The experience sampling methodology as a digital clinical tool for more person-centered mental health care: an implementation research agenda.

This position paper by the international IMMERSE consortium reviews the evidence of a digital mental health solution based on Experience Sampling Methodology (ESM) for advancing person-centered mental health care and outlines a research agenda for implementing innovative digital mental health tools into routine clinical practice. ESM is a structured diary technique recording real-time self-report data about the current mental state using a mobile application. We will review how ESM may contribute to (1) service user engagement and empowerment, (2) self-management and recovery, (3) goal direction in clinical assessment and management of care, and (4) shared decision-making. However, despite the evidence demonstrating the value of ESM-based approaches in enhancing person-centered mental health care, it is hardly integrated into clinical practice. Therefore, we propose a global research agenda for implementing ESM in routine mental health care addressing six key challenges: (1) the motivation and ability of service users to adhere to the ESM monitoring, reporting and feedback, (2) the motivation and competence of clinicians in routine healthcare delivery settings to integrate ESM in the workflow, (3) the technical requirements and (4) governance requirements for integrating these data in the clinical workflow, (5) the financial and competence related resources related to IT-infrastructure and clinician time, and (6) implementation studies that build the evidence-base. While focused on ESM, the research agenda holds broader implications for implementing digital innovations in mental health. This paper calls for a shift in focus from developing new digital interventions to overcoming implementation barriers, essential for achieving a true transformation toward person-centered care in mental health.

Trustworthiness judgments and pupil-size in individuals with schizophrenia.

Individuals with schizophrenia show aberrant processing of social cues. In the current study, we (1) compared trustworthiness ratings of faces between patients with schizophrenia and healthy controls, (2) compared pupillary reactivity between patients and controls (3) examined whether trustworthiness judgments in schizophrenia are related to pupil reactivity, (4) and examined associations between trustworthiness judgements and symptom severity, specifically paranoia. Patients with schizophrenia spectrum disorders (N = 48) and healthy controls (N = 33) completed a Trustworthiness Task, during which their pupil size was measured via an eye-tracking device. The mean baseline-corrected pupil size was calculated from 24 pictures of real neutral faces, each presented for 2500 ms. Self-reported psychotic experiences were measured by Community Assessment of Psychic Functioning (CAPE-42), and symptom severity was rated by Brief Psychiatric Rating Scale (BPRS). No group differences were found in trustworthiness ratings or pupil reactivity parameters during trustworthiness judgments. Separately, among patients, absolute difference in pupil-size change and dilation after reaching minimum size were related to more severe positive symptoms and self-reported paranoia. Our results did not show social cognitive biases in the stable outpatients with schizophrenia, or the role of pupil reactivity in trustworthiness judgments. Future studies should use longer stimuli for pupillary reactivity and control the type and dosage of utilized antipsychotic medication. Further studies are required to explore relationships in larger and more symptomatic groups of patients.

Strategies, processes, outcomes, and costs of implementing experience sampling-based monitoring in routine mental health care in four European countries: study protocol for the IMMERSE effectiveness-implementation study.

BACKGROUND: Recent years have seen a growing interest in the use of digital tools for delivering person-centred mental health care. Experience Sampling Methodology (ESM), a structured diary technique for capturing moment-to-moment variation in experience and behaviour in service users' daily life, reflects a particularly promising avenue for implementing a person-centred approach. While there is evidence on the effectiveness of ESM-based monitoring, uptake in routine mental health care remains limited. The overarching aim of this hybrid effectiveness-implementation study is to investigate, in detail, reach, effectiveness, adoption, implementation, and maintenance as well as contextual factors, processes, and costs of implementing ESM-based monitoring, reporting, and feedback into routine mental health care in four European countries (i.e., Belgium, Germany, Scotland, Slovakia). METHODS: In this hybrid effectiveness-implementation study, a parallel-group, assessor-blind, multi-centre cluster randomized controlled trial (cRCT) will be conducted, combined with a process and economic evaluation. In the cRCT, 24 clinical units (as the cluster and unit of randomization) at eight sites in four European countries will be randomly allocated using an unbalanced 2:1 ratio to one of two conditions: (a) the experimental condition, in which participants receive a Digital Mobile Mental Health intervention (DMMH) and other implementation strategies in addition to treatment as usual (TAU) or (b) the control condition, in which service users are provided with TAU. Outcome data in service users and clinicians will be collected at four time points: at baseline (t0), 2-month post-baseline (t1), 6-month post-baseline (t2), and 12-month post-baseline (t3). The primary outcome will be patient-reported service engagement assessed with the service attachment questionnaire at 2-month post-baseline. The process and economic evaluation will provide in-depth insights into in-vivo context-mechanism-outcome configurations and economic costs of the DMMH and other implementation strategies in routine care, respectively. DISCUSSION: If this trial provides evidence on reach, effectiveness, adoption, implementation and maintenance of implementing ESM-based monitoring, reporting, and feedback, it will form the basis for establishing its public health impact and has significant potential to bridge the research-to-practice gap and contribute to swifter ecological translation of digital innovations to real-world delivery in routine mental health care. TRIAL REGISTRATION: ISRCTN15109760 (ISRCTN registry, date: 03/08/2022).

Temporal pathways from attachment insecurity to paranoia in a heterogeneous clinical sample: An experience sampling study.

INTRODUCTION: There has been growing interest in the role of attachment mechanisms in the onset and maintenance of paranoia. The latest systematic reviews of mixed samples of healthy individuals and psychiatric patients have revealed that increased trait attachment anxiety and avoidance are associated with experiencing paranoia, with trait attachment anxiety showing a stronger association. Few studies have examined attachment and paranoia in naturalistic conditions via the Experience Sampling Method. OBJECTIVES: The present study examined whether experiences of attachment anxiety and avoidance fluctuate in the flow of daily life, and whether a within-person change in both attachment states precedes the experience of momentary paranoia, and negative and positive emotions. METHODS: Thirty-seven clinical participants and twenty-six healthy controls were studied over six consecutive days using the Experience Sampling Method (ESM). An experience-in-close-relationships questionnaire (ECR-R 16 SF) was used to capture trait attachment dimensions. Several ESM items were used to capture momentary negative and positive affect, paranoia and attachment insecurity states. RESULTS: The findings revealed that fluctuations in both attachment insecurity states were significantly higher in the clinical group. A prior elevated attachment anxiety and avoidance was followed by an increase in negative affect in the next moment and elevated attachment avoidance was additionally followed by a decrease in positive affect and an increase in paranoia. CONCLUSION: Our findings reveal the specific temporal associations between momentary attachment insecurity states as predictors of change in emotions/affects and paranoia, along with evidence that state attachment avoidance has a superior impact on momentary affect and paranoia compared to state attachment anxiety. These results contrast with those of recent cross-sectional studies.

Connections between and within extended psychosis and autistic phenotypes and social relationships in the general population.

OBJECTIVES: Non - clinical individuals with higher levels of autistic traits and psychotic experiences also have problems in social relationships. Therefore, this study aimed to model complex associations between autistic and psychotic phenotypes and indicators of social relationships in the general population using a network approach. METHODS: The sample consisted of 649 participants with a mean age of M = 40.23 and SD = 13.09 sampled from the general population. The sample was representative for the 18-65 years old general population in the Slovak Republic. The following scales were administered: Community Assessment of Psychic Experiences, The Comprehensive Autistic Trait Inventory, and NIH Toolbox Adult Social Relationship Scales. Associations between variables and the presence of communities were identified using Exploratory Graph Analysis. RESULTS: Results revealed four highly stable and densely connected communities within the network: social relationships, autistic traits, positive symptoms, and the last one consisting of all negative symptoms, problems in social interactions, and depression. The most important variables in the network were difficulties in social interaction, perceived rejection, bizarre ideas, depression, and social withdrawal. CONCLUSIONS: The psychotic and autistic phenotypes in the general population showed a network of connections with characteristics of social relationships. Community detection revealed that autistic traits and psychotic-like experiences formed relatively independent communities. Further, there was substantial overlap between negative symptoms (e.g., social withdrawal), and core features of the autistic phenotype, especially social interaction difficulties.

Normative data for the Slovak version of the Frontal Assessment Battery (FAB).

The Frontal Assessment Battery (FAB) is a well-established screening measure of frontal lobe pathology. The aim of this study is the development of normative data for healthy Slovak adults. The final sample consisted of 487 healthy adults (54% of them female). The mean age in our sample was M = 55.29 (SD = 19.96). For the whole sample, the mean score on the FAB was 16.46 and the SD was 1.64. The mean score on the MMSE for the whole sample was 28.39 and the SD was 1.43. All participants underwent a complex neuropsychological examination spanning the relevant cognitive domains. FAB scores were found to be negatively associated with age (rs = -0.464, p < 0.001) and positively associated with years of education (rs = 0.199, p < 0.001). FAB scores positively correlated with the performance in MMSE (rs = 0.266, p < 0.001). Statistically significant and theoretically meaningful associations to other neuropsychological tests used in this study suggested the adequate convergent validity of the Slovak version of the FAB. The present study provided accurate normative FAB data, which can be used for clinical and research purposes.

Slovak version of the Trail Making Test: Normative data.

The Trail Making Test (TMT) is a popular measure of cognitive functioning, especially processing speed and cognitive flexibility. This study aims to provide normative data for the Slovak adult population. The secondary aim is to test the convergent validity by examining relationships of direct and derived indices to other neuropsychological measures. A sample of 487 healthy adults undertook neuropsychological testing. The relationships of TMT scores to demographic variables and other neuropsychological measures were tested. Age was positively correlated with TMT-A (r = 0.444, p < .01), TMT-B (r = 0.426, p < .01), and the B-A index (r = 0.317, p < .01). Years of education were negatively correlated with TMT-B (r = -0.183, p < .01), B-A difference (r = -0.188, p < .01) and B/A ratio (r = -0.119, p < .01). There were no statistically significant differences in performance based on gender. The test scores were correlated with other measures of processing speed and executive functions. Presented normative data are stratified into 7 age categories. For more accurate interpretation, regression equations were calculated to take years of education into account. TMT-A and B performance, as well as B-A difference score, must be interpreted in relation to age, while education can provide additional information. The B/A ratio is independent from age but should be also corrected for educational level.

An Analysis of Eye-Tracking Features and Modelling Methods for Free-Viewed Standard Stimulus: Application for Schizophrenia Detection.

Currently psychiatry is a medical field lacking an automated diagnostic process. The presence of a mental disorder is established by observing its typical symptoms. Eye-movement specifics have already been established as an "endophenotype" for schizophrenia, but an automated diagnostic process of eye-movement analysis is still lacking. This article presents several novel approaches for the automatic detection of a schizophrenic disorder based on a free-view image test using a Rorschach inkblot and an eye tracker. Several features that enabled us to analyse the eye-tracker signal as a whole as well as its specific parts were tested. The variety of features spans global (heat maps, gaze plots), sequences of features (means, variances, and spectra), static (x and y signals as 2D images), dynamic (velocities), and model-based (limiting probabilities and transition matrices) categories. For each set of features, a proper modelling and classification method was designed (convolutional, recurrent, fully connected and combined neural networks; Hidden Markov models). By doing so, it was possible to find the importance of each feature and its physical representation using k-fold cross validation and a paired t-test. The dataset was sampled on 22 people with schizophrenia and 22 healthy individuals. The most successful approach was based on heat maps using all data and convolutional networks, reaching a 78.8% accuracy, which is a 10.5% improvement over the reference method. From all tested methods, there are two in an 85% accuracy range and over fifteen others in a 75% accuracy range at a 10% significance level.

Theory of mind - not emotion recognition - mediates the relationship between executive functions and social functioning in patients with schizophrenia.

BACKGROUND: Dysfunction of social-cognitive abilities is one of the hallmark features of schizophrenia and is associated with neurocognition and social functioning. The Green and Nuechterlein model proposed that social cognition mediates the relationship between neurocognition and functional outcome. We tested this hypothesis in schizophrenia patients in the everyday clinical setting. SUBJECTS AND METHODS: Social cognition, executive function and social functioning were assessed in a group of 43 patients with schizophrenia or schizoaffective disorder using a range of measures. RESULTS: Theory of mind was associated with executive functions and social functioning. Results of our mediation analysis suggested that the relationship between executive functions and social functioning was mediated by theory of mind. No relationships between emotion recognition and the domains of social functioning were found. CONCLUSIONS: In line with prior research, zero-order associations were found between theory of mind and social functioning. Theory of mind was a mediator of the relationships between neurocognition and social functioning. Our results suggest that theory of mind should be a potential target of interventions to improve social functioning.