Case Studies

Boston Children's Hospital: Ecological Momentary Intervention for Marijuana Use in Youth

Synopsis

The team used motivational counseling with adolescents using marijuana. They found it effective but wondered if they could make it more effective by adding an ecological momentary intervention component.

They used the mEMA System to provide personalized messages to participants throughout the day that were tailored to the specific momentary context (e.g. hanging out with friends). The messages were personalized based on counselors' in-person interactions with each participant then added into the app by the clinical team each week.

They found that participants in both the motivational counseling condition and the motivational counseling condition assisted by ecological momentary intervention showed reduced desire for and use of marijuana at the end of the study. And that desire to use marijuana during targeted contexts was reduced even more in the EMI assisted condition. Their patients enjoyed using the app and reading the messages.
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Lydia Shrier, MD, MPH

Attending physician at Boston Children’s Hospital
Research Profile 
mHealth (Full Text)

Harvard Medical School: Digital Phenotyping in Suicidal Ideation

Synopsis

Before work with the mEMA System suicidal thinking was seen as a homogenous construct. Typically snapshot assessments were taken days, weeks, or months apart with missed the variation in suicidal thought that happens over hours. The available methodologies blunted our understanding.

A group from Harvard Medical School used the mEMA System for “digital phenotyping” – real-time characterization and quantification in human thought in situ.

They found five previously unknown distinct phenotypes of suicidal thought. there was a significant relationship between some of these phenotypes and a recent suicide attempt. This work has opened up a new avenue in the understanding of suicide and its prevention.

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Evan Kleiman Ph.D

Assistant Professor, Rutgers University
Research Profile 
“Depression & Anxiety” (Full Text Paper)

Ambulatory Digital Phenotyping of Blunted Affect and Alogia using Objective Facial and Vocal Analysis: Proof of Concept

Synopsis

Negative symptoms of Schizophrenia – including blunted affect and alogia – are poorly understood yet amongst the most debilitating to patients. They are traditionally assessed with questionnaire measures or clinician ratings both of which are subject to bias and limited to whenever the patient comes into a clinic. There is a need for measures that are objective and more accessible for patients.
A team from Louisiana State University, University of Nevada, and University of Georgia used the mEMA System to capture ambulatory video from patients with schizophrenia and non-psychiatric controls as they went about their daily life. They collected 788 videos, 80% of which were usable for analysis.
They analyzed facial and vocal features of these ambulatory videos and found them to have significant convergence with “gold standard” measures of negative symptomology. Additionally, they found that the ambulatory facial/vocal measures were more highly associated with work and social engagement than standard measures. This novel, objective, and highly accessible methods of symptom assessment would not have been discovered without access to a reliable system for collecting ambulatory video samples.
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Alex Cohen

Professor, Louisiana State University
Profile 
Schizophrenia Research - April 2020

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Remote Monitoring of Negative Symptoms in Schizophrenia

Synopsis

Reliable and valid scales for assessment of the negative symptoms of Schizophrenia are available. However, they have certain issues that affect their validity, such as recall biases, halo effects, and issues of social desirability as they are usually completed with the clinician. Dr. Strauss’s group wanted to know if digital phenotyping methods could be complementary to the existing scales.

Dr. Strauss and his team used the mEMA platform to prompt participants at various times of day, across different contexts to complete momentary, digital versions of these scales. They also obtained passive digital phenotyping measures, such as geolocation, accelerometry, and ambient sound (VOX) concurrently with the mEMA surveys.

Dr. Strauss and his team found the digital versions to be reliable and psychometrically valid and to have much better resolution both temporally and across contexts. These findings open the possibility for both enhanced assessment and a digital therapeutics application that would allow patients from all parts of the world to monitor their own symptoms, and let the app prompt them when it’s time to seek additional treatment. Validation of the EMA and passive digital phenotyping approaches may allow for siteless clinical trials in the future.

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Gregory Strauss, Ph.D

Assistant Professor of Psychology and Neuroscience
Research Profile 
Director of the Clinical Effective Neuroscience Laboratory
Director of the Georgia Psychiatric Risk Evaluation Program
University of Georgia

More Schizophrenia Insights from Dr. Strauss' Lab
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UT Southwestern Medical Center: Feasibility Study of Problem-Solving Training for Care Partners of Adults With Traumatic Brain Injury, Spinal Cord Injury, Burn Injury, or Stroke During the Inpatient Hospital Stay

Synopsis

Dr. Shannon B. Juengst’s study using Ecological Momentary Assessment was designed to determine the feasibility of delivering an evidence-based self-management intervention, problem-solving training (PST), to care partners of individuals with traumatic brain injury (TBI), spinal cord injury (SPI), burn injury, or stroke during the inpatient hospital stay. PST is a metacognitive self-management intervention that teaches individuals a global strategy for addressing self-selected problems. Participants received up to six sessions of PST in person or via telephone during their care recipient’s inpatient stay. 

Dr.Juengst’s team used the mEMA System to measure the feasibility of recruitment, intervention delivery, and post-intervention use of Smartphone-based assessments measuring problem-solving, participant satisfaction, and engagement with the intervention.

Participants were very satisfied with PST, reported a strong working alliance, and demonstrated very good engagement. It was concluded that delivering a self-management intervention to care partners via a Smartphone app during the care recipient’s acute hospital stay is feasible for a subset of potential participants. Short lengths of stay, language fluency, and perceiving no potential benefit were noted barriers. Boosters via smartphone app have the potential for self-management intervention.

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Shannon B. Juengst, Ph.D

Assistant Professor, Department of Physical Medicine and Rehabilitation, at the University of Texas Southwestern Medical Center
Research Profile 
Archives of Rehabilitation Research and Clinical Translation

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McMaster University: MovingU – A prospective cohort study to understand behavioral and environmental contexts influencing physical activity during transition into emerging adulthood.

Synopsis

In his study, Dr. Matthew Kwan examines the acute transition of physical activity (PA) of out of high school-aged adolescents into early adulthood. The MovingU study works to gain a comprehensive understanding of the behavioral patterns and the socio-ecological factors related to the changes in PA during transition out of high school. The MovingU study was comprised of two phases where Phase one followed 120 students in their last year of high school through their first year out of high school. Phase two was a cross-sectional study involving 100 first-year university students. 

In both phases, students were asked to wear a wrist-worn accelerometer and to complete questionnaires measuring various psychological and socio-environmental variables four times throughout the transition period. Daily questionnaires were presented to students on their own Smartphones using the mEMA System.  Students in Phase two of the study were asked to wear the wrist-worn device for five days and complete ecological momentary assessments using their smartphones at randomly selected times throughout the day to capture information regarding contextual and momentary correlates to PA.

Dr. Kwan’s study is the first to evaluate the social and environmental influences of PA behavior changes, including the use of intensive real-time data capture strategies during the transition out of high school. The study’s information will be critical in the development of interventions aimed to prevent or attenuate drastic declines in physical activity during emerging adulthood.

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Matthew Y.W. Kwan, Ph.D

Assistant Professor, Department of Family Medicine, 
McMaster University
Research Profile 
BMC Public Health

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University of British Colombia: An examination of diurnal variations in neuropathic pain and affect, on exercise and non-exercise days, in adults with spinal cord injury.

Synopsis

Dr. Kathleen Martin Ginis’ study utilizes ecological momentary assessment to measure the intra-individual diurnal variations in neuropathic pain and affect on exercise and non-exercise days in a community setting. The study aims to provide a deeper understanding of how neuropathic pain and affect change from pre to post-exercise, and over time.

Using the mEMA System, participants with spinal cord injuries (SCI) completed the Feeling Scale, Felt Arousal Scale, and Neuropathic Scale in response to six daily prompts, before and after exercise. Paired samples t-tests were conducted on changes in neuropathic pain and affect from pre to post-exercise.

Participants experienced a significant decrease in neuropathic pain following completion of at least one bout of exercise. The overall results suggest exercise can reduce neuropathic pain, and may also increase feelings of pleasure. Further research is needed to look at both individual characteristics and characteristics of exercise that may moderate changes in neuropathic pain and affect for adults with SCI.

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Kathleen Martin Ginis, Ph.D

Professor at the School of Health and Exercise Sciences
University of British Columbia
Research Profile 
Spinal Cord Series and Cases

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Rutgers: Are suicidal thoughts reinforcing? A preliminary real-time monitoring study on the potential affect regulation function of suicidal thinking.

Synopsis

Dr. Evan Kleinman’s study examines whether the occurrence of suicidal thinking was followed by decreased negative affect and increased positive affect in 43 adult participants who attempted suicide at least once in the past year.

The mEMA System was used to run 28 days of smartphone-based real-time monitoring, where participants were signaled four times per day to report on current affect and whether they were having suicidal thoughts. Additionally, participants could initiate a survey whenever they had a suicidal thought.

Changes in affect occurred when suicidal thinking was active at the current time but not at approximately 4-8 hours later. Negative affect decreased and positive affect increased when participants went from a period when they were experiencing suicidal thoughts to a period where they were not. Findings provided preliminary evidence that suicidal thinking leads to shifts in affect. These shifts in affect may be reinforcing, helping to explain why suicidal thinking is so persistent for some patients.

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Evan M. Kleinman, Ph.D

Assistant Professor, Department of Psychology
Rutgers, The State University of New Jersey
Research Profile 
Journal of Affective Disorders

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Universidade Estadual de Londrina: Characterization and Agreement Between Application of Mobile Ecological Momentary Assessment (mEMA) and Accelerometry in the Identification of Prevalence of Sedentary Behavior in Young Adults

Synopsis

Catiana Leila Possamai Romanzini’s study describes sedentary behavior (SB) in the physical, social, and environmental contexts and verifies the agreement between mobile Ecological Momentary Assessment (mEMA) and accelerometry in the identification of SB in young adults.

Over the course of seven days, 123 young adults used concomitant mEMA and Actigraph wGT3xBT accelerometer. Data of 2,262 mEMA prompts and respective count values in each minute were included in the analysis. mEMA identified the presence of SB in 78.1% of prompts, while accelerometry identified 70.9%.

The study demonstrates the viability of mEMA use to obtain information about the occurrence of SB in contextual factors and good sensitivity to identify the presence of SB in young adults. The combined use of these methods is suggested in future studies about SB in young adults.

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Catiana Leila Possamai Romanzini

Assistant Professor, Department of Physical Education
State University of Londrina Brazil
Research Profile 
Frontiers in Psychology

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University of Illinois at Chicago: Feasibility of ecological momentary assessment to study mood and risk behavior among young people who inject drugs

Synopsis

Dr. Mary E. Mackesy-Amiti’s study tests the acceptability and feasibility of ecological momentary assessment (EMA) of mood and injection risk behavior among young people who inject drugs (PWID), using mobile phones.

Participants used the mEMA System to respond to momentary surveys on mood, substance use, and injection risk behavior for 15 days. Participants were assigned to receive surveys four, five, or six times per day.

This study demonstrated high acceptability and feasibility of EMA among PWID with up to six survey prompts per day. EMA of mood and injection behavior is feasible. EA is a promising approach to the study of mood and injection risk behavior.

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Mary E. Mackesy-Amiti, Ph.D

Research Assistant Professor at the University of Chicago
Research Profile 
Journal of Drug and Alcohol Dependence

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Zoom-Based Mindfulness-Oriented Recovery Enhancement Plus Just-in-Time Mindfulness Practice Triggered by Wearable Sensors for Opioid Craving and Chronic Pain

Synopsis

Eric Garland and his team have been developing mindfulness based interventions for those with chronic pain who misuse opioids now for over a decade. Eric’s Mindfulness-Oriented Recovery Enhancement (MORE) intervention program. The MORE program has been tested multiple times, each time reliably showing that it significantly reduces opioid craving and use and decrease the amount of pain people are experiencing. 
 
The content of the MORE program is no longer a question. It’s a robust treatment. The challenge has been how to get it out to the people who really need it, especially those in rural areas. We already know that psychological interventions can be delivered by Telehealth. But finding ways to encourage people to practice at home, essential for MORE, can be challenging.
 
Eric wanted to be able to remind people of the practices of the MORE intervention at the times they needed it most - when they were stressed or in pain. A MORE just-in-time-adaptive-intervention (JITAI). That’s where the mEMA System really came into its own. If the study participants are wearing a Garmin smartwatch then we know exactly when those moment are greatest need are occurring. The mEMA app is then able to offer the participant a short mindfulness-based audio session. 
 
The results of this pilot RTC showed significant reductions in pain, stress and craving and increased positive affect over time for the JITAI group over the control group. This evidence-based intervention of opioid misuse just increased it’s ability to reach more people who need it and the power of it’s efficacy. All without drawing on already strained local mental health services.
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Eric Gardland, Ph.D

Distinguished Endowed Chair in Research, College Of Social Work
Health Intervention Development (C-MIIND), College Of Social Work
Associate Director of Integrative Medicine - Supportive Oncology, Huntsman Cancer Institute

 

Research Profile 
Full Journal Text

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Positive Encounters as a Buffer: Pain and Sleep Disturbances in Older Adults’ Everyday Lives

Synopsis

This study used EMA to investigate the impacts of social interactions and sleep on pain levels in older adults. The link between sleep and was already well understood. Less  or lower quality sleep tends to lead to greater pain  the following day. But little was known about how social interactions throughout the day may influence that link and there was already evidence to suggest that positive social interactions may attenuate the impact of poor sleep on pain.
 
This group in Texas recruited about 300 people (average age 74 yrs) to discover if positive social interactions might lessen the impact of poor sleep on pain levels. This isn't data you can collect with a questionnaire at the end of the week. Neither level of pain or the number and quality of social interactions is likely to be remembered with enough accuracy. EMA is perfect for this kind of data collection. The participants received study phone with the mEMA app pre-loaded and populated with personalized surveys. The app prompted them multiple times a day to report on their social interactions and once a day on previous night's sleep and pain levels. This level of granularity of self-report data can only be achieved with EMA methods.
 
The results showed that on days participants hadn't slept well but experienced a positive social interaction, especially with someone close to them, they were more likely to feel less pain. The positive interaction with their loved one seemed to somehow reduce the impact of the poor sleep on how much pain they were feeling. This is an important nuance that would not have been picked up without a mobile EMA system. It opens the door for possible interventions to assist those close to people who suffer with chronic pain to find ways to increase fun, pleasurable interactions each day.
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Meng Huo, PhD1 et al, 2021


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Wearable Technology for the Terminally Ill

Synopsis

Many people with terminal cancer would prefer to stay home and spend their last weeks with their loved ones. Often this is not possible because of the high level of care required and the stress placed on family members. An Australian research group headed by Thilo Schuler are tackling this problem with the mMEA System. They designed a study to see if they could use this technology to maximizes patient's time at home and reduce caregiver burden. This exploratory study provided 15 patient-caregiver dyads with Garmin smartwatches that detect stress levels and sync with the mMEA app on their phone. Thresholds were set for each individual so that when the smartwatch detected higher than usual stress for each person it would trigger a mobile survey. Physiological data was captured continuously for a 5 minute period around them filling in that short survey. Both patients and caregivers were happy to wear the smartwatch (73% adherence) and complete the surveys (78% adherence). The team collected 1395 surveys over the 5 week trial period which gave them additional information about what was causing stress and sleep disturbance. The conclusion was that the technology was well received by both patients and caregivers and holds the potential to help keep the dying in their homes longer and reduce stress for caregivers. The team are planning further studies using predictive algorithms.
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Thilo Schuler MD

Researcher Website
Full Journal Text

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Diabetes Stress

Synopsis

A research group in Germany lead by Dominic Ehrmann and Andreas Schmitt wanted to investigate more closely how the emotional distress associated with living with Type 1 Diabetes impacts glucose management. Previous work has found a highly varied relationship between the two. There are likely many factors involved in the unclarity of this relationship, issues of methodology are one relatively easy to tackle.
 
They used the mEMA System to track diabetes related stress in some patients while the other group filled in standardized questionnaires at baseline and 3-month follow up (total n= 178). Both groups also used continuous glucose monitors to measure their blood glucose levels. This allowed the researchers to see throughout the course of 17 days how patient's emotional state around diabetes related to their actual blood sugar levels.
 
What they found will help move the field of diabetes care forward. The group completing the standardized questionnaires as usually done showed no correlation between diabetes related stress and their blood sugar levels. The group using mEMA to report on their diabetes related stress daily however, showed a significant correlation between stress and glucose levels. The more fine grained data available with use of a system such as mEMA allowed the picture of the relationship of diabetes stress and glucose levels to come into sharper focus. Further work will be able to dive deeper into this relationship and hopefully design and test just-in-time-adaptive-interventions.
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Andreas Schmitt

Researcher Website
Full Journal Text

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Movement

Synopsis

We know that physical activity is good for us and that sitting still a lot of the day has detrimental health effects. There has also been lot of research on how to encourage people to get engaged in more physical activity. But getting started dosen't always translate to sustaining the behavior.
 
A group of occupational therapists and doctors in California got together to look at how to help people sustain more physical activity in their daily lives by looking at the short-term relationship of physical activity and positive mood. They realized that retrospective reporting had limited previous research . They used EMA to gather mood ratings 5-6 times a day alongside objective physical activity data from an accelerometer for 14 days.
 
They found that physical activity, at any intensity level, was associated with increased positive affect and reduced fatigue over a three hour period. Sitting still was associated with decreased positive affect and increased fatigue. Additionally, people's mood increased even more when they did a physical activity they enjoyed and was meaningful to them.
 
This research sets the stage for developing just-in-time interventions that could help individuals see which types of activities help them feel better and remind them of that at important points in the day. Although the effect sizes were small they point out that over a lifetime the experience of feeling better after certain types of physical activity is likely to encourage people to stick with it.
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Beth Pyatak

Researcher Website
Full Journal Text

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