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ReApp – an mHealth app increasing reappraisal: results from two randomized controlled trials
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Abstract
Introduction: Reappraisal is one of the highly modifiable resilience factors and an important emotion regulation strategy. Reappraisal training can be delivered via mobile apps; however, such apps have typically combined reappraisal with other techniques. To address this gap, we developed ReApp, which engages users solely in reappraisal. Methods: For two trials, we invited 40 and 95 young adults with low levels of reappraisal skills. Participants were randomized into either control (CG) or intervention group (IG). The CG had access only to the Ecological Momentary Assessment component of the app, while the IG could also access the reappraisal training. We analyzed the self-report data using linear mixed models.Results: In both trials, adherence was high. Trial 1 revealed that only participants with very low reappraisal skills at baseline benefited from ReApp. This outcome was replicated in Trial 2 but there were no significant differences between the groups in the follow-up in mental health symptoms severity.Discussion: High adherence suggests that participants found it easy to integrate ReApp into their daily routines. Furthermore, ReApp successfully increased reappraisal in individuals with low level of reappraisal skills. Future studies will focus on assessing the efficacy of EMI-delivered reappraisal training on healthy and clinical populations.
... To investigate the abovementioned differences, we implemented an EMI mobile app, called ReApp, for this randomized clinical trial. 22 ReApp is solely based on the therapeutic component of a positive cognitive reappraisal (PCR), which eliminates the confounding factors associated with using multiple therapeutic targets and strategies within one EMI. Moreover, PCR is a well-researched and central CBT component 23,24 and a core resilience factor 25,26 encouraging the users to find positive reinterpretations to events appraised by them as stressful or negative. ...
... The third arm, which represents the control condition, did not receive an intervention and is not included in the current work. Please see Marciniak et al. 22 The study proposal received approval from the Ethics Committee for the Faculty of Arts and Social Sciences at the University of Zurich (approval #21.2.12). The ClinicalTrials.gov ...
... Please see Marciniak et al. for details. 22 Three participants dropped out due to technical problems (i.e. the app did not work on their phones). One dropped out without providing a reason. ...
Objective
Digital mental health interventions delivered via smartphone-based apps effectively treat various conditions; however, optimizing their efficacy while minimizing participant burden remains a key challenge. In this study, we investigated the potential benefits of a burst delivery design (i.e. interventions delivered only in pre-defined time intervals) in comparison to the continuous delivery of interventions.
Methods
We randomly assigned 93 participants to the continuous delivery (CD) or burst delivery (BD) group. The CD group engaged in ReApp, a mobile app that increases positive cognitive reappraisal with a consistent delivery schedule that provides five prompts per day throughout the 3-week-long study, while the BD group received five daily prompts only in the first and third weeks of the study.
Results
No significant differences were found between the groups in terms of adherence, mental health outcomes (specifically depressive and anxiety symptoms), level of perceived stress, and perceived helpfulness of intervention. The BD group showed a significantly decreased perceived difficulty of intervention over time.
Conclusions
The results suggest that the burst delivery may be as suitable for digital mental health interventions as the continuous delivery. The perceived difficulty of the intervention declined more steeply for the BD group, indicating that it improved the feasibility of the positive cognitive reappraisal intervention without hurting its efficacy. This outcome may inform the design of less burdensome interventions with improved outcomes in future research.
... The repeated assessment of several potential resilience factors in the online monitoring questionnaires is complemented by repetitions of parts of the baseline characterization phase after six and eight months ('follow-up phase'; Fig. 1). Importantly, upon completion of the baseline characterization phase, participants enter an ecological momentary intervention (EMI) phase where they are randomly assigned to one of two EMIs designed by our consortium that aim to improve two distinct resilience factors: 'ReApp' , targeting positive cognitive reappraisal of recent stressful or negative events [64], or 'Imager' , targeting reward sensitivity by positive mental imagery [31,65]. The interventions are accompanied by ecological momentary assessments (EMA) using smartphones and ecological physiological assessments (EPA) using wearables (wristbands) to assess mood and stress reaction patterns in real time during real life and to allow triggering of EMIs as JITAIs at times of high stress. ...
... For target engagement specifically, we will assess changes in the use frequency of positive cognitive reappraisal during and after the ReApp JITAI and changes in reward sensitivity during and after the Imager JITAI. These patterns could be interpreted as further evidence for intervention success [31,64]. The efficacy tests primarily use the biweekly assessed self-report measures of stressor exposure, mental health, positive cognitive reappraisal, and reward sensitivity. ...
... In this intervention, participants are asked to think about negative events they experienced or are about to experience in the close future and positively reinterpret them by generating positive reappraisals (e.g., learning from the event, the event has some unexpected positive aspects, advice that they would give to a friend, advice that they would receive from a friend). For details, see [64]. One intervention takes about 2-3 min. ...
Background
Stress-related disorders such as anxiety and depression are highly prevalent and cause a tremendous burden for affected individuals and society. In order to improve prevention strategies, knowledge regarding resilience mechanisms and ways to boost them is highly needed. In the Dynamic Modelling of Resilience – interventional multicenter study (DynaM-INT), we will conduct a large-scale feasibility and preliminary efficacy test for two mobile- and wearable-based just-in-time adaptive interventions (JITAIs), designed to target putative resilience mechanisms. Deep participant phenotyping at baseline serves to identify individual predictors for intervention success in terms of target engagement and stress resilience.
Methods
DynaM-INT aims to recruit N = 250 healthy but vulnerable young adults in the transition phase between adolescence and adulthood (18–27 years) across five research sites (Berlin, Mainz, Nijmegen, Tel Aviv, and Warsaw). Participants are included if they report at least three negative burdensome past life events and show increased levels of internalizing symptoms while not being affected by any major mental disorder. Participants are characterized in a multimodal baseline phase, which includes neuropsychological tests, neuroimaging, bio-samples, sociodemographic and psychological questionnaires, a video-recorded interview, as well as ecological momentary assessments (EMA) and ecological physiological assessments (EPA).
Subsequently, participants are randomly assigned to one of two ecological momentary interventions (EMIs), targeting either positive cognitive reappraisal or reward sensitivity. During the following intervention phase, participants' stress responses are tracked using EMA and EPA, and JITAIs are triggered if an individually calibrated stress threshold is crossed. In a three-month-long follow-up phase, parts of the baseline characterization phase are repeated. Throughout the entire study, stressor exposure and mental health are regularly monitored to calculate stressor reactivity as a proxy for outcome resilience. The online monitoring questionnaires and the repetition of the baseline questionnaires also serve to assess target engagement.
Discussion
The DynaM-INT study intends to advance the field of resilience research by feasibility-testing two new mechanistically targeted JITAIs that aim at increasing individual stress resilience and identifying predictors for successful intervention response. Determining these predictors is an important step toward future randomized controlled trials to establish the efficacy of these interventions.
... Irrespective of further theoretical progress, our results highlight a promising avenue for promoting resilience, via boosting of PAS through more targeted interventions. This may involve positive mindset interventions 59 , social-psychological interventions 60 , or dedicated positive reappraisal 61,62 or bias modification 63 trainings. Such mechanistically specific resilience trainings may become an important tool in the global fight against stress-related disorders. ...
Stress resilience is the maintenance of mental health despite adversity. We have predicted that a tendency to appraise stressors in a realistic to slightly unrealistically positive fashion (positive appraisal style, PAS) is prospectively associated with more resilient outcomes; that PAS is a proximal and integrative resilience factor, mediating the pro-resilience effects of other protective factors (e.g., social support); and that PAS is modifiable, with changes in PAS leading to corresponding changes in resilience. In two independent observational samples (N=132 and N=1034), we find PAS to predict resilience over three and more years and to mediate the positive effects of social support. Analyzing the effects of a multi-component intervention (N=232) that targets a broad set of resilience factors, we find that the intervention increases PAS and that this prospectively mediates the intervention-induced increases in resilience. This establishes PAS as a proximal and plastic resilience factor with likely causal effects on resilience.
... ReApp is based on principles of cognitive behavioral therapy and reappraisal. Full development protocol can be found elsewhere [35]. The participants used the app for 21 days before completing the mARM-G. ...
Background
The mobile Agnew Relationship Measure (mARM) is a self-report questionnaire for the evaluation of digital mental health interventions and their interactions with users. With the global increase in digital mental health intervention research, translated measures are required to conduct research with local populations.
Objective
The aim of this study was to translate and validate the original English version of the mARM into a German version (mARM-G).
Methods
A total of 2 native German speakers who spoke English as their second language conducted forward translation of the original items. This version was then back translated by 2 native German speakers with a fluent knowledge of English. An independent bilingual reviewer then compared these drafts and created a final German version. The mARM-G was validated by 15 experts in the field of mobile app development and 15 nonexperts for content validity and face validity; 144 participants were recruited to conduct reliability testing as well as confirmatory factor analysis.
Results
The content validity index of the mARM-G was 0.90 (expert ratings) and 0.79 (nonexperts). The face validity index was 0.89 (experts) and 0.86 (nonexperts). Internal consistency for the entire scale was Cronbach α=.91. Confirmatory factor analysis results were as follows: the chi-square statistic to df ratio was 1.66. Comparative Fit Index was 0.87 and the Tucker-Lewis Index was 0.86. The root mean square error of approximation was 0.07.
Conclusions
The mARM-G is a valid and reliable tool that can be used for future studies in German-speaking countries.
Background
Advancing evidence-based, tailored interventions for substance use disorders (SUDs) requires understanding temporal directionality while upholding ecological validity. Previous studies identified loneliness and craving as pivotal factors associated with alcohol consumption, yet the precise directionality of these relationships remains ambiguous.
Objective
This study aims to establish a smartphone-based real-life intervention platform that integrates momentary assessment and intervention into everyday life. The platform will explore the temporal directionality of contextual influences on alcohol use among individuals experiencing loneliness and craving.
Methods
We will target 180 individuals aged 18 to 70 in Germany who report loneliness, alcohol cravings, and meet risk or binge drinking criteria (over 14 standard drinks per week or five drinks in a single day for males, and over seven drinks per week or four drinks in a single day for females). Using a Within-Person-Encouragement-Design and Just-In-Time-Adaptive-Interventions, we will manipulate the contexts of loneliness and alcohol craving with cognitive reappraisal and physical activity interventions against a control condition (working memory task).
Results
Recruitment started in June 2024, with data collection and processing expected by June 2027.
Conclusion
Our real-life intervention platform endeavors to serve as a robust tool for discerning the directionality of the effects from time series data in everyday life influences on alcohol use for the future study. Ultimately, it will pave the way for low-threshold prevention, clinical treatment, and therapy to target diverse contexts of everyday life in SUD.
Trial registration
German Clinical Trials Register DRKS00033133.
This study investigates the role of positive cognitive reappraisal (PCR) flexibility and variability in mental health in response to real-life stressors among college students. We employed ecological momentary assessment and intervention through ReApp, a mobile app designed to train and promote PCR. We analyzed data from the intervention groups across three randomized trials with a total of 163 participants who used ReApp for either one or three weeks. Stressors due to health problems, uncomfortable environment (e.g., rainy weather, crowded buses, etc.), and lack of time were reported most frequently. Stressors related to the war in Ukraine, fear of the future, exams, and COVID-19 were reported as the most severe. To reappraise these stressors, the participants used mostly acceptance and learning tactics. A key finding is the role of emotional demand–dependent PCR flexibility in mental health. Specifically, the flexible adaptation of PCR tactics in response to stressor severity was associated with a more substantial decline in perceived stress over the study period among participants reporting low tendency to use PCR at the study’s baseline (B = -0.963, p = .016, Cohen’s f = 0.26). In contrast, stressor domain–dependent flexibility and contextually independent between-tactic variability had no moderating effect on stress, depression, and anxiety symptoms. This study contributes to the field of emotion regulation flexibility by highlighting the adaptive role of emotional demand–dependent PCR flexibility in mental well-being among young adults navigating real-life stressors and underscores the importance of tailoring interventions based on the emotional demands of stressors.
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