Dror Ben-Zeev

StudentLife: assessing mental health, academic performance and behavioral trends of college students using smartphones

Much of the stress and strain of student life remains hidden. The StudentLife continuous sensing app assesses the day-to-day and week-by-week impact of workload on stress, sleep, activity, mood, sociability, mental well-being and academic performance of a single class of 48 students across a 10 week term at Dartmouth College using Android phones. Results from the StudentLife study show a number of significant correlations between the automatic objective sensor data from smartphones and mental health and educational outcomes of the student body. We also identify a Dartmouth term lifecycle in the data that shows students start the term with high positive affect and conversation levels, low stress, and healthy sleep and daily activity patterns. As the term progresses and the workload increases, stress appreciably rises while positive affect, sleep, conversation and activity drops off. The StudentLife dataset is publicly available on the web.

Mobile Assessment and Treatment for Schizophrenia (MATS): A Pilot Trial of An Interactive Text-Messaging Intervention for Medication Adherence, Socialization, and Auditory Hallucinations

Mobile Assessment and Treatment for Schizophrenia (MATS) employs ambulatory monitoring methods and cognitive behavioral therapy interventions to assess and improve outcomes in consumers with schizophrenia through mobile phone text messaging. Three MATS interventions were developed to target medication adherence, socialization, and auditory hallucinations. Participants received up to 840 text messages over a 12-week intervention period. Fifty-five consumers with schizophrenia or schizoaffective disorder were enrolled, but 13 consumers with more severe negative symptoms, lower functioning, and lower premorbid IQ did not complete the intervention, despite repeated prompting and training. For completers, the average valid response rate for 216 outcome assessment questions over the 12-week period was 86%, and 86% of phones were returned undamaged. Medication adherence improved significantly, but only for individuals who were living independently. Number of social interactions increased significantly and a significant reduction in severity of hallucinations was found. In addition, the probability of endorsing attitudes that could interfere with improvement in these outcomes was also significantly reduced in MATS. Lab-based assessments of more general symptoms and functioning did not change significantly. This pilot study demonstrated that low-intensity text-messaging interventions like MATS are feasible and effective interventions to improve several important outcomes, especially for higher functioning consumers with schizophrenia.

Mobile Interventions for Severe Mental Illness: Design and Preliminary Data from Three Approaches

Mobile devices can be used to deliver psychosocial interventions, yet there is little prior application in severe mental illness. We provide the rationale, design, and preliminary data from 3 ongoing clinical trials of mobile interventions developed for bipolar disorder or schizophrenia. Project 1 used a personal digital assistant to prompt engagement in personalized self-management behaviors based on real-time data. Project 2 employed experience sampling through text messages to facilitate case management. Project 3 was built on group functional skills training for schizophrenia by incorporating between-session mobile phone contacts with therapists. Preliminary findings were of minimal participant attrition, and no broken devices; yet, several operational and technical barriers needed to be addressed. Adherence was similar to that reported in nonpsychiatric populations, with high participant satisfaction. Therefore, mobile devices seem feasible and acceptable in augmenting psychosocial interventions for severe mental illness, with future research in establishing efficacy, cost effectiveness, and ethical and safety protocols.

DSM-V and the stigma of mental illness

Stigma associated with mental illness has been shown to have devastating effects on the lives of people with psychiatric disorders, their families, and those who care for them. In the current article, the relationship between diagnostic labels and stigma is examined in the context of the forthcoming DSM-V. Three types of negative outcomes are reviewed in detail – public stigma, self-stigma, and label avoidance. The article illustrates how a clinical diagnosis may exacerbate these forms of stigma through socio-cognitive processes of groupness, homogeneity, and stability. Initial draft revisions recently proposed by the DSM-V work groups are presented, and their possible future implications for stigma associated with mental illness are discussed.

Real-Time Electronic Ambulatory Monitoring of Substance Use and Symptom Expression in Schizophrenia

OBJECTIVE Despite evidence demonstrating elevated comorbidity between schizophrenia and substance use disorders, the underlying mechanisms of association remain poorly understood. The brief time intervals that characterize interactions between substance use and psychotic symptoms in daily life are inaccessible to standard research protocols. The authors used electronic personal digital assistants (PDAs) to examine the temporal association of diverse forms of substance use with psychotic symptoms and psychological states in natural contexts. METHOD Of 199 community-dwelling individuals with schizophrenia or schizoaffective disorder who were contacted to participate in the study, 92% accepted and 73% completed the study. The 145 participants who completed the study provided reports of substance use, psychotic symptoms, mood, and event negativity multiple times per day over 7 consecutive days through PDAs. RESULTS Participants responded to 72% of the electronic interviews (N=2,737) across daily life contexts. Strong within-day prospective associations were observed in both directions between substance use and negative psychological states or psychotic symptoms, but considerable variation was observed by substance type. Consistent with the notion of self-medication, alcohol use was most likely to follow increases in anxious mood or psychotic symptoms. Cannabis and other illicit substances, demonstrating more complex patterns, were more likely to follow certain psychological states but were also associated with the later onset of psychotic symptoms. CONCLUSIONS The dynamic interplay of substance use and psychotic symptoms is in many cases consistent with both causal and self-medication mechanisms, and these patterns of association should be considered in the design of treatment and prevention strategies.

Stigma of mental illness and service use in the military

Background Many service members do not utilize the available services designed to assist them in coping with post-traumatic stress disorder and other mental health problems that emerge during active duty. Aims In the current paper, we discuss the possible role stigma plays in the underutilization of treatments in the military, and attempt to transfer a well-articulated framework for understanding stigma and stigma-change in civilian populations to the military context. Methods The literature was searched for papers reviewing negative beliefs about mental illness and fears of stigmatization and underutilization of treatments, especially as relevant to service members. Results We explain how public stigma, self stigma, and label avoidance may emerge as barriers to care seeking and service participation in soldiers, and propose approaches/strategies for change. We then discuss a number of recent applications of these approaches in both civilian and military initiatives. Conclusions Stigma-change programs specifically created by/for the military that integrate components of education and direct contact with respected peers or veterans who have coped with mental health problems may have great utility at both the early stages of military training and later, when soldiers return from theatres of operation.

Social Disinterest Attitudes and Group Cognitive-Behavioral Social Skills Training for Functional Disability in Schizophrenia

The majority of clinical trials of cognitive-behavioral therapy (CBT) for schizophrenia have used individual therapy to target positive symptoms. Promising results have been found, however, for group CBT interventions and other treatment targets like psychosocial functioning. CBT for functioning in schizophrenia is based on a cognitive model of functional outcome in schizophrenia that incorporates dysfunctional attitudes (eg, social disinterest, defeatist performance beliefs) as mediators between neurocognitive impairment and functional outcome. In this report, 18 clinical trials of CBT for schizophrenia that included measures of psychosocial functioning were reviewed, and two-thirds showed improvements in functioning in CBT. The cognitive model of functional outcome was also tested by examining the relationship between social disinterest attitudes and functional outcome in 79 people with schizophrenia randomized to either group cognitive-behavioral social skills training or a goal-focused supportive contact intervention. Consistent with the cognitive model, lower social disinterest attitudes at baseline and greater reduction in social disinterest during group therapy predicted better functional outcome at end of treatment for both groups. However, the groups did not differ significantly with regard to overall change in social disinterest attitudes during treatment, suggesting that nonspecific social interactions during group therapy can lead to changes in social disinterest, regardless of whether these attitudes are directly targeted by cognitive therapy interventions.

Strategies for mHealth Research: Lessons from 3 Mobile Intervention Studies

The capacity of Mobile Health (mHealth) technologies to propel healthcare forward is directly linked to the quality of mobile interventions developed through careful mHealth research. mHealth research entails several unique characteristics, including collaboration with technologists at all phases of a project, reliance on regional telecommunication infrastructure and commercial mobile service providers, and deployment and evaluation of interventions “in the wild”, with participants using mobile tools in uncontrolled environments. In the current paper, we summarize the lessons our multi-institutional/multi-disciplinary team has learned conducting a range of mHealth projects using mobile phones with diverse clinical populations. First, we describe three ongoing projects that we draw from to illustrate throughout the paper. We then provide an example for multidisciplinary teamwork and conceptual mHealth intervention development that we found to be particularly useful. Finally, we discuss mHealth research challenges (i.e. evolving technology, mobile phone selection, user characteristics, the deployment environment, and mHealth system “bugs and glitches”), and provide recommendations for identifying and resolving barriers, or preventing their occurrence altogether.

Mobile Technologies in the Study, Assessment, and Treatment of Schizophrenia

Mobile technologies are developing at a phenomenal rate and hold tremendous promise for transforming schizophrenia research and treatment. Over the last decade, mobile devices including microcomputers, mobile phones, and smartphones have become ubiquitous. The United Nations’ telecommunication agency recently reported that mobile phone subscriptions have reached almost 6 billion worldwide.1 Developing countries now account for close to 3 quarters of the mobile phones in use, and in some developed countries, the number of mobile phones already exceeds the size of the population, with many individuals owning multiple mobile devices. Recent national surveys in the United States found that mobile devices are helping bridge the digital information divide between various socioeconomic groups, as several traditionally underserved populations who typically could not afford access to home computers and internet packages now often use smartphones as their primary connection to information on the Internet. Remarkably, there is emerging evidence that many chronically homeless individuals now also use mobile devices regularly. The characteristics of contemporary mobile technologies (ie, portability, self-contained power source, increasingly user-friendly design) allow for something quite revolutionary—they enable us to transport research, assessment, and treatment out of the laboratories and clinics and into the real-time/real-world context in which individuals negotiate their daily lives and contend with chronic psychiatric illnesses and functional impairment. As infrastructure for mobile telecommunication continues to develop globally, it will create opportunities for far-reaching implementation of evidence-based interventions and wide-scale dissemination of information and resources in a manner that is unprecedented. The inherent advantages of mobile technologies are not going unnoticed by researchers, clinicians, and forward-thinking policy makers. The incorporation of various mobile devices in support of prevention and treatment initiatives across biomedical and behavioral disciplines is growing rapidly,2,3 the National Institutes of Health has recently begun to offer specialized training and funding opportunities focusing specifically on Mobile Health (mHealth) research, The Center for Medicare and Medicaid Services is exploring new payment models that may allow for expanded reimbursement of technology-based services, and the US Food and Drug Administration has already released statements regarding guidelines for regulating the use of some mobile devices and applications. While enthusiasm for utilization of mobile technology in research and clinical care is gaining momentum across a wide array of physical and mental health disciplines, many schizophrenia researchers and clinicians remain skeptical about the ability or willingness of patients with psychotic illnesses to comply with mobile research protocols or engage in mobile interventions. This apprehension is largely unfounded, and evidence suggests that given opportunity and appropriate training, many individuals with schizophrenia can and will use various mobile technologies successfully, even when they are quite symptomatic. The purpose of this special issue is to cultivate discussion about new opportunities for leveraging existing and emerging mobile technologies in the study of psychotic illnesses and to encourage investigators to think creatively about how these novel approaches can improve our understanding of the etiological risk factors, contextual influences, and possible treatments for schizophrenia. In the first article in this collection, we have asked Kimhy et al4 to discuss the rationale for mobile technology research in schizophrenia and provide concrete guidelines and practical suggestions for studies with this population. Their expert insights and shared collective experiences will undoubtedly be useful to investigators who are unfamiliar with mobile technology study design, hardware and software requirements, and statistical approaches necessary to successfully analyze the rich data that are characteristic of these paradigms. In the articles that follow, investigators demonstrate how 3 generations of mobile devices, including preprogrammed wristwatches used in conjunction with paper-and-pencil diaries, microcomputers, and mobile phones, can be effectively deployed for mobile research and treatment development. Ben-Zeev and colleagues5 use mobile technology to assist in the evaluation of patient clinical self-reports. They compare real-time/real-place momentary mobile assessments collected over 7 days in individuals with schizophrenia and a nonclinical comparison group to retrospective reports provided by both groups for the same period of time. Their findings indicate that study compliance in individuals with schizophrenia can be exceptionally high and that various dimensions of one’s symptomological and emotional experience are not well captured by traditional reports and better captured by momentary mobile assessments. Oorschot and colleagues6 and Granholm and colleagues7 deploy mobile devices in a therapeutic context. Oorschot and associates demonstrate how mobile data can be used to elucidate idiosyncratic symptom patterns and dynamic changes within individuals longitudinally, and articulate how this approach can augment face-to-face treatments by improving the therapeutic relationship between clinician and patient, providing important information for psychoeducation and treatment personalization. Granholm and colleagues7 report on an innovative automated mobile assessment and intervention for schizophrenia. In their pilot study, text messages sent from a remote preprogrammed server to patients’ mobile phones are used to administer cognitive-behavioral interventions in support of medication adherence, social functioning, and coping with auditory hallucinations. In the context of a growing body of evidence suggesting symptoms, affect, and functioning in schizophrenia are not nearly as static as previously believed, such paradigms may prove to be an especially powerful tool for identification of risk or preventive factors that could perhaps be targeted with real-time mobile interventions. As mobile devices infiltrate more and more areas of life of the general population, they will undoubtedly become more prevalent among those with schizophrenia as well. Statistically, many of those who are currently growing up with these technologies in hand will go on to develop serious mental illnesses in the future. Looking forward, now is the opportune time for innovative investigators and clinicians to examine how these emerging technologies can be harnessed as a powerful new platform for research and treatment approaches that can be made available in the years ahead.

Real-time predictors of suicidal ideation: mobile assessment of hospitalized depressed patients.

Suicidal ideation is a risk factor for suicide attempt and completion. Cross-sectional or retrospective studies cannot capture the dynamic course and possible predictors of suicidal ideation as it occurs in daily life. This study utilizes an experience sampling paradigm to identify real-time predictors of suicidal ideation in inpatients with major depressive disorder. Thirty-one depressed patients admitted to a psychiatric unit were signaled by a mobile device to record suicidal ideation, affect, and other symptoms, multiple times a day over 1 week. Participants completed a total of 1350 questionnaires. Seventy-four percent of the sample reported suicidal ideation during the week. Time-lagged analyses revealed that momentary ratings of Sadness, Tension, and Boredom (as well as suicidal ideation itself) predicted subsequent suicidal thoughts in the following hours. Baseline severity of depression and past suicide attempts were both correlated with mean ideation severity during the week. A number of predictors identified in prior research (e.g. hopelessness) were unrelated to subsequent suicidal ideation in the current study. Momentary interventions that guide individuals through activities designed to reduce levels of Sadness, Tension, and Boredom in real-time (e.g., thought challenging, relaxation, behavioral activation) may be especially warranted.