of concepts, theories and frameworks for knowledge transfer – many of which are untested – has not advanced the field. Stakeholder involvement is regarded as crucial for successful knowledge implementation, but many approaches are poorly specified and unvalidated. Despite the apparent decreased appreciation of rigorous designs for effect evaluation, such as randomized trials, these should remain within the portfolio of implementation research. Outcome measures for knowledge implementation tend to be crude, but it is important to integrate patient preferences and the increased precision of knowledge.
Conclusions
We suggest that the research enterprise be redesigned in several ways to address these problems and enhance scientific progress in the interests of patients and populations. It is crucially important to establish substantial programmes of research on implementation and improvement in healthcare, and better recognize the societal and practical benefits of research.
BACKGROUND: Randomised controlled trials (RCTs) are used to evaluate social and psychological interventions and inform policy decisions about them. Accurate, complete, and transparent reports of social and psychological intervention RCTs are essential for understanding their design, conduct, results, and the implications of the findings. However, the reporting of RCTs of social and psychological interventions remains suboptimal. The CONSORT Statement has improved the reporting of RCTs in biomedicine. A similar high-quality guideline is needed for the behavioural and social sciences. Our objective was to develop an official extension of the Consolidated Standards of Reporting Trials 2010 Statement (CONSORT 2010) for reporting RCTs of social and psychological interventions: CONSORT-SPI 2018. METHODS: We followed best practices in developing the reporting guideline extension. First, we conducted a systematic review of existing reporting guidelines. We then conducted an online Delphi process including 384 international participants. In March 2014, we held a 3-day consensus meeting of 31 experts to determine the content of a checklist specifically targeting social and psychological intervention RCTs. Experts discussed previous research and methodological issues of particular relevance to social and psychological intervention RCTs. They then voted on proposed modifications or extensions of items from CONSORT 2010. RESULTS: The CONSORT-SPI 2018 checklist extends 9 of the 25 items from CONSORT 2010: background and objectives, trial design, participants, interventions, statistical methods, participant flow, baseline data, outcomes and estimation, and funding. In addition, participants added a new item related to stakeholder involvement, and they modified aspects of the flow diagram related to participant recruitment and retention. CONCLUSIONS: Authors should use CONSORT-SPI 2018 to improve reporting of their social and psychological intervention RCTs. Journals should revise editorial policies and procedures to require use of reporting guidelines by authors and peer reviewers to produce manuscripts that allow readers to appraise study quality, evaluate the applicability of findings to their contexts, and replicate effective interventions.
Background:
Randomised controlled trials (RCTs) are used to evaluate social and psychological interventions and inform policy decisions about them. Accurate, complete, and transparent reports of social and psychological intervention RCTs are essential for understanding their design, conduct, results, and the implications of the findings. However, the reporting of RCTs of social and psychological interventions remains suboptimal. The CONSORT Statement has improved the reporting of RCTs in biomedicine. A similar high-quality guideline is needed for the behavioural and social sciences. Our objective was to develop an official extension of the Consolidated Standards of Reporting Trials 2010 Statement (CONSORT 2010) for reporting RCTs of social and psychological interventions: CONSORT-SPI 2018.
Methods:
We followed best practices in developing the reporting guideline extension. First, we conducted a systematic review of existing reporting guidelines. We then conducted an online Delphi process including 384 international participants. In March 2014, we held a 3-day consensus meeting of 31 experts to determine the content of a checklist specifically targeting social and psychological intervention RCTs. Experts discussed previous research and methodological issues of particular relevance to social and psychological intervention RCTs. They then voted on proposed modifications or extensions of items from CONSORT 2010.
Results:
The CONSORT-SPI 2018 checklist extends 9 of the 25 items from CONSORT 2010: background and objectives, trial design, participants, interventions, statistical methods, participant flow, baseline data, outcomes and estimation, and funding. In addition, participants added a new item related to stakeholder involvement, and they modified aspects of the flow diagram related to participant recruitment and retention.
Conclusions:
Authors should use CONSORT-SPI 2018 to improve reporting of their social and psychological intervention RCTs. Journals should revise editorial policies and procedures to require use of reporting guidelines by authors and peer reviewers to produce manuscripts that allow readers to appraise study quality, evaluate the applicability of findings to their contexts, and replicate effective interventions.
In the mental health field, there is a growing awareness that the study of psychiatric symptoms in the context of everyday life, using experience sampling methodology (ESM), may provide a powerful and necessary addition to more conventional research approaches. ESM, a structured self‐report diary technique, allows the investigation of experiences within, and in interaction with, the real‐world context. This paper provides an overview of how zooming in on the micro‐level of experience and behaviour using ESM adds new insights and additional perspectives to standard approaches. More specifically, it discusses how ESM: a) contributes to a deeper understanding of psychopathological phenomena, b) allows to capture variability over time, c) aids in identifying internal and situational determinants of variability in symptomatology, and d) enables a thorough investigation of the interaction between the person and his/her environment and of real‐life social interactions. Next to improving assessment of psychopathology and its underlying mechanisms, ESM contributes to advancing and changing clinical practice by allowing a more fine‐grained evaluation of treatment effects as well as by providing the opportunity for extending treatment beyond the clinical setting into real life with the development of ecological momentary interventions. Furthermore, this paper provides an overview of the technical details of setting up an ESM study in terms of design, questionnaire development and statistical approaches. Overall, although a number of considerations and challenges remain, ESM offers one of the best opportunities for personalized medicine in psychiatry, from both a research and a clinical perspective.
Shortcomings of approaches to classifying psychopathology based on expert consensus have given rise to contemporary efforts to classify psychopathology quantitatively. In this paper, we review progress in achieving a quantitative and empirical classification of psychopathology. A substantial empirical literature indicates that psychopathology is generally more dimensional than categorical. When the discreteness versus continuity of psychopathology is treated as a research question, as opposed to being decided as a matter of tradition, the evidence clearly supports the hypothesis of continuity. In addition, a related body of literature shows how psychopathology dimensions can be arranged in a hierarchy, ranging from very broad “spectrum level” dimensions, to specific and narrow clusters of symptoms. In this way, a quantitative approach solves the “problem of comorbidity” by explicitly modeling patterns of co‐occurrence among signs and symptoms within a detailed and variegated hierarchy of dimensional concepts with direct clinical utility. Indeed, extensive evidence pertaining to the dimensional and hierarchical structure of psychopathology has led to the formation of the Hierarchical Taxonomy of Psychopathology (HiTOP) Consortium. This is a group of 70 investigators working together to study empirical classification of psychopathology. In this paper, we describe the aims and current foci of the HiTOP Consortium. These aims pertain to continued research on the empirical organization of psychopathology; the connection between personality and psychopathology; the utility of empirically based psychopathology constructs in both research and the clinic; and the development of novel and comprehensive models and corresponding assessment instruments for psychopathology constructs derived from an empirical approach.
The Consolidated Standards of Reporting Trials (CONSORT) statement is a guideline designed to improve the transparency and quality of the reporting of randomised controlled trials (RCTs). In this article we present an extension to that statement for randomised pilot and feasibility trials conducted in advance of a future definitive RCT. The checklist applies to any randomised study in which a future definitive RCT, or part of it, is conducted on a smaller scale, regardless of its design (eg, cluster, factorial, crossover) or the terms used by authors to describe the study (eg, pilot, feasibility, trial, study). The extension does not directly apply to internal pilot studies built into the design of a main trial, non-randomised pilot and feasibility studies, or phase II studies, but these studies all have some similarities to randomised pilot and feasibility studies and so many of the principles might also apply.
The development of the extension was motivated by the growing number of studies described as feasibility or pilot studies and by research that has identified weaknesses in their reporting and conduct. We followed recommended good practice to develop the extension, including carrying out a Delphi survey, holding a consensus meeting and research team meetings, and piloting the checklist.
The aims and objectives of pilot and feasibility randomised studies differ from those of other randomised trials. Consequently, although much of the information to be reported in these trials is similar to those in randomised controlled trials (RCTs) assessing effectiveness and efficacy, there are some key differences in the type of information and in the appropriate interpretation of standard CONSORT reporting items. We have retained some of the original CONSORT statement items, but most have been adapted, some removed, and new items added. The new items cover how participants were identified and consent obtained; if applicable, the prespecified criteria used to judge whether or how to proceed with a future definitive RCT; if relevant, other important unintended consequences; implications for progression from pilot to future definitive RCT, including any proposed amendments; and ethical approval or approval by a research review committee confirmed with a reference number.
This article includes the 26 item checklist, a separate checklist for the abstract, a template for a CONSORT flowchart for these studies, and an explanation of the changes made and supporting examples. We believe that routine use of this proposed extension to the CONSORT statement will result in improvements in the reporting of pilot trials.
Editor’s note: In order to encourage its wide dissemination this article is freely accessible on the BMJ and Pilot and Feasibility Studies journal websites.
Electronic supplementary material
The online version of this article (doi:10.1186/s40814-016-0105-8) contains supplementary material, which is available to authorized users.
Die Deutsche Version der Positive and Negative Affect Schedule (PANAS) wurde aus dem weit verbreiteten englischsprachigen Instrument zur Erfassung der emotionalen Befindlichkeit PANAS von Watson, Clark und Tellegen (1988) adaptiert. Der Fragebogen besteht aus 20 Adjektiven, die unterschiedliche Empfindungen und Gefühle beschreiben. Jeweils 10 Adjektive erfassen die Dimensionen Positiver Affekt und Negativer Affekt. Die Skala kann für unterschiedliche Untersuchungsziele eingesetzt werden. Je nach Instruktion können sowohl aktuelle, zeitlich begrenzte Affekte als auch überdauernde, habituelle Affektivitätsmerkmale gemessen werden. Die Items wurden in der zweiten Welle des GESIS Panel (2014) verwendet. Zentrale Kennwerte Titel: Deutsche Version der Positive and Negative Affect Schedule PANAS (GESIS Panel)
Background:
Evidence has accumulated that implicates childhood trauma in the aetiology of psychosis, but our understanding of the putative psychological processes and mechanisms through which childhood trauma impacts on individuals and contributes to the development of psychosis remains limited. We aimed to investigate whether stress sensitivity and threat anticipation underlie the association between childhood abuse and psychosis.
Method:
We used the Experience Sampling Method to measure stress, threat anticipation, negative affect, and psychotic experiences in 50 first-episode psychosis (FEP) patients, 44 At-Risk Mental State (ARMS) participants, and 52 controls. Childhood abuse was assessed using the Childhood Trauma Questionnaire.
Results:
Associations of minor socio-environmental stress in daily life with negative affect and psychotic experiences were modified by sexual abuse and group (all p FWE < 0.05). While there was strong evidence that these associations were greater in FEP exposed to high levels of sexual abuse, and some evidence of greater associations in ARMS exposed to high levels of sexual abuse, controls exposed to high levels of sexual abuse were more resilient and reported less intense negative emotional reactions to socio-environmental stress. A similar pattern was evident for threat anticipation.
Conclusions:
Elevated sensitivity and lack of resilience to socio-environmental stress and enhanced threat anticipation in daily life may be important psychological processes underlying the association between childhood sexual abuse and psychosis.
While contemporary models of psychosis have proposed a number of putative psychological mechanisms, how these impact on individuals to increase intensity of psychotic experiences in real life, outside the research laboratory, remains unclear. We aimed to investigate whether elevated stress sensitivity, experiences of aberrant novelty and salience, and enhanced anticipation of threat contribute to the development of psychotic experiences in daily life. We used the Experience Sampling Method (ESM) to assess stress, negative affect, aberrant salience, threat anticipation, and psychotic experiences in 51 individuals with First-Episode Psychosis (FEP), 46 individuals with an At-Risk Mental State (ARMS) for psychosis, and 53 controls with no personal or family history of psychosis. Linear mixed models were used to account for the multilevel structure of ESM data. In all three groups, elevated stress sensitivity, aberrant salience, and enhanced threat anticipation were associated with an increased intensity of psychotic experiences. However, elevated sensitivity to minor stressful events (χ2=6.3, p=0.044), activities (χ2=6.7, p=0.036), and areas (χ2=9.4, p=0.009) and enhanced threat anticipation (χ2=9.3, p=0.009) were associated with more intense psychotic experiences in FEP individuals than controls. Sensitivity to outsider status (χ2=5.7, p=0.058) and aberrantly salient experiences (χ2=12.3, p=0.002) were more strongly associated with psychotic experiences in ARMS individuals than controls. Our findings suggest that stress sensitivity, aberrant salience, and threat anticipation are important psychological processes in the development of psychotic experiences in daily life in the early stages of the disorder.
Integrated models of psychotic disorders have posited a number of putative psychological mechanisms that may contribute to the development of psychotic symptoms, but it is only recently that a modest amount of experience sampling research has provided evidence on their role in daily life, outside the research laboratory. A number of methodological challenges remain in evaluating specificity of potential causal links between a given psychological mechanism and psychosis outcomes in a systematic fashion, capitalizing on longitudinal data to investigate temporal ordering. In this paper, we argue for testing ecological interventionist causal models that draw on real-world and real-time-delivered, ecological momentary interventions for generating evidence on several causal criteria (association, time order, and direction/sole plausibility) under real-world conditions, whilst maximizing generalisability to social contexts and experiences in heterogeneous populations. Specifically, this approach tests whether ecological momentary interventions can i) modify a putative mechanism and ii) produce changes in the mechanism that lead to sustainable changes in intended psychosis outcomes in individuals’ daily lives. Future research using this approach will provide translational evidence on the active ingredients of mobile health and in-person interventions that promote sustained effectiveness of ecological momentary interventions and, thereby, contribute to ongoing efforts that seek to enhance effectiveness of psychological interventions under real-world conditions.
http://schizophreniabulletin.oxfordjournals.org/content/early/2015/12/25/schbul.sbv193.abstract
Purpose:
The objective of this review is to report on recent developments in youth mental health incorporating all levels of severity of mental disorders encouraged by progress in the field of early intervention in psychotic disorders, research in deficiencies in the current system and social advocacy.
Methods:
The authors have briefly reviewed the relevant current state of knowledge, challenges and the service and research response across four countries (Australia, Ireland, the UK and Canada) currently active in the youth mental health field.
Results:
Here we present information on response to principal challenges associated with improving youth mental services in each country. Australia has developed a model comprised of a distinct front-line youth mental health service (Headspace) to be implemented across the country and initially stimulated by success in early intervention in psychosis; in Ireland, Headstrong has been driven primarily through advocacy and philanthropy resulting in front-line services (Jigsaw) which are being implemented across different jurisdictions; in the UK, a limited regional response has addressed mostly problems with transition from child-adolescent to adult mental health services; and in Canada, a national multi-site research initiative involving transformation of youth mental health services has been launched with public and philanthropic funding, with the expectation that results of this study will inform implementation of a transformed model of service across the country including indigenous peoples.
Conclusions:
There is evidence that several countries are now engaged in transformation of youth mental health services and in evaluation of these initiatives.
Background:
Mental health outcome measures are used to monitor the quality and effectiveness of mental health services. There is also a growing expectation for implementation of routine measurement and measures being used by clinicians as a feedback monitoring system to improve client outcomes. The recent focus in Australia and elsewhere targeting mental health services to young people aged 12-25 years has meant that outcome measures relevant to this age range are now needed. This is a shift from the traditional divide of child and adolescent services versus adult services with a transitioning age at 18 years. This systematic review is the first to examine mental health outcome measures that are appropriate for the 12 to 25 year age range.
Methods:
MEDLINE and PsychINFO databases were systematically searched to identify studies using mental health outcome measures with young people aged 12 to 25 years. The search strategy complied with the relevant sections of the PRISMA statement.
Results:
A total of 184 published articles were identified, covering 29 different outcome measures. The measures were organised into domains that consisted of eight measures of cognition and emotion, nine functioning measures, six quality of life measures, and six multidimensional mental health measures. No measures were designed specifically for young people aged 12 to 25 years and only two had been used by clinicians as a feedback monitoring system. Five measures had been used across the whole 12 to 25 year age range, in a range of mental health settings and were deemed most appropriate for this age group.
Conclusions:
With changes to mental health service systems that increasingly focus on early intervention in adolescence and young adulthood, there is a need for outcome measures designed specifically for those aged 12 to 25 years. In particular, multidimensional measures that are clinically meaningful need to be developed to ensure quality and effectiveness in youth mental health. Additionally, outcome measures can be clinically useful when designed to be used within routine feedback monitoring systems.
Mental imagery research has weathered both disbelief of the phenomenon and inherent methodological limitations. Here we review recent behavioral, brain imaging, and clinical research that has reshaped our understanding of mental imagery. Research supports the claim that visual mental imagery is a depictive internal representation that functions like a weak form of perception. Brain imaging work has demonstrated that neural representations of mental and perceptual images resemble one another as early as the primary visual cortex (V1). Activity patterns in V1 encode mental images and perceptual images via a common set of low-level depictive visual features. Recent translational and clinical research reveals the pivotal role that imagery plays in many mental disorders and suggests how clinicians can utilize imagery in treatment. Recent research suggests that visual mental imagery functions as if it were a weak form of perception.Evidence suggests overlap between visual imagery and visual working memory - those with strong imagery tend to utilize it for mnemonic performance.Brain imaging work suggests that representations of perceived stimuli and mental images resemble one another as early as V1.Imagery plays a pivotal role in many mental disorders and clinicians can utilize imagery to treat such disorders.
The goal of this special section is to examine the mechanisms of enhanced sensitivity and sensitization to stress as they influence the etiology and pathophysiology of psychopathology. The 12 articles in the section focus on some of the most crucial and unanswered questions regarding the underlying mechanisms and functional consequences of stress sensitivity and stress sensitization in psychopathology. They address the constructs of stress sensitivity and stress sensitization using state-of-the-art, and often novel, methodologies. The special section also focuses on an important terminological distinction between two related but distinct stress mechanisms that are often conflated. Individuals who are sensitive to stress possess this characteristic as a putative trait that develops through genetically mediated transactional relations between temperamental characteristics and the early contextual environment. In contrast, individuals who are sensitized to stress become so over time through repeated exposure to external, as well as endogenous, stressors. Enhanced stress sensitivity and sensitization have been included in conceptual models of psychopathology. Yet, the specific mechanisms by which these stress processes impact the onset and course of psychiatric disorders are not fully understood. These articles focus on several mechanistic accounts of stress sensitivity and sensitization. (PsycINFO Database Record (c) 2015 APA, all rights reserved).
Research on life stress in bipolar disorder largely fails to account for the possibility of a dynamic relationship between psychosocial stress and episode initiation. The kindling hypothesis (Post, 1992) states that over the course of recurrent affective disorders, there is a weakening temporal relationship between major life stress and episode initiation that could reflect either a progressive sensitization or progressive autonomy to life stress. The present study involved a comprehensive and precise examination of the kindling hypothesis in 102 participants with bipolar II disorder that allowed for a direct comparison of sensitization and autonomy models. Polarity-specific tests were conducted across the continuum of event severity with respect to impact and frequency of life events. Hypotheses were polarity- and event-valence specific and were based on the stress sensitization model. Results were only partially consistent with the sensitization model: Individuals with more prior mood episodes had an increased frequency of minor negative events before depression and of minor positive events before hypomania. However, the number of past episodes did not moderate relationships between life events and time until prospective onset of mood episodes. These results are more consistent with a sensitization than an autonomy model, but several predictions of the sensitization model were not supported. Methodological strengths, limitations, and implications are discussed regarding putative changes in stress reactivity that may occur with repeated exposure to mood episodes in bipolar II disorder. (PsycINFO Database Record (c) 2015 APA, all rights reserved).
Without a complete published description of interventions, clinicians and patients cannot reliably implement interventions that are shown to be useful, and other researchers cannot replicate or build on research findings. The quality of description of interventions in publications, however, is remarkably poor. To improve the completeness of reporting, and ultimately the replicability, of interventions, an international group of experts and stakeholders developed the Template for Intervention Description and Replication (TIDieR) checklist and guide. The process involved a literature review for relevant checklists and research, a Delphi survey of an international panel of experts to guide item selection, and a face-to-face panel meeting. The resultant 12-item TIDieR checklist (brief name, why, what (materials), what (procedure), who intervened, how, where, when and how much, tailoring, modifications, how well (planned), how well (actually carried out)) is an extension of the CONSORT 2010 statement (item 5) and the SPIRIT 2013 statement (item 11). While the emphasis of the checklist is on trials, the guidance is intended to apply across all evaluative study designs. This paper presents the TIDieR checklist and guide, with a detailed explanation of each item, and examples of good reporting. The TIDieR checklist and guide should improve the reporting of interventions and make it easier for authors to structure the accounts of their interventions, reviewers and editors to assess the descriptions, and readers to use the information.
© Georg Thieme Verlag KG Stuttgart · New York.
Shame and self-criticism are transdiagnostic problems. People who experience them may struggle to feel relieved, reassured or safe. Research suggests that a specialised affect regulation sys tem (or systems) underpins feelings of reassurance, safeness and well-being. It is believed to have evolved with attachment systems and, in particular, the ability to register and respond with calming and a sense of well-being to being cared for. In compassion-focused therapy it is hypothesised that this affect regulation system is poorly accessible in people with high shame and self-criticism, in whom the 'threat' affect regulation system dominates orientation to their inner and outer worlds. Compassion-focused therapy is an integrated and multimodal approach that draws from evolutionary, social, developmental and Buddhist psychology, and neuro science. One of its key concerns is to use compassionate mind training to help people develop and work with experiences of inner warmth, safeness and soothing, via compassion and self-compassion.
Background
Cross-cultural comparison of mental health service utilisation and costs is complicated by the heterogeneity of service systems. For data to be locally meaningful yet internationally comparable, a carefully constructed approach to its collection is required.
Aims
To develop a research method and instrument for the collection of data on the service utilisation and related characteristics of people with mental disorders, as the basis for calculating the costs of care.
Method
Various approaches to the collection of service use data and key stages of instrument development were identified in order to select the most appropriate methods.
Results
Based on previous work, and following translation and cross-cultural validation, an instrument was developed: the Client Socio-Demographic and Service Receipt Inventory – European Version (CSSRI–EU). This was subsequently administered to 404 people with schizophrenia across five countries.
Conclusion
The CSSRI – EU provides a standardised yet adaptable method for collating service receipt and associated data alongside assessment of patient outcomes.
In recent studies of the structure of affect, positive and negative affect have consistently emerged as two dominant and relatively independent dimensions. A number of mood scales have been created to measure these factors; however, many existing measures are inadequate, showing low reliability or poor convergent or discriminant validity. To fill the need for reliable and valid Positive Affect and Negative Affect scales that are also brief and easy to administer, we developed two 10-item mood scales that comprise the Positive and Negative Affect Schedule (PANAS). The scales are shown to be highly internally consistent, largely uncorrelated, and stable at appropriate levels over a 2-month time period. Normative data and factorial and external evidence of convergent and discriminant validity for the scales are also presented. (PsycINFO Database Record (c) 2010 APA, all rights reserved)
Web-based and mobile health interventions (also called "Internet interventions" or "ehealth/mhealth interventions") are tools or treatments, typically behaviorally based, that are operationalized and transformed for delivery via the Internet or mobile platforms. These include electronic tools for patients, informal caregivers, healthy consumers, and health care providers. The "Consolidated Standards of Reporting Trials" (CONSORT) was developed to improve the suboptimal reporting of randomized controlled trials (RCTs). While broadly the CONSORT statement can be applied to provide guidance on how ehealth and mhealth trials should be reported, RCTs of web-based interventions pose very specific issues and challenges, in particular related to reporting sufficient details of the intervention to allow replication and theory-building.
To develop a checklist, dubbed CONSORT-EHEALTH (Consolidated Standards of Reporting Trials of Electronic and Mobile HEalth Applications and onLine TeleHealth), as an extension of the CONSORT statement that provides guidance for authors of ehealth and mhealth interventions.
A literature review was conducted, followed by a survey among ehealth experts and a workshop.
An instrument and checklist was constructed as an extension of the CONSORT statement. The instrument has been adopted by the Journal of Medical Internet Research (JMIR) and authors of ehealth RCTs are required to submit an electronic checklist explaining how they addressed each subitem.
CONSORT-EHEALTH has the potential to improve reporting and provides a basis for evaluating the validity and applicability of ehealth trials. Subitems describing how the intervention should be reported can also be used for non-RCT evaluation reports. As part of the development process, an evaluation component is essential, therefore feedback from authors will be solicited, and a before-after study will evaluate whether reporting has been improved.
Daily-life stress sensitivity is associated with depression, but prospective data are lacking.
To examine associations between baseline ecological daily-life stress sensitivity and later depression, and to identify genetic and non-genetic factors moderating the transition from stress sensitivity to depression.
Daily-life stress sensitivity was assessed at baseline in twins (n = 502). One baseline and four follow-up measurements of depressive symptoms and negative life events were collected, as well as interview-based diagnoses at baseline and last follow-up. Hypothesised genetic markers were determined.
Baseline stress sensitivity was associated with increased depressive symptoms at follow-up and risk of major depressive disorder. Both genetic liability and major life events moderated the probability of transition from stress sensitivity to depression.
Onset of depression is attributable to pre-onset ecological measurements of stress sensitivity, particularly where genetic liability is high and individuals have reached a stage where the influence of competing environmental causes is low.
Cognitive behavior therapy (CBT) evolved from behavioral theory and developed to focus more on cognitive models that incorporated
reappraisal of thinking errors and schema change strategies. This article will describe the key elements of CBT for schizophrenia
and the current evidence of its efficacy and effectiveness. We conclude with a description of recent concepts that extend
the theoretical basis of practice and expand the range of CBT strategies for use in schizophrenia. Mindfulness, meta-cognitive
approaches, compassionate mind training, and method of levels are postulated as useful adjuncts for CBT with psychotic patients.
Paranoid delusions are a common symptom of a range of psychotic disorders. A variety of psychological mechanisms have been implicated in their cause, including a tendency to jump to conclusions, an impairment in the ability to understand the mental states of other people (theory of mind), an abnormal anticipation of threat, and an abnormal explanatory style coupled with low self-esteem.
To determine the structure of the relationships among psychological mechanisms contributing to paranoia in a transdiagnostic sample.
Cross-sectional design, with relationships between predictor variables and paranoia examined by structural equation models with latent variables.
Publicly funded psychiatric services in London and the North West of England.
One hundred seventy-three patients with schizophrenia spectrum disorders, major depression, or late-onset schizophrenia-like psychosis, subdivided according to whether they were currently experiencing paranoid delusions. Sixty-four healthy control participants matched for appropriate demographic variables were included.
Assessments of theory of mind, jumping to conclusions bias, and general intellectual functioning, with measures of threat anticipation, emotion, self-esteem, and explanatory style.
The best fitting (chi(2)(96) = 131.69, P = .01; comparative fit index = 0.95; Tucker-Lewis Index = 0.96; root-mean-square error of approximation = 0.04) and most parsimonious model of the data indicated that paranoid delusions are associated with a combination of pessimistic thinking style (low self-esteem, pessimistic explanatory style, and negative emotion) and impaired cognitive performance (executive functioning, tendency to jump to conclusions, and ability to reason about the mental states of others). Pessimistic thinking correlated highly with paranoia even when controlling for cognitive performance (r = 0.65, P < .001), and cognitive performance correlated with paranoia when controlling for pessimism (r = -0.34, P < .001).
Both cognitive and emotion-related processes are involved in paranoid delusions. Treatment for paranoid patients should address both types of processes.
Introduction/objective:
This study aimed to investigate efficacy of Acceptance and Commitment Therapy in Daily Life (ACT-DL), combining face-to-face therapy with an Ecological Momentary Intervention (EMI), in addition to treatment as usual (TAU) for psychotic distress, in comparison to TAU.
Methods:
Individuals aged 15-65 years with clinically established ultra-high risk or first episode of psychosis were randomly assigned to TAU or ACT-DL+TAU. ACT-DL+TAU consisted of 8 ACT-sessions augmented with an EMI-app. The primary outcome was psychotic distress assessed with the Comprehensive Assessment scale of At Risk Mental State (CAARMS) at post-intervention and 6- and 12-month follow-up. Secondary outcomes were functioning, symptom severity, and momentary psychotic distress. We performed multivariate mixed models according to intent-to-treat principles.
Results:
Between June 1, 2015 and December 31, 2018, 668 participants were referred, of whom 148 were randomized to ACT-DL+TAU (n = 71) or TAU (n = 77). One hundred and fifteen (78%) provided primary outcome data at least at one follow-up assessment. There was no evidence of greater reduction in the primary outcome measure CAARMS distress in ACT-DL+TAU compared to TAU (χ2(3) = 2.36; p = 0.50). However, out of the tested secondary outcomes, global functioning (χ2(3) = 9.05; p = 0.033), and negative symptoms (χ2(3) = 19.91; p<0.001) improved in ACT-DL+TAU compared to TAU, as did momentary psychotic distress (χ2(3) = 21.56; p < 0.001).
Conclusions:
INTERACT did not support a significant effect of ACT-DL over TAU on the primary outcome measure of psychotic distress as assessed with the CAARMS. Although significant improvements were found for some secondary outcome measures, further replication studies are needed to confirm the strength and specificity of these effects.
The validity of the classification of non‐affective and affective psychoses as distinct entities has been disputed, but, despite calls for alternative approaches to defining psychosis syndromes, there is a dearth of empirical efforts to identify transdiagnostic phenotypes of psychosis. We aimed to investigate the validity and utility of general and specific symptom dimensions of psychosis cutting across schizophrenia, schizoaffective disorder and bipolar I disorder with psychosis. Multidimensional item‐response modeling was conducted on symptom ratings of the Positive and Negative Syndrome Scale, Young Mania Rating Scale, and Montgomery‐Åsberg Depression Rating Scale in the multicentre Bipolar‐Schizophrenia Network on Intermediate Phenotypes (B‐SNIP) consortium, which included 933 patients with a diagnosis of schizophrenia (N=397), schizoaffective disorder (N=224), or bipolar I disorder with psychosis (N=312). A bifactor model with one general symptom dimension, two distinct dimensions of non‐affective and affective psychosis, and five specific symptom dimensions of positive, negative, disorganized, manic and depressive symptoms provided the best model fit. There was further evidence on the utility of symptom dimensions for predicting B‐SNIP psychosis biotypes with greater accuracy than categorical DSM diagnoses. General, positive, negative and disorganized symptom dimension scores were higher in African American vs. Caucasian patients. Symptom dimensions accurately classified patients into categorical DSM diagnoses. This study provides evidence on the validity and utility of transdiagnostic symptom dimensions of psychosis that transcend traditional diagnostic boundaries of psychotic disorders. Findings further show promising avenues for research at the interface of dimensional psychopathological phenotypes and basic neurobiological dimensions of psychopathology.
Introduction: There is an ongoing debate about whether negative affect are consequences or triggers of paranoid thinking. It has also been suggested that aberrant salience is central to the development of delusions. This study modelled the moment-to-moment relationships between negative affect, aberrant salience, and paranoia in acute inpatients with psychosis.
Methods: Participants with active paranoid delusions were assessed using clinical rating scales and experience sampling method (ESM) over 14 days. ESM data were analysed using time-lagged multilevel regression modelling.
Results: Both negative affect and aberrant salience predicted an increase in paranoia at the next time point. Conversely, the level of paranoia did not predict subsequent changes in negative affect or aberrant salience. Negative affect predicted an increase in aberrant salience at the next time point, and vice versa.
Conclusions: Negative affect and aberrant salience appear to drive and exacerbate paranoia, rather than being merely the sequelae of the symptom. Our results suggest both direct and indirect (via aberrant salience) pathways from negative affect to paranoia.
Several integrated models of psychosis have implicated adverse, stressful contexts and experiences, and affective and cognitive processes in the onset of psychosis. In these models, the effects of stress are posited to contribute to the development of psychotic experiences via pathways through affective disturbance, cognitive biases, and anomalous experiences. However, attempts to systematically test comprehensive models of these pathways remain sparse. Using the Experience Sampling Method in 51 individuals with first-episode psychosis (FEP), 46 individuals with an at-risk mental state (ARMS) for psychosis, and 53 controls, we investigated how stress, enhanced threat anticipation, and experiences of aberrant salience combine to increase the intensity of psychotic experiences. We fitted multilevel moderated mediation models to investigate indirect effects across these groups. We found that the effects of stress on psychotic experiences were mediated via pathways through affective disturbance in all 3 groups. The effect of stress on psychotic experiences was mediated by threat anticipation in FEP individuals and controls but not in ARMS individuals. There was only weak evidence of mediation via aberrant salience. However, aberrant salience retained a substantial direct effect on psychotic experiences, independently of stress, in all 3 groups. Our findings provide novel insights on the role of affective disturbance and threat anticipation in pathways through which stress impacts on the formation of psychotic experiences across different stages of early psychosis in daily life.
Without a complete published description of interventions, clinicians and patients cannot reliably implement interventions that are shown to be useful, and other researchers cannot replicate or build on research findings. The quality of description of interventions in publications, however, is remarkably poor. To improve the completeness of reporting, and ultimately the replicability, of interventions, an international group of experts and stakeholders developed the Template for Intervention Description and Replication (TIDieR) checklist and guide. The process involved a literature review for relevant checklists and research, a Delphi survey of an international panel of experts to guide item selection, and a face-to-face panel meeting. The resultant 12-item TIDieR checklist (brief name, why, what (materials), what (procedure), who intervened, how, where, when and how much, tailoring, modifications, how well (planned), how well (actually carried out)) is an extension of the CONSORT 2010 statement (item 5) and the SPIRIT 2013 statement (item 11). While the emphasis of the checklist is on trials, the guidance is intended to apply across all evaluative study designs. This paper presents the TIDieR checklist and guide, with a detailed explanation of each item, and examples of good reporting. The TIDieR checklist and guide should improve the reporting of interventions and make it easier for authors to structure the accounts of their interventions, reviewers and editors to assess the descriptions, and readers to use the information.
Purpose of review:
In this review, we discuss feasibility, content, and where possible efficacy of ecological momentary interventions (EMIs) in psychiatry. EMIs adopt mobile devices, such as personal digital assistants or smartphones, for the delivery of treatments in the daily life of patients. We will discuss EMIs in the field of schizophrenia, bipolar disorder and major depression disorder, as well as one generic, transdiagnostic EMI.
Recent findings:
The few studies that are available all underscore feasibility and acceptability of mobile health approaches in patients with severe mental illness. In terms of content, there is a huge variety in approaches ranging from a mixture of face-to-face contacts augmented with EMI components to a fully automated EMI. With regard to efficacy, only two randomized clinical trials have been conducted, supporting the efficacy of EMIs in mental health. Evidence seems to point toward greater efficacy when EMI is integrated with real-life assessment using experience sampling methodology, preferentially tailoring the intervention toward the specific needs of the individual as well as toward those moments when intervention is needed.
Summary:
The review demonstrates that mobile health may be an important asset to the mental health field but underscores that it still is in its very early ages. In the discussion, we point toward ways of improving EMIs for severe mental illness, changing our perspective from testing feasibility to testing efficacy and ultimately implementing EMIs in routine mental health services.
A large body of research indicates that weak expressions of positive psychotic symptoms ("psychotic experiences") can be measured in the general population, and likely represent the behavioural manifestation of distributed multifactorial (genetic and non-genetic) risk for psychosis. Psychotic experiences are a transdiagnostic phenomenon: the majority of individuals with these experiences have a diagnosis of non-psychotic disorder, particularly common mental disorder, in which psychotic experiences predict greater illness severity and poorer treatment response. Some of the people with common mental disorder and psychotic experiences will present to mental health services meeting criteria for "clinical high risk". Treatment of the transdiagnostic dimension of psychosis in individuals with common mental disorder who meet "clinical high risk" criteria thus may improve outcome (which cannot be interpreted as prevention of "schizophrenia"). Subthreshold psychotic experiences are transitory in about 80% of individuals, while around 20% go on to develop persistent psychotic experiences and 7% a psychotic disorder, with an annual transition rate of 0.5-1%. Persistence is associated, on the one hand, with environmental exposures, particularly childhood trauma, and, on the other, with network-type dynamic interactions between psychotic experiences themselves (e.g., interactions between hallucinatory experiences and delusional ideation) and between symptom dimensions (e.g., interactions between affective symptoms and psychotic experiences, or interactions between subthreshold negative symptoms and psychotic experiences). The study of psychotic experiences is helping to elucidate the mechanisms by which environmental and genetic influences shape the transdiagnostic expression of psychosis proneness, that is mostly transitory but may first become persistent over time and eventually give rise to transition to a psychotic disorder.
Negative emotional states and low self-esteem play a crucial role in the development of persecutory delusions. This study therefore tests whether a brief intervention that targets negative emotions and self-esteem will reduce paranoid thoughts and whether this reduction will be mediated by a decrease in negative emotions and an increase in self-esteem. Healthy participants (n = 71) with varying levels of subclinical symptoms of psychosis (assessed with the Community Assessment of Psychic Experiences) were randomly assigned to a compassion-focused (CF) or a neutral control condition. Negative emotions were induced before the intervention by in sensu exposure to personally relevant distressing situations. Participants were then instructed to apply a previously trained compassion-focused versus a neutral image. Before and after the intervention paranoid thoughts were assessed by a state-adapted item from the Paranoia Checklist. Participants in the CF condition reported significantly lower levels of negative emotion, higher self-esteem and less paranoid thoughts compared to participants in the control condition. The effect of the CF-intervention on paranoid thoughts was mediated by reduced negative emotions but not by increased self-esteem. Persons with higher baseline scores on the CAPE responded to the intervention with a significantly stronger reduction of paranoid thoughts than persons with low or medium baseline scores. Interventions targeting the emotional processes involved in delusion formation might have potential to prevent the formation of paranoid beliefs in persons at risk of developing psychosis and reduce delusions in persons with clinically relevant symptom levels.
In order to bring about implementation of routine screening for psychosis risk, a brief version of the Prodromal Questionnaire (PQ; Loewy et al., 2005) was developed and tested in a general help-seeking population. We assessed a consecutive patient sample of 3533 young adults who were help-seeking for nonpsychotic disorders at the secondary mental health services in the Hague with the PQ. We performed logistic regression analyses and CHi-squared Automatic Interaction Detector decision tree analysis to shorten the original 92 items. Receiver operating characteristic curves were used to examine the psychometric properties of the PQ-16. In the general help-seeking population, a cutoff score of 6 or more positively answered items on the 16-item version of the PQ produced correct classification of Comprehensive Assessment of At-Risk Mental State (Yung et al., 2005) psychosis risk/clinical psychosis in 44% of the cases, distinguishing Comprehensive Assessment of At-Risk Mental States (CAARMS) diagnosis from no CAARMS diagnosis with high sensitivity (87%) and specificity (87%). These results were comparable to the PQ-92. The PQ-16 is a good self-report screen for use in secondary mental health care services to select subjects for interviewing for psychosis risk. The low number of items makes it quite appropriate for screening large help-seeking populations, thus enhancing the feasibility of detection and treatment of ultra high-risk patients in routine mental health services.
Given high relapse rates and residual symptoms in depression, new strategies to increase treatment effectiveness are required. A promising avenue is to investigate how electronic momentary assessment technology may contribute to clinical assessment and interventions in depression.
A literature search was conducted focusing on the potential contribution of momentary assessments to clinical applications in depression.
Momentary assessments are able to reveal subtle, small but repetitive and relevant patterns of emotional expression that predict future course of depression. A momentary assessment tool may expose manageable pieces of daily life behaviour contributing to the depressive experience that patients can influence. The use of this explicit knowledge of daily life experience is understudied with regard to its contribution to diagnostic assessment, monitoring of treatment effects and feedback interventions in depressed patients. The clinical application of momentary assessments may stimulate a shift from passive consumption of treatment to an active role for patients in their recovery and increased patient ownership.
The precise, prospective and fine-grained information that momentary assessment technology provides may contribute to clinical practice in various ways. Future studies should examine the clinical impact of its use and the feasibility of its implementation in mental health care.
Young people aged 10-24 years represent 27% of the world's population. Although important health problems and risk factors for disease in later life emerge in these years, the contribution to the global burden of disease is unknown. We describe the global burden of disease arising in young people and the contribution of risk factors to that burden.
We used data from WHO's 2004 Global Burden of Disease study. Cause-specific disability-adjusted life-years (DALYs) for young people aged 10-24 years were estimated by WHO region on the basis of available data for incidence, prevalence, severity, and mortality. WHO member states were classified into low-income, middle-income, and high-income countries, and into WHO regions. We estimated DALYs attributable to specific global health risk factors using the comparative risk assessment method. DALYs were divided into years of life lost because of premature mortality (YLLs) and years lost because of disability (YLDs), and are presented for regions by sex and by 5-year age groups.
The total number of incident DALYs in those aged 10-24 years was about 236 million, representing 15·5% of total DALYs for all age groups. Africa had the highest rate of DALYs for this age group, which was 2·5 times greater than in high-income countries (208 vs 82 DALYs per 1000 population). Across regions, DALY rates were 12% higher in girls than in boys between 15 and 19 years (137 vs 153). Worldwide, the three main causes of YLDs for 10-24-year-olds were neuropsychiatric disorders (45%), unintentional injuries (12%), and infectious and parasitic diseases (10%). The main risk factors for incident DALYs in 10-24-year-olds were alcohol (7% of DALYs), unsafe sex (4%), iron deficiency (3%), lack of contraception (2%), and illicit drug use (2%).
The health of young people has been largely neglected in global public health because this age group is perceived as healthy. However, opportunities for prevention of disease and injury in this age group are not fully exploited. The findings from this study suggest that adolescent health would benefit from increased public health attention.
None.
Most life stress literature in bipolar disorder (BD) fails to account for the possibility of a changing relationship between psychosocial context and episode initiation across the course of the disorder. According to Post's (1992) influential kindling hypothesis, major life stress is required to trigger initial onsets and recurrences of affective episodes, but successive episodes become progressively less tied to stressors and may eventually occur autonomously. Subsequent research on kindling has largely focused on unipolar depression (UD), and the model has been tested in imprecise and inconsistent ways. The aim of the present paper is to evaluate evidence for the kindling model as it applies to BD. We first outline the origins of the hypothesis, the evidence for the model in UD, and the issues needing further clarification. Next, we review the extant literature on the changing relationship between life stress and bipolar illness over time, and find that evidence from the methodologically strongest studies is inconsistent with the kindling hypothesis. We then integrate this existing body of research with two emerging biopsychosocial models of BD: the Behavioral Approach System dysregulation model, and the circadian and social rhythm theory. Finally, we present therapeutic implications and suggestions for future research.
Epidemiological research has shown that stressful environmental factors can play an aetiological role in the development of psychosis. However, the mechanism underlying the link between stress and psychosis is still not fully understood. In this article it is argued that the interaction between stressful environmental factors and epigenetic factors can bring about psychological and biological changes. Both types of change can be referred to as 'sensitisation'. The underlying mechanism of sensitisation can be interpreted on the one hand as cognitive misinterpretations (psychological sensitisation) and on the other hand as altered dopaminergic neurotransmission (biological sensitisation). Both of these deviations can facilitate the onset and persistence of psychotic symptoms. With the help of epidemiological research at psychometric level sensitisation can be quantified as (i) stress-induced persistence (indicating continuous sensitisation) of the normally transient expression of subclinical psychotic experiences during adolescence and early adulthood and as (ii) the increased risk of transition from gradually more persistent subclinical psychotic experiences to a clinical psychotic disorder.
It has been suggested that self-reported, common, non-clinical psychotic experiences may represent the transitory developmental expression of distributed genetic risk for psychosis. In a sample of female MZ (176 pairs) and DZ twins (113 pairs), cross-twin, cross-trait analyses were conducted to investigate the association between repeated continuous measures of self-reported psychotic experiences (PE-three measures over 18 months), assessed with the CAPE, in one twin and clinical interview categorical measures of psychotic symptoms (PS), assessed with SCID-I, in the other twin. The results showed that in MZ but not DZ pairs (interaction: chi(2) = 7.9, df = 1, P = 0.005), the cross-twin association between PE and PS was large and significant (standardized effect size: 0.26, 95% CI: 0.10-0.42) and of similar magnitude as the within-twin PE-PS association (standardized effect size: 0.28, 95% CI: 0.10-0.45), demonstrating both PE validity and genetic effects. In addition, the cross-twin association between PE and PS was significantly larger (interaction: chi(2) = 20.3, df = 1, P < 0.0001) for younger MZ twins (standardized effect size: 0.67, 95% CI: 0.44-0.90) than older MZ twins (standardized effect size: -0.05, 95% CI: -0.26 to 0.16), demonstrating developmental effects. This study indicates that self-reported psychotic experiences in the general population may represent the developmental expression of population genetic risk for psychosis.