Stephen M. Schueller

Behavioral Intervention Technologies: Evidence review and recommendations for future research in mental health

OBJECTIVE A technical expert panel convened by the Agency for Healthcare Research and Quality and the National Institute of Mental Health was charged with reviewing the state of research on behavioral intervention technologies (BITs) in mental health and identifying the top research priorities. BITs refers to behavioral and psychological interventions that use information and communication technology features to address behavioral and mental health outcomes. METHOD This study on the findings of the technical expert panel. RESULTS Videoconferencing and standard telephone technologies to deliver psychotherapy have been well validated. Web-based interventions have shown efficacy across a broad range of mental health outcomes. Social media such as online support groups have produced disappointing outcomes when used alone. Mobile technologies have received limited attention for mental health outcomes. Virtual reality has shown good efficacy for anxiety and pediatric disorders. Serious gaming has received little work in mental health. CONCLUSION Research focused on understanding reach, adherence, barriers and cost is recommended. Improvements in the collection, storage, analysis and visualization of big data will be required. New theoretical models and evaluation strategies will be required. Finally, for BITs to have a public health impact, research on implementation and application to prevention is required.

Mobile Phone Sensor Correlates of Depressive Symptom Severity in Daily-Life Behavior: An Exploratory Study

Background Depression is a common, burdensome, often recurring mental health disorder that frequently goes undetected and untreated. Mobile phones are ubiquitous and have an increasingly large complement of sensors that can potentially be useful in monitoring behavioral patterns that might be indicative of depressive symptoms. Objective The objective of this study was to explore the detection of daily-life behavioral markers using mobile phone global positioning systems (GPS) and usage sensors, and their use in identifying depressive symptom severity. Methods A total of 40 adult participants were recruited from the general community to carry a mobile phone with a sensor data acquisition app (Purple Robot) for 2 weeks. Of these participants, 28 had sufficient sensor data received to conduct analysis. At the beginning of the 2-week period, participants completed a self-reported depression survey (PHQ-9). Behavioral features were developed and extracted from GPS location and phone usage data. Results A number of features from GPS data were related to depressive symptom severity, including circadian movement (regularity in 24-hour rhythm; r=-.63, P=.005), normalized entropy (mobility between favorite locations; r=-.58, P=.012), and location variance (GPS mobility independent of location; r=-.58, P=.012). Phone usage features, usage duration, and usage frequency were also correlated (r=.54, P=.011, and r=.52, P=.015, respectively). Using the normalized entropy feature and a classifier that distinguished participants with depressive symptoms (PHQ-9 score ≥5) from those without (PHQ-9 score <5), we achieved an accuracy of 86.5%. Furthermore, a regression model that used the same feature to estimate the participants’ PHQ-9 scores obtained an average error of 23.5%. Conclusions Features extracted from mobile phone sensor data, including GPS and phone usage, provided behavioral markers that were strongly related to depressive symptom severity. While these findings must be replicated in a larger study among participants with confirmed clinical symptoms, they suggest that phone sensors offer numerous clinical opportunities, including continuous monitoring of at-risk populations with little patient burden and interventions that can provide just-in-time outreach.

Pursuit of pleasure, engagement, and meaning: Relationships to subjective and objective measures of well-being

Pleasure, engagement, and meaning are all unique predictors of individuals’ well-being. We explored the relationship between the pursuit of each of these pathways and well-being. Participants (N = 13,565) visited a website and completed a measure about their orientation toward pleasure, engagement, and meaning as a pathway to happiness as well as measures of subjective and objective well-being (OWB). All three pathways correlated with higher levels of subjective well-being (SWB). Pursuing engagement and meaning, however, were more strongly related to SWB than pursuing pleasure. Objective indicators of well-being, including measures of occupational and educational attainment, displayed a similar pattern, with engagement and meaning positively related, whereas pleasure was negatively related. Although these results are merely correlational, it suggests that engaging and meaningful activities may have stronger influences on well-being than pursuing pleasure.

Disseminating Self-Help: Positive Psychology Exercises in an Online Trial

Background The recent growth of positive psychology has led to a proliferation in exercises to increase positive thoughts, behaviors, and emotions. Preliminary evidence suggests that these exercises hold promise as an approach for reducing depressive symptoms. These exercises are typically researched in isolation as single exercises. The current study examined the acceptability of several multi-exercise packages using online dissemination. Objective The purpose of this study was to investigate methods of dissemination that could increase the acceptability and effectiveness of positive psychology exercises. To achieve this goal, we compared the use of positive psychology exercises when delivered in packages of 2, 4, or 6 exercises. Methods Self-help–seeking participants enrolled in this study by visiting an online research portal. Consenting participants were randomly assigned to receive 2, 4, or 6 positive psychology exercises (or assessments only) over a 6-week period. These exercises drew from the content of group positive psychotherapy. Participants visited an automated website that distributed exercise instructions, provided email reminders, and contained the baseline and follow-up assessments. Following each exercise, participants rated their enjoyment of the exercise, answered how often they had used each technique, and completed outcome measures. Results In total, 1364 individuals consented to participate. Attrition rates across the 2-, 4-, and 6-exercise conditions were similar at 55.5% (181/326), 55.8% (203/364), and 52.7% (168/319) respectively but were significantly greater than the attrition rate of 42.5% (151/355) for the control condition (χ2 3 = 16.40, P < .001). Participants in the 6-exercise condition were significant more likely than participants in the 4-exercise condition to use both the third (F 1,312 = 5.61, P = .02) and fourth (F 1,313 = 6.03, P = .02) exercises. For 5 of the 6 exercises, enjoyment was related to continued use of the exercise at 6-week follow-up (r’s = .12 to .39). All conditions produced significant reductions in depressive symptoms (F 1,656 = 94.71, P < .001); however, a significant condition by time interaction (F 3,656 = 4.77, P = .003) indicated that this reduction was larger in the groups that received 2 or 4 exercises compared with the 6-exercise or control condition. Conclusion Increasing the number of exercises presented to participants increased the use of the techniques and did not increase dropout. Participants may be more likely to use these skills when presented with a variety of options. Increasing the number of exercises delivered to participants produced a curvilinear relationship with those in the 2- and 4-exercise conditions reporting larger decreases in depressive symptoms than participants in the 6-exercise or control conditions. Although research generally offers a single exercise to test isolate effects, this study supports that studying variability in dissemination can produce important findings.

Preferences for positive psychology exercises

Positive psychologists have developed a variety of techniques to increase well-being. This study explored whether preferences for some interventions are linked to preferences for other interventions. A total of 792 participants received up to six positive psychology exercises. After each exercise, participants indicated their preference for each exercise and how often they engaged in it. A factor analysis of these scores revealed three groupings of subjective preferences: active-constructive responding and savoring; blessings and life summary; and gratitude visit and strengths. Individuals who had high preference for an exercise were more likely to complete the exercise. Implications for application of positive psychology exercises and future recommendations are discussed including the use of such a framework for tailoring custom programs of interventions.

Optimism and Pessimism

Publisher Summary This chapter discusses the link between pessimism and optimism and the onset and recurrence of depression. Optimistic individuals tend to be happier, more successful, and more resistant to a variety of mental disorders, including depression. Pessimists, on the other hand, worry about the future, doubt they will reach their goals, and expect the worst. Not surprisingly, pessimists are more likely to experience depression and the most pessimistic individuals experience the most severe episodes. Although optimism is commonly defined as expecting the best and looking to the positive side of life, there are two dominant modes of measurement: dispositional optimism and attributional style. Optimism is related to the onset of depression, the characteristics of depressive episodes, and the occurrence of subsequent episodes. The link between optimism and depression is best understood within the framework of cognitive theories of depression. Cognitive theories of depression posit that onset is caused by a maladaptive cognitive style. Depressogenic cognitions are a risk factor for depression in just the same way that smoking is a risk factor for lung cancer. Different optimism interventions that have been successful in preventing depression are discussed.

Trials of Intervention Principles: Evaluation Methods for Evolving Behavioral Intervention Technologies

In recent years, there has been increasing discussion of the limitations of traditional randomized controlled trial (RCT) methodologies for the evaluation of eHealth and mHealth interventions, and in particular, the requirement that these interventions be locked down during evaluation. Locking down these interventions locks in defects and eliminates the opportunities for quality improvement and adaptation to the changing technological environment, often leading to validation of tools that are outdated by the time that trial results are published. Furthermore, because behavioral intervention technologies change frequently during real-world deployment, even if a tested intervention were deployed in the real world, its shelf life would be limited. We argue that RCTs will have greater scientific and public health value if they focus on the evaluation of intervention principles (rather than a specific locked-down version of the intervention), allowing for ongoing quality improvement modifications to the behavioral intervention technology based on the core intervention principles, while continuously improving the functionality and maintaining technological currency. This paper is an initial proposal of a framework and methodology for the conduct of trials of intervention principles (TIPs) aimed at minimizing the risks of in-trial changes to intervention technologies and maximizing the potential for knowledge acquisition. The focus on evaluation of intervention principles using clinical and usage outcomes has the potential to provide more generalizable and durable information than trials focused on a single intervention technology.

Realizing the Potential of Behavioral Intervention Technologies

Behavioral intervention technologies (BITs) apply behavioral and psychological intervention strategies by using digital media to target behaviors, cognitions, and emotions in support of physical and mental health. BITs offer promising opportunities to expand psychological practice. However, to realize the potential of BITs, psychologists must understand both the possibilities and the limitations associated with using technology to advance psychology. We review examples of the most cutting-edge BITs and discuss features that differentiate BITs from traditional modes of delivery. We highlight major challenges in designing BITs, including adherence, engagement, technological and interventional obsolescence, multidisciplinary collaboration, and a reliance on psychological skeuomorphisms. Psychologists who do not understand the conceptual and applied considerations involved in creating BITs risk being left out of the development of BITs in the future. Teaming psychologists with experts in technology will help to promote novel interventions rather than using technology to disseminate existing treatments.

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.

Efficacy of a Web-based, crowdsourced peer-to-peer cognitive reappraisal platform for depression: randomized controlled trial.

Background Self-guided, Web-based interventions for depression show promising results but suffer from high attrition and low user engagement. Online peer support networks can be highly engaging, but they show mixed results and lack evidence-based content. Objective Our aim was to introduce and evaluate a novel Web-based, peer-to-peer cognitive reappraisal platform designed to promote evidence-based techniques, with the hypotheses that (1) repeated use of the platform increases reappraisal and reduces depression and (2) that the social, crowdsourced interactions enhance engagement. Methods Participants aged 18-35 were recruited online and were randomly assigned to the treatment group, “Panoply” (n=84), or an active control group, online expressive writing (n=82). Both are fully automated Web-based platforms. Participants were asked to use their assigned platform for a minimum of 25 minutes per week for 3 weeks. Both platforms involved posting descriptions of stressful thoughts and situations. Participants on the Panoply platform additionally received crowdsourced reappraisal support immediately after submitting a post (median response time=9 minutes). Panoply participants could also practice reappraising stressful situations submitted by other users. Online questionnaires administered at baseline and 3 weeks assessed depression symptoms, reappraisal, and perseverative thinking. Engagement was assessed through self-report measures, session data, and activity levels. Results The Panoply platform produced significant improvements from pre to post for depression (P=.001), reappraisal (P<.001), and perseverative thinking (P<.001). The expressive writing platform yielded significant pre to post improvements for depression (P=.02) and perseverative thinking (P<.001), but not reappraisal (P=.45). The two groups did not diverge significantly at post-test on measures of depression or perseverative thinking, though Panoply users had significantly higher reappraisal scores (P=.02) than expressive writing. We also found significant group by treatment interactions. Individuals with elevated depression symptoms showed greater comparative benefit from Panoply for depression (P=.02) and perseverative thinking (P=.008). Individuals with baseline reappraisal deficits showed greater comparative benefit from Panoply for depression (P=.002) and perseverative thinking (P=.002). Changes in reappraisal mediated the effects of Panoply, but not the expressive writing platform, for both outcomes of depression (ab=-1.04, SE 0.58, 95% CI -2.67 to -.12) and perseverative thinking (ab=-1.02, SE 0.61, 95% CI -2.88 to -.20). Dropout rates were similar for the two platforms; however, Panoply yielded significantly more usage activity (P<.001) and significantly greater user experience scores (P<.001). Conclusions Panoply engaged its users and was especially helpful for depressed individuals and for those who might ordinarily underutilize reappraisal techniques. Further investigation is needed to examine the long-term effects of such a platform and whether the benefits generalize to a more diverse population of users. Trial Registration ClinicalTrials.gov NCT02302248; https://clinicaltrials.gov/ct2/show/NCT02302248 (Archived by WebCite at http://www.webcitation.org/6Wtkj6CXU).