Use of the experience sampling method in adolescents with Duchenne muscular dystrophy: a feasibility study.

Experience sampling methods (ESM) using mobile health (mHealth) technology with a smartphone application are increasingly used in clinical practice and research. Still, recommendations are limited in young people, and adaptations may be necessary. Patients with Duchenne muscular dystrophy (DMD) are chronically treated with steroids from a young age. However, the impact of intermittent treatment schedules on fluctuations in somatic, cognitive and behavioural symptoms is poorly investigated. Existing studies are often cross-sectional and occur in controlled clinical settings, which do not provide sufficiently detailed insights into possible correlations. ESM might alleviate these problems. ESM innovates data collection with a smartphone application, which repeatedly assesses specific symptoms and contextual factors at random moments in daily life. We aimed to evaluate its feasibility in adolescents with DMD. In three (without/with/without steroids) 4-day periods of ESM, that were nested in 10/10 or 11/9 day on/off-medication periods, we evaluated its user-friendliness and compliance, and explored its ability to objectify fluctuations in somatic, cognitive and behavioural symptom severity and their relationship with contextual factors in seven DMD patients (age range 12-18 years) using intermittent corticosteroid treatment (dosage range 0.3-0.6 mg/kg/day). Patients reported that ESM was convenient and user-friendly. We were able to capture extensive intra-individual symptom fluctuations during intermittent corticosteroid treatment that were not revealed by routine clinical assessment. Implementing ESM to evaluate symptom fluctuation patterns in relation to treatment effects shows promise in adolescents with DMD. Optimization in further research is needed.

How to use experience-sampling technology to understand daily functioning: A practical guide for mental health professionals.

Satisfying daily life functioning is essential in mental healthcare. Standard assessments focus on symptoms and are designed to detect underlying vulnerabilities. However, they offer insufficient insight into patterns of contextual variability and resilience. Consequently, interventions are planned using incomplete information. The experience-sampling method (ESM) is a structured moment-to-moment diary assessing the individual's affect, thoughts, perception and behaviour in the daily life context. ESM helps to understand variation in mental states (e.g., anxiety or sleeping problems) as adaptational processes in relation to contextual challenges (functional analysis). Although ESM has been extensively studied across psychological disorders, the adoption by mental health professionals and their patients remains limited because the 'how to' is unclear. This paper presents a practical guide for ESM application in routine clinical care. It integrates empirical knowledge with expert experiences and provides real-world examples and recommendations for successful implementation. The guide comprises how to engage and motivate patients and how to customize assessments to the patient's needs. It also includes instructions to interpret results and create an atmosphere of shared decision-making. Experience-sampling technology has merits for patients with various mental health complaints and across healthcare settings, although the exact use and implementation may vary depending on the individual case.

A Comprehensive Assessment to Enable Recovery of the Homeless: The HOP-TR Study.

Background: Homelessness is an increasing problem in Western European countries. In the Netherlands, policy reforms and austerity measures induced an urgent need for management information on local homeless citizens. Municipal authorities initiated cross-sectional reviews of Homeless Service (HS) users. The resulting Homeless People Treatment and Recovery (HOP-TR) study developed a health and needs assessment strategy over different domains to comprehensively assess individuals and care networks with the perspective on recovery. Methods: Dutch HS users were selected using a naturalistic meta-snowball sampling. Semi-structured interviews provided the primary data source. The interview content was partly derived from the InterRAI Community Mental Health questionnaire and the "Homelessness Supplement." Using the raw interview data, algorithmic summary scores were computed and integrating clinical parameters assessed. The data describe health and needs in a rights-based, recovery-oriented frame of reference. The mental health approach is transdiagnostic. The positive health framework is used for structuring health and needs aspects in relation to the symptomatic (physical and mental health), social (daily living, social participation), and personal (quality of life, meaning) dimensions of recovery. Results: Recruitment (between 2015 and 2017) resulted in a saturated sample of 436 HS users in 16 facilities and seven cities. Most participants were long-term or intermittently homeless. The sample characteristics reveal the multi domain character of needs and the relevance of a broad, comprehensive approach. Local authorities used the reports to reflect and discuss needs, care provision, access, and network cooperation. These dialogs incited to improve the quality of care at various ecosystem levels. Discussion: This paper describes new recruitment strategies and data collections of comprehensive data domains, to improve our knowledge in the field of homelessness. Traditional epidemiological literature on homelessness is often domain specific and relies on administrative sources. The HOP-TR study uses an analytical epidemiological approach. It shifts the assessment focus from problem-centered marginalization processes toward a comprehensive, three-dimensional recovery-oriented vision of health. Different perspectives are integrated to explore the interaction of homeless people with care networks.

Factors That Influence the Use of Electronic Diaries in Health Care: Scoping Review.

BACKGROUND: A large number of people suffer from psychosocial or physical problems. Adequate strategies to alleviate needs are scarce or lacking. Symptom variation can offer insights into personal profiles of coping and resilience (detailed functional analyses). Hence, diaries are used to report mood and behavior occurring in daily life. To reduce inaccuracies, biases, and noncompliance with paper diaries, a shift to electronic diaries has occurred. Although these diaries are increasingly used in health care, information is lacking about what determines their use. OBJECTIVE: The aim of this study was to map the existing empirical knowledge and gaps concerning factors that influence the use of electronic diaries, defined as repeated recording of psychosocial or physical data lasting at least one week using a smartphone or a computer, in health care. METHODS: A scoping review of the literature published between January 2000 and December 2018 was conducted using queries in PubMed and PsycInfo databases. English or Dutch publications based on empirical data about factors that influence the use of electronic diaries for psychosocial or physical purposes in health care were included. Both databases were screened, and findings were summarized using a directed content analysis organized by the Consolidated Framework for Implementation Research (CFIR). RESULTS: Out of 3170 articles, 22 studies were selected for qualitative synthesis. Eleven themes were determined in the CFIR categories of intervention, user characteristics, and process. No information was found for the CFIR categories inner (eg, organizational resources, innovation climate) and outer (eg, external policies and incentives, pressure from competitors) settings. Reminders, attractive designs, tailored and clear data visualizations (intervention), smartphone experience, and intrinsic motivation to change behavior (user characteristics) could influence the use of electronic diaries. During the implementation process, attention should be paid to both theoretical and practical training. CONCLUSIONS: Design aspects, user characteristics, and training and instructions determine the use of electronic diaries in health care. It is remarkable that there were no empirical data about factors related to embedding electronic diaries in daily clinical practice. More research is needed to better understand influencing factors for optimal electronic diary use.

Attachment as a framework to facilitate empowerment for people with severe mental illness.

OBJECTIVES: Recovery and empowerment have evolved into key objectives in the treatment and care of people with severe mental illness (SMI), and interest has grown in the role of social relationships in recovery. This study is the first to explore whether attachment styles are related to levels of empowerment, and secondly, whether attachment anxiety and attachment avoidance are associated with lower empowerment levels, independently of quality and frequency of social contact. DESIGN: We used a cross-sectional design. METHODS: In a sample of 157 participants with SMI in outpatient care, associations between attachment (Revised Adult Attachment Scale), self-reported social functioning, and empowerment (Netherlands Empowerment List) were assessed. RESULTS: Attachment anxiety and attachment avoidance were both associated with lower levels of empowerment. A stepwise multiple regression analysis showed that the prediction of empowerment was significantly improved by adding attachment anxiety and attachment avoidance to quality and frequency of social contact. Attachment anxiety, attachment avoidance, and quality of social contact were significant predictors; frequency of social contact was not. CONCLUSIONS: Although our design does not allow causal conclusions, our results highlight the importance of interpersonal processes and behaviours as routes to improving empowerment for people with SMI. A promising approach might thus consist of securing attachment bonds with significant others so that the self and the other are perceived as reliable resources. Our findings also feature the importance of reciprocity and equality in social relationships. Taken together, our study emphasizes the value of social, contextualized interventions in recovery work for people with SMI. PRACTITIONER POINTS: Working towards attachment safety in interpersonal relations may be important in recovery-oriented treatment and care for people with severe mental illness (SMI). Helping people with SMI to recognize and change how they tend to relate themselves to others may promote engagement and effectiveness of recovery-oriented treatment and care. Reciprocity and equality in social relationships as vital complements to the more one-sided nature of 'standing alongside' and offering support may be important requisites for empowerment.

Monitoring risk assessment on an acute psychiatric ward: Effects on aggression, seclusion and nurse behaviour.

Evidence of risk assessment procedures is scarce and inconclusive. The aim of this study is to evaluate the effects of risk assessment on aggression and the use of coercive interventions in an acute psychiatric admission setting. In addition, we evaluated nurse behaviour before and after the use of risk assessment. To take the fluctuations with regard to aggression and coercive interventions into account, we allowed 26 weeks for baseline measurements, followed by a 26 weeks steady-state period after the implementation of the risk assessment instrument. Contrary to expectations, no positive effects of risk assessment were found on aggression or on coercive interventions. Time spent in seclusion increased significantly with more than 10 hours on average after implementation. Furthermore, there were only negative effects on nurse behaviour and experiences. Among other things, they felt more stressed, spent more time on administration tasks and spent less time with patients after the implementation. In conclusion, there is insufficient evidence to use structured short-term risk assessment to reduce aggression or coercive interventions.

Psychometric Properties of the Korean Version of the PsyMate Scale Using a Smartphone App: Ecological Momentary Assessment Study.

BACKGROUND: Ecological momentary assessment (EMA) is a method for capturing the changes in the variables in daily life with increased accuracy and decreased recall bias. The PsyMate scale assesses momentary moods in daily life and can be used in various settings. OBJECTIVE: The aim of this study was to develop a Korean version of the PsyMate (K-PsyMate) scale and evaluate its psychometric properties by using the EMA method in patients with moyamoya disease (MMD) in South Korea. METHODS: Patients with MMD aged over 18 years were recruited from July 2018 to January 2019 at the inpatient and outpatient departments of a university hospital in South Korea. The K-PsyMate scale comprising 13 items was developed following a translation/back translation approach of the English version and loaded onto a mobile app. Participants were instructed to enter their moods 4 times a day for 7 consecutive days. Content validity index, factor analysis, and Pearson's correlation were performed for validity analysis. For reliability, intraclass correlation coefficients between the first and last measurements were estimated by mean rating, absolute agreement, and a 2-way mixed-effects model. Usability was analyzed through a descriptive analysis, 2-tailed t test, and analysis of variance, and the results were confirmed by Mann-Whitney U test and the Kruskal-Wallis test, as the dependent variable was not normally distributed. RESULTS: In total, 1929 assessments from 93 patients were analyzed. The mean age of the participants was 40.59 (SD 10.06) years, and 66 (71%) of the 93 participants were women. Content validity was excellent as content validity index was 0.99, and 2 factors, negative affect and positive affect, were derived by an exploratory factor analysis. The correlations between the subdomains of the K-PsyMate scale and Hospital Anxiety and Depression Scale were significant (P<.001). The agreement between the first and last measurements was poor to moderate according to the obtained intraclass correlation coefficient values. Usability was evaluated by 67 (72%) out of the 93 participants. The participants rated the accuracy of assessing their momentary moods on the app at 4.13 (SD 0.97), easiness in understanding questions, operating, and inputting answers at 4.12 (SD 0.88), and interruption by the survey alarms at 2.48 (SD 1.02) out of 5. CONCLUSIONS: The K-PsyMate scale has good validity but poor to moderate agreement, which reflects the characteristics of the EMA data collected in real and natural living environments without control. The findings of our study show that the K-PsyMate scale uploaded in a mobile app can be a valid and reliable tool for evaluating the momentary mood of patients with MMD because using a mobile app is convenient and patients are familiar with their own smartphones, which they use in their daily lives.

Measuring within-day cognitive performance using the experience sampling method: A pilot study in a healthy population.

INTRODUCTION: People with depression, anxiety, or psychosis often complain of confusion, problems concentrating or difficulties cognitively appraising contextual cues. The same applies to people with neurodegenerative diseases or brain damage such as dementia or stroke. Assessments of those cognitive difficulties often occurs in cross-sectional and controlled clinical settings. Information on daily moment-to-moment cognitive fluctuations and its relation to affect and context is lacking. The development and evaluation of a digital cognition task is presented. It enables the fine-grained mapping of cognition and its relation to mood, intrapersonal factors and context. METHODS: The momentary Digit Symbol Substitution Task is a modified digital version of the original paper-and-pencil task, with a duration of 30 seconds and implemented in an experience sampling protocol (8 semi-random assessments a day on 6 consecutive days). It was tested in the healthy population (N = 40). Descriptive statistics and multilevel regression analyses were used to determine initial feasibility and assess cognitive patterns in everyday life. Cognition outcome measures were the number of trials within the 30-second sessions and the percentage of correct trials. RESULTS: Subjects reported the task to be easy, pleasant and do-able. On average, participants completed 11 trials with 97% accuracy per 30-second session. Cognitive variation was related to mood, with an interaction between positive and negative affect for accuracy (% correct) (p = .001) and an association between positive affect and speed (number of trials) (p = .01). Specifically, cheerful, irritated and anxious seem to covary with cognition. Distraction and location are relevant contextual factors. The number of trials showed a learning effect (p < .001) and was sensitive to age (p < .001). CONCLUSION: Implementing a digital cognition task within an experience-sampling paradigm shows promise. Fine-tuning in further research and in clinical samples is needed. Gaining insight into cognitive functioning could help patients navigate and adjust the demands of daily life.

Identifying psychosis spectrum disorder from experience sampling data using machine learning approaches.

The ubiquity of smartphones opened up the possibility of widespread use of the Experience Sampling Method (ESM). The method is used to collect longitudinal data of participants' daily life experiences and is ideal to capture fluctuations in emotions (momentary mental states) as an indicator for later mental ill-health. In this study, ESM data of patients with psychosis spectrum disorder and controls were used to examine daily life emotions and higher order patterns thereof. We attempted to determine whether aggregated ESM data, in which statistical measures represent the distribution and dynamics of the original data, were able to distinguish patients from controls in a predictive modeling framework. Variable importance, recursive feature elimination, and ReliefF methods were used for feature selection. Model training, tuning, and testing were performed in nested cross-validation, based on algorithms such as Random Forests, Support Vector Machines, Gaussian Processes, Logistic Regression, and Neural Networks. ROC analysis was used to post-process these models. Stability of model performance was studied using Monte Carlo simulations. The results provide evidence that patterns in emotion changes can be captured by applying a combination of these techniques. Acceleration in the variables anxious and insecure was particularly successful in adding further predictive power to the models. The best results were achieved by Support Vector Machines with radial kernel (accuracy = 82% and sensitivity = 82%). This proof-of-concept work demonstrates that synergistic machine learning and statistical modeling may be used to harness the power of ESM data in the future.

Implementing Experience Sampling Technology for Functional Analysis in Family Medicine - A Design Thinking Approach.

BACKGROUND: A paradigm shift in health care from illness to wellbeing requires new assessment technologies and intervention strategies. Self-monitoring tools based on the Experience Sampling Method (ESM) might provide a solution. They enable patients to monitor both vulnerability and resilience in daily life. Although ESM solutions are extensively used in research, a translation from science into daily clinical practice is needed. OBJECTIVE: To investigate the redesign process of an existing platform for ESM data collection for detailed functional analysis and disease management used by psychological assistants to the general practitioner (PAGPs) in family medicine. METHODS: The experience-sampling platform was reconceptualized according to the design thinking framework in three phases. PAGPs were closely involved in co-creation sessions. In the 'understand' phase, knowledge about end-users' characteristics and current eHealth use was collected (nominal group technique - 2 sessions with N = 15). In the 'explore' phase, the key needs concerning the platform content and functionalities were evaluated and prioritized (empathy mapping - 1 session with N = 5, moderated user testing - 1 session with N = 4). In the 'materialize' phase, the adjusted version of the platform was tested in daily clinical practice (4 months with N = 4). The whole process was extensively logged, analyzed using content analysis, and discussed with an interprofessional project group. RESULTS: In the 'understand' phase, PAGPs emphasized the variability in symptoms reported by patients. Therefore, moment-to-moment assessment of mood and behavior in a daily life context could be valuable. In the 'explore' phase, (motivational) functionalities, technological performance and instructions turned out to be important user requirements and could be improved. In the 'materialize' phase, PAGPs encountered barriers to implement the experience-sampling platform. They were insufficiently facilitated by the regional primary care group and general practitioners. CONCLUSION: The redesign process in co-creation yielded meaningful insights into the needs, desires and daily routines in family medicine. Severe barriers were encountered related to the use and uptake of the experience-sampling platform in settings where health care professionals lack the time, knowledge and skills. Future research should focus on the applicability of this platform in family medicine and incorporate patient experiences.

Virtual-reality-based cognitive behavioural therapy versus waiting list control for paranoid ideation and social avoidance in patients with psychotic disorders: a single-blind randomised controlled trial.

BACKGROUND: Many patients with psychotic disorders have persistent paranoid ideation and avoid social situations because of suspiciousness and anxiety. We investigated the effects of virtual-reality-based cognitive behavioural therapy (VR-CBT) on paranoid thoughts and social participation. METHODS: In this randomised controlled trial at seven Dutch mental health centres, outpatients aged 18-65 years with a DSM-IV-diagnosed psychotic disorder and paranoid ideation in the past month were randomly assigned (1:1) via block randomisation to VR-CBT (in addition to treatment as usual) or the waiting list control group (treatment as usual). VR-CBT consisted of 16 individual therapy sessions (each 1 h long). Assessments were done at baseline, after treatment (ie, 3 months from baseline), and at a 6 month follow-up visit. The primary outcome was social participation, which we operationalised as the amount of time spent with other people, momentary paranoia, perceived social threat, and momentary anxiety. Analysis was by intention to treat. This trial was retrospectively registered with ISRCTN, number 12929657. FINDINGS: Between April 1, 2014, and Dec 31, 2015, 116 patients with a psychotic disorder were randomly assigned, 58 to the VR-CBT group and 58 to the waiting list control group. Compared with the control, VR-CBT did not significantly increase the amount of time spent with other people at the post-treatment assessment. Momentary paranoid ideation (b=-0·331 [95% CI -0·432 to -0·230], p<0·0001; effect size -1·49) and momentary anxiety (-0·288 [-0·438 to -0·1394]; p=0·0002; -0·75) were significantly reduced in the VR-CBT group compared with the control group at the post-treatment assessment, and these improvements were maintained at the follow-up assessment. Safety behaviour and social cognition problems were mediators of change in paranoid ideation. No adverse events were reported relating to the therapy or assessments. INTERPRETATION: Our results suggest that the addition of VR-CBT to standard treatment can reduce paranoid ideation and momentary anxiety in patients with a psychotic disorder. FUNDING: Fonds NutsOhra, Stichting tot Steun VCVGZ.

Constructing a Reward-Related Quality of Life Statistic in Daily Life-a Proof of Concept Study Using Positive Affect.

Background: Mental healthcare needs person-tailored interventions. Experience Sampling Method (ESM) can provide daily life monitoring of personal experiences. This study aims to operationalize and test a measure of momentary reward-related Quality of Life (rQoL). Intuitively, quality of life improves by spending more time on rewarding experiences. ESM clinical interventions can use this information to coach patients to find a realistic, optimal balance of positive experiences (maximize reward) in daily life. rQoL combines the frequency of engaging in a relevant context (a 'behavior setting') with concurrent (positive) affect. High rQoL occurs when the most frequent behavior settings are combined with positive affect or infrequent behavior settings co-occur with low positive affect. Methods: Resampling procedures (Monte Carlo experiments) were applied to assess the reliability of rQoL using various behavior setting definitions under different sampling circumstances, for real or virtual subjects with low-, average- and high contextual variability. Furthermore, resampling was used to assess whether rQoL is a distinct concept from positive affect. Virtual ESM beep datasets were extracted from 1,058 valid ESM observations for virtual and real subjects. Results: Behavior settings defined by Who-What contextual information were most informative. Simulations of at least 100 ESM observations are needed for reliable assessment. Virtual ESM beep datasets of a real subject can be defined by Who-What-Where behavior setting combinations. Large sample sizes are necessary for reliable rQoL assessments, except for subjects with low contextual variability. rQoL is distinct from positive affect. Conclusion: rQoL is a feasible concept. Monte Carlo experiments should be used to assess the reliable implementation of an ESM statistic. Future research in ESM should asses the behavior of summary statistics under different sampling situations. This exploration is especially relevant in clinical implementation, where often only small datasets are available.

Demonstrating the reliability of transdiagnostic mHealth Routine Outcome Monitoring in mental health services using experience sampling technology.

BACKGROUND: Routine Outcome Monitoring (ROM) should provide a dynamic, within-treatment forward feedback loop to guide individual treatment decisions across diagnostic categories. It has been suggested that the Experience Sampling Method (ESM), capturing the film of daily life adaptive processes, offers a flexible, personalised and transdiagnostic feedback system for monitoring and adapting treatment strategies. This is the first study that uses an ESM application (the PsyMate™) as a routine mobile-ROM (mROM) tool in an ambulatory mental health setting. OBJECTIVE: To demonstrate adequate psychometric properties of the PsyMate™ app assessing both symptom severity levels as well as daily life functioning. METHOD: In a transdiagnostic sample of 64 outpatients, an mROM protocol (ESM for 6 days, at 10 semi-random moments a day) and a standard ROM instrument (HADS) were administered at baseline and at three-month follow-up. We measured positive affect (PA), negative affect (NA), quality of sleep, positive social interaction, activity-related stress, tiredness, and feeling unwell. RESULTS: Subjects completed 53% of the measurements at baseline (N = 64) and 48% at follow-up (N = 29). Factor analysis and subsequent reliability analysis of PA and NA confirmed the two constructs. Significant and meaningful correlations were found between PA, NA and HADS scores (ranging from r = .4 to r = .7). Multilevel analyses yielded significant change scores for all measures. CONCLUSION: The ESM-based, transdiagnostic mROM tool can be used reliably in clinical settings: it shows adequate psychometric properties, as well as concurrent validity and sensitivity to change over time with respect to relevant ROM constructs. Person-tailored items can be added. In addition, mROM offers added value over standard symptom-based ROM, as it provides information on adaptive functioning in the daily environment of patients.

Assertive community treatment and associations with delinquency.

This article draws on a prospective longitudinal study in which Assertive Community Treatment (ACT) model fidelity and patient outcomes were assessed in twenty outpatient treatment teams. 530 severely mentally ill patients participated in the study. Delinquency outcomes were assessed three times during a two-year follow-up period. At baseline, 49% of the patients had a recent criminal history, meaning that they had at least one reported contact with the police and/or the justice system in the past year. Patients with a recent criminal history had more serious psychosocial problems at baseline compared to those without a recent criminal history. Delinquency outcomes showed improvement over time, but this was not associated with ACT model fidelity. The study shows an association for homelessness and criminal activity. The persistent criminal activities of some of the patients showed that for this group extra interventions are needed that specifically target reduction of criminal behavior.

Use of the experience sampling method in the context of clinical trials.

OBJECTIVE: The experience sampling method (ESM) is a structured diary technique to appraise subjective experiences in daily life. It is applied in psychiatric patients, as well as in patients with somatic illness. Despite the potential of ESM assessment, the improved logistics and its increased administration in research, its use in clinical trials remains limited. This paper introduces ESM for clinical trials in psychiatry and beyond. METHODS: ESM is an ecologically valid method that yields a comprehensive view of an individual's daily life. It allows the assessment of various constructs (eg, quality of life, psychopathology) and psychological mechanisms (eg, stress-sensitivity, coping). These constructs are difficult to assess using cross-sectional questionnaires. ESM can be applied in treatment monitoring, as an ecological momentary intervention, in clinical trials, or in single case clinical trials. Technological advances (eg, smartphone applications) make its implementation easier. RESULTS: Advantages of ESM are highlighted and disadvantages are discussed. Furthermore, the ecological nature of ESM data and its consequences are explored, including the potential pitfalls of ambiguously formulated research questions and the specificities of ESM in statistical analyses. The last section focuses on ESM in relation to clinical trials and discusses its future use in optimising clinical decision-making. CONCLUSIONS: ESM can be a valuable asset in clinical trial research and should be used more often to study the benefits of treatment in psychiatry and somatic health.

Routine outcome measurement in the Netherlands - A focus on benchmarking.

Routine outcome measurement (ROM) is a 'hot' topic in the Netherlands. Over recent years the Netherlands have developed a centralized monitoring system for all reimbursed mental health interventions, in an attempt to improve the quality of care. The Foundation for Benchmarking Mental Health (SBG) is an independent knowledge centre for mental health providers and insurance companies. It was founded to organize and manage the countrywide ROM initiative. A Dutch countrywide ROM initiative is appealing, and the procedures in the Netherlands are described. However, the national ROM system was oversold. Arguments are discussed. It would have been a far better strategy if insurance companies and authorities had not focused on a national system but stimulated local data collection and requested a managerial plan-do-check-act (PDCA) cycle to stimulate service improvements from year to year. Within the same service, chances are higher that the same kind of clientele is served from year to year and therefore it will be easier to interpret the data. The ROM should regain its clinical focus. Mobile ROM systems using smartphones that collect sampled experiences could be an interesting future solution.

Measuring health-related quality of life by experiences: the experience sampling method.

OBJECTIVE: To explore the potential value of obtaining momentary, instead of retrospective, accounts of the description and valuation of a person's own health-related quality of life (HRQOL). METHODS: Momentary HRQOL was examined with the experience sampling method (ESM) in 139 participants from four different samples. The ESM consists of a so-called beep questionnaire that was administered 10 times a day by an electronic device. Feasibility was determined by assessing willingness to participate in the study and by analyzing the percentage of dropouts and the number of completed beep questionnaires. Multilevel analysis was used to investigate the relation between momentary HRQOL and momentary feelings and symptoms. The relation between momentary outcomes and the EuroQol visual analogue scale was investigated with a multiple regression model. RESULTS: The overall participation rate was low, but there were no dropouts and the number of completed beeps was comparable to that in other studies. Multilevel analysis showed that feelings and symptoms were significant predictors of momentary HRQOL. The strength of these relations differed among three patient groups and a population-based sample. The EuroQol visual analogue scale was not predicted by momentary feelings and symptoms. CONCLUSIONS: We can conclude that the use of the ESM to measure accounts of the momentary experience of health in different populations is feasible. Retrospective measures may provide a biased account of the impact of health problems in the daily lives of people who are affected. Moreover, the bias may be different in different conditions.

Assertive community treatment and associations with substance abuse problems.

This study examined the associations between substance abuse problems in severely mentally ill patients, outcome and Assertive Community Treatment (ACT) model fidelity. In a prospective longitudinal study, ACT model fidelity and patient outcomes were assessed in 20 outpatient treatment teams using the Health of the Nation Outcome Scales, Camberwell Assessment of Needs short appraisal schedule and measures of service use. Five hundred and thirty severely mentally ill patients participated in the study. Substance abuse problems were assessed three times during a 2-year follow-up period. This study found that among patients with severe mental illness, patients with an addiction problem had more serious psychosocial problems at baseline. Substance abuse problems showed improvement over time, but this was not associated with ACT model fidelity. The study indicates that investment by teams to improve a patient's psychosocial situation can lead to improvements on substance problems.

Depression, subthreshold depression and comorbid anxiety symptoms in older Europeans: results from the EURODEP concerted action.

BACKGROUND: In the epidemiology of late life depression, few insights are available on the co-occurrence of subthreshold depression and comorbid symptoms of anxiety. The current study aims to describe prevalence patterns of comorbid anxiety symptoms across different levels of depression in old age, and to describe the burden of depressive symptoms and functional disability across patterns of comorbidity. METHODS: Respondents were older adults in the community, age 65-104 (N=14,200), from seven European countries, with in total nine study centres, collaborating in the EURODEP concerted action. Depression and anxiety were assessed using the Geriatric Mental State examination (GMS-AGECAT package), providing subthreshold level and case-level diagnoses. Presence of anxiety symptoms was defined as at least three distinct symptoms of anxiety. Number of depressive symptoms was assessed with the EURO-D scale. RESULTS: The prevalence of anxiety symptoms amounts to 32% for respondents without depression, 67% for those with subthreshold depression, and 87% for those with case-level depression. The number of depressive symptoms is similar for those with subthreshold-level depression with comorbid anxiety, compared to case-level depression without symptoms of anxiety. In turn, at case level, comorbid symptoms of anxiety are associated with higher levels of depressive symptoms and more functional disability. LIMITATIONS: GMS-AGECAT is insufficiently equipped with diagnostic procedures to identify specific types of anxiety disorders. CONCLUSIONS: Anxiety symptoms in late life depression are highly prevalent, and are likely to contribute to the burden of symptoms of the depression, even at subthreshold level.

Consumer-providers in assertive community treatment programs: associations with client outcomes.

OBJECTIVE: This study examined whether employing mental health consumers as consumer-providers in assertive community treatment teams can enhance outcomes for clients with severe mental illness. METHODS: In a prospective longitudinal study, presence of consumer-providers and outcomes of 530 clients with severe mental illness in 20 outpatient teams were assessed at baseline and at one-year and two-year follow-ups. Measures included the Health of the Nation Outcome Scales (HoNOS), the Camberwell Assessment of Need Short Assessment Schedule (CANSAS), the Working Alliance Scale, the number of hospital days, and the number of days of homelessness. Multilevel regression was used with the independent variables consumer-provider presence, time of measurement, and their interaction. RESULTS: A positive association was found between consumer-provider presence and improvements in functioning on the HoNOS (p = .020), met needs in relation to personal recovery (p=.044), unmet needs in relation to personal recovery (p = .008), and number of homeless days (p<.001). A negative association was found for consumer-provider presence and the number of hospital days (p = .019). CONCLUSIONS: Consumer-providers are important participants in outpatient teams serving clients with severe mental illnesses, although integrating these providers as part of a team is a slow process.