Benchmarking Mental Health Status Using Passive Sensor Data: Protocol for a Prospective Observational Study.

BACKGROUND: Computational psychiatry has the potential to advance the diagnosis, mechanistic understanding, and treatment of mental health conditions. Promising results from clinical samples have led to calls to extend these methods to mental health risk assessment in the general public; however, data typically used with clinical samples are neither available nor scalable for research in the general population. Digital phenotyping addresses this by capitalizing on the multimodal and widely available data created by sensors embedded in personal digital devices (eg, smartphones) and is a promising approach to extending computational psychiatry methods to improve mental health risk assessment in the general population. OBJECTIVE: Building on recommendations from existing computational psychiatry and digital phenotyping work, we aim to create the first computational psychiatry data set that is tailored to studying mental health risk in the general population; includes multimodal, sensor-based behavioral features; and is designed to be widely shared across academia, industry, and government using gold standard methods for privacy, confidentiality, and data integrity. METHODS: We are using a stratified, random sampling design with 2 crossed factors (difficulties with emotion regulation and perceived life stress) to recruit a sample of 400 community-dwelling adults balanced across high- and low-risk for episodic mental health conditions. Participants first complete self-report questionnaires assessing current and lifetime psychiatric and medical diagnoses and treatment, and current psychosocial functioning. Participants then complete a 7-day in situ data collection phase that includes providing daily audio recordings, passive sensor data collected from smartphones, self-reports of daily mood and significant events, and a verbal description of the significant daily events during a nightly phone call. Participants complete the same baseline questionnaires 6 and 12 months after this phase. Self-report questionnaires will be scored using standard methods. Raw audio and passive sensor data will be processed to create a suite of daily summary features (eg, time spent at home). RESULTS: Data collection began in June 2022 and is expected to conclude by July 2024. To date, 310 participants have consented to the study; 149 have completed the baseline questionnaire and 7-day intensive data collection phase; and 61 and 31 have completed the 6- and 12-month follow-up questionnaires, respectively. Once completed, the proposed data set will be made available to academic researchers, industry, and the government using a stepped approach to maximize data privacy. CONCLUSIONS: This data set is designed as a complementary approach to current computational psychiatry and digital phenotyping research, with the goal of advancing mental health risk assessment within the general population. This data set aims to support the field's move away from siloed research laboratories collecting proprietary data and toward interdisciplinary collaborations that incorporate clinical, technical, and quantitative expertise at all stages of the research process. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID): DERR1-10.2196/53857.

The impact of trauma-focused psychotherapy for posttraumatic stress disorder on interpersonal functioning: A systematic review and meta-analysis of randomized clinical trials.

Interpersonal functioning is a common concern for people with postttraumatic stress disorder (PTSD) but is not a key target of most trauma-focused psychotherapies (TFPs). We preregistered and undertook a systematic review and meta-analysis of randomized clinical trials (RCTs) examining the efficacy of TFPs for improving interpersonal functioning. Studies were identified through the PTSD Trials Standardized Data Repository, scholarly databases, and the solicitation of unpublished data from the PTSD research community following current PRISMA guidelines. We used random effects meta-analysis to estimate within-group change (i.e., pre- to posttreatment) in interpersonal functioning. Meta-analytic findings yielded a medium total effect of TFP on interpersonal functioning, g = 0.54, 95% CI [0.37, 0.72], with high between-study heterogeneity. Sensitivity analyses yielded substantively equivalent point estimates when outliers were excluded, g = 0.55, and when only the most well-established individual TFPs were included, g = 0.57. In contrast, allocation to a control condition was associated with little average change in interpersonal functioning, g = 0.04 [-0.12, 0.21]. Formal tests did not yield clear evidence of publication bias. Bias-corrected estimates varied but centered around a medium effect, gs = 0.41-1.11. There was a medium-to-large association between change in interpersonal functioning and change in PTSD symptoms, rs = -.35--.44. The extant literature on TFPs and interpersonal functioning is small and heterogeneous, indicating the need for more focused attention on this outcome. Results suggest that, on average, TFPs are moderately efficacious for improving interpersonal functioning; however, additional treatment may be needed to meet the desired level of improvement.

Impact of Treatment Setting and Format on Symptom Severity Following Cognitive Processing Therapy for Posttraumatic Stress Disorder.

Preliminary data suggest cognitive processing therapy (CPT) significantly reduces posttraumatic stress disorder (PTSD) symptom severity among military personnel and veterans when delivered over 12 days and combined with daily recreational activities (Bryan et al., 2018). The present study aimed to examine how therapy pace (i.e., daily vs. weekly sessions) and setting (i.e., clinic vs. recreational) impacts change in PTSD symptom severity. Forty-five military personnel and veterans diagnosed with PTSD chose to receive CPT (a) daily at a recreational facility with recreational programming, (b) daily on a university campus without recreational programming, and (c) weekly on a university campus without recreational programming. PTSD symptom severity was assessed with the Clinician Administered PTSD Scale for DSM-5 (CAPS-5) and the Posttraumatic Stress Disorder Checklist for DSM-5 (PCL-5). Reductions in CAPS-5 and PCL-5 scores were large and statistically significant across all three settings (Cohen's ds > 2.1). As compared to reductions in CAPS-5 and PCL-5 scores in daily therapy at a recreational facility (CAPS-5: d = 1.63-2.40; PCL-5: d = 1.99-2.17), reductions in CAPS-5 and PCL-5 scores were significantly larger in daily therapy on campus, CAPS-5: t(80) = -2.9, p = .005, d = 2.23-2.69; PCL-5: t(78) = 2.6, p = .010, d = 2.54-4.43, but not weekly therapy on campus, CAPS-5: t(80) = 0.2, p = .883, d = 1.04-2.47; PCL-5: t(78) = 1.0, p = .310, d = 1.77-3.44. Participants receiving daily therapy on campus and weekly therapy on campus also had higher rates of clinically significant improvement and good end-state functioning. Results support the effectiveness of CPT across multiple treatment settings and formats and suggest that daily CPT may be less effective when delivered in combination with recreational activities.

Utilizing the couple relationship to prevent suicide: A preliminary examination of Treatment for Relationships and Safety Together.

OBJECTIVE: To evaluate the feasibility, preliminary effects, and acceptability of the first comprehensive couple-based treatment for suicide, called Treatment for Relationships and Safety Together (TR&ST). METHOD: In a preliminary examination, five couples (N = 10) participated in 10 weekly sessions of TR&ST. All couples included a veteran who reported active suicidal ideation at baseline and their partner. Couples completed measures of relationship functioning, perceived burdensomeness, thwarted belonging, and suicidal ideation at baseline, mid-treatment, and posttreatment. RESULTS: TR&ST was feasible to deliver. Veteran and partner relationship functioning improved and veteran perceived burdensomeness, thwarted belonging, and suicidal ideation decreased. There were no suicide related behaviors, hospitalizations, or crisis line calls during the study. TR&ST seemed acceptable to couples (100% retention and high satisfaction ratings). CONCLUSION: Couple-based suicide prevention may provide an additional avenue for suicide prevention in veterans.

The effect of time outdoors on veterans receiving treatment for PTSD.

OBJECTIVES: Duration, frequency, and intensity of nature exposure link to different physical and psychological benefits. The present study aimed to determine how time outdoors affected military veterans' posttraumatic stress disorder (PTSD) symptomology during PTSD treatment. METHOD: Hypotheses regarding time outdoors and the effect of program duration on PTSD symptoms were examined using multilevel models. The authors hypothesized that hours outdoors, both within- and between-persons, would predict reduced PTSD symptomology, program duration would predict reduced PTSD symptomology, and that hours outdoors and program duration would be significant when accounting for the other. RESULTS: The present study found that time outdoors correlated with participants' decreased PTSD symptomology: the more time participants spent outdoors, the greater the reduction in their PTSD symptoms. CONCLUSION: The effect of time outdoors was significant within-person, not between persons, suggesting that nature exposure may be used as an adjunct to traditional mental health treatment where exposure or dosage should be person-specific.

Suicide as an interpersonal phenomenon: Dyadic methodological and statistical considerations in suicide research.

Interpersonal risk and resilience factors are prominent in current conceptual models of suicide. A growing body of empirical evidence links suicidal thoughts and behaviors to a range of interpersonal phenomenon adding further support to the value of this line of inquiry. At present, research on interpersonal phenomenon focuses on assessing individuals' perceptions of interpersonal phenomenon, such as appraisals of burdensomeness, experienced loneliness, and thwarted belongingness. As this line of research continues to develop, we argue that it would be valuable to consider incorporating conceptual models of interpersonal phenomenon and corresponding methodological approaches from closely allied fields. After providing a brief overview of interpersonal models of suicide, we present an introduction to conceptual models of interpersonal phenomenon developed in relationship science, describe how these models can be applied to the study of interpersonal phenomenon in suicide research, and close with a guided tutorial on data collection and statistical analysis methods for testing hypotheses derived from these conceptual approaches. References for additional reading are provided, and the Appendix S1 provides simulated data sets and statistical code for the analyses in the tutorial section.

Using Machine Learning to Predict Suicide Attempts in Military Personnel.

Identifying predictors of suicide attempts is critical in intervention and prevention efforts, yet finding predictors has proven difficult due to the low base rate and underpowered statistical approaches. The objective of the current study was to use machine learning to examine predictors of suicidal behaviors among high-risk suicidal Soldiers who received outpatient mental health services in a randomized controlled trial of Brief Cognitive Behavioral Therapy for Suicide Prevention (BCBT) compared to treatment as usual (TAU). Self-report measures of clinical and demographic variables, administered prior to the start of outpatient treatment to 152 participants with recent suicidal thoughts and/or behaviors were analyzed using machine learning software to identify the best combination of variables for predicting suicide attempts during or after treatment. Worst-point suicidal ideation, history of multiple suicide attempts, treatment group (i.e., BCBT or TAU), suicidogenic cognitions, and male sex were found, in combination, correctly classified 30.8% of patients who attempted suicide during the two-year follow-up period. This combination has higher sensitivity than many models that have previously been used to predict suicidal behavior. Overall, this study provides a combination of variables that can be assessed clinical to help identify high-risk suicidal individuals.

The impact of negative attributions on the link between observed partner social support and posttraumatic stress disorder symptom severity.

Lack of perceived social support is one of the strongest correlates of the development and maintenance of posttraumatic stress disorder (PTSD). However, little is known about observed social support and PTSD. The stress buffering effect of social support may be partly determined by the subjective experience of support, which is created by attributions regarding support behaviors. We examined negative attributions about partner-provided support as a moderator of the expected relation between observed support during couple discussions and PTSD symptom severity. Participants included 128 individuals from 64 heterosexual married or cohabitating couples. Per clinician-administered interview, 72 (56%) participants met subthreshold or diagnostic criteria for PTSD. Receipt of relatively more partner support was modestly associated with lower PTSD symptom severity. Negative causal attributions about partner support were not associated with the amount of support received, but were associated with higher PTSD severity. Additionally, the frequency and quality of received partner support was associated with lower PTSD symptom severity only among those who did not make strong negative causal attributions about partner support. Thus, negative causal attributions may dampen the positive effects of social support on PTSD symptoms. PTSD treatments may more effectively facilitate recovery from trauma by decreasing negative support attributions.

Examining the effectiveness of an intensive, 2-week treatment program for military personnel and veterans with PTSD: Results of a pilot, open-label, prospective cohort trial.

OBJECTIVE: This study aimed to examine the effectiveness of cognitive processing therapy (CPT) for posttraumatic stress disorder (PTSD) when administered on a daily basis during a 2-week period of time. METHOD: In an open-label, prospective cohort pilot trial, 20 U.S. military personnel and veterans diagnosed with PTSD or subthreshold PTSD participated in 12 daily sessions of CPT. Primary outcomes included Clinician Administered PTSD Scale for DSM-5 and PTSD Checklist for DSM-5 scores. Secondary outcomes included Patient Health Questionnaire-8 and Beck Scale for Suicide Ideation (BSSI) scores. Interviews and self-report scales were completed at pretreatment, posttreatment, and 6 months after the treatment. RESULTS: Relative to baseline, PTSD symptom severity and rates of PTSD diagnosis were significantly reduced at posttreatment and 6-month follow-up. Depression symptom severity did not significantly improve, but suicide ideation significantly decreased at 6-month follow-up. CONCLUSIONS: Daily administration of CPT is associated with significant reductions in PTSD and suicide ideation.

Observed Emotional Expressivity, Posttraumatic Stress Disorder Symptoms, and Intimate Partner Violence Perpetration Among Community Couples.

Impaired emotional processes are related to posttraumatic stress disorder (PTSD) and are implicated in intimate partner violence (IPV) perpetration. To address the interpersonal context of PTSD, emotion, and IPV, we examined interactions among one's own and one's partner's emotional expressivity and PTSD symptom severity in association with IPV perpetration. Heterosexual couples (N = 56) in which at least one partner met screening criteria for PTSD engaged in two video-recorded discussions about negative and positive aspects of their relationships. Videos were coded for observed emotional expressiveness during moments participants reported experiencing significant emotions. Actor-partner interdependence models revealed few main effects of emotional expressivity, except that women's expressivity of positive emotions was positively associated with men's IPV perpetration, r2adj = .14. Emotional expressivity played a larger role among couples managing PTSD symptoms; that is, the association between one's own PTSD symptom severity and more IPV perpetration was stronger among men who expressed more negative emotions, r2adj = .19, and women who expressed fewer negative emotions, r2adj = .21. Several partner effects suggested the importance of understanding the dyadic nature of these constructs. For example, men's PTSD symptom severity was differentially associated with each partners' IPV perpetration based on women's expressivity of positive emotion, r2adj = .22-.27. Understanding of emotional expressivity in the link between PTSD and IPV must include consideration of gender differences in how these constructs operate interpersonally. Strategies to promote moderate and safe communication of positive and negative emotions may prevent IPV escalation, particularly among couples managing PTSD symptoms.

Moral injury, posttraumatic stress disorder, and suicidal behavior among National Guard personnel.

OBJECTIVE: To empirically examine similarities and differences in the signs and symptoms of posttraumatic stress disorder (PTSD) and moral injury and to determine if the combination of these 2 constructs is associated with increased risk for suicidal thoughts and behaviors in a sample of U.S. National Guard personnel. METHOD: 930 National Guard personnel from the states of Utah and Idaho completed an anonymous online survey. Exploratory structural equation modeling (ESEM) was used to test a measurement model of PTSD and moral injury. A structural model was next constructed to test the interactive effects of PTSD and moral injury on history of suicide ideation and attempts. RESULTS: Results of the ESEM confirmed that PTSD and moral injury were distinct constructs characterized by unique symptoms, although depressed mood loaded onto both PTSD and moral injury. The interaction of PTSD and moral injury was associated with significantly increased risk for suicide ideation and attempts. A sensitivity analysis indicated the interaction remained a statistically significant predictor of suicide attempt even among the subgroup of participants with a history of suicide ideation. CONCLUSION: PTSD and moral injury represent separate constructs with unique signs and symptoms. The combination of PTSD and moral injury confers increased risk for suicidal thoughts and behaviors, and differentiates between military personnel who have attempted suicide and those who have only thought about suicide. (PsycINFO Database Record

Posttraumatic stress disorder symptoms impact the emotional experience of intimacy during couple discussions.

We examined the impact of PTSD symptom severity on emotional reactions to one's own and one's partner's intimacy behaviors. Heterosexual, community couples in which at least one partner reported elevated symptoms of PTSD were video-recorded discussing a relationship problem and self-reported their emotions immediately before and after the discussion. Each partner's intimacy behaviors were coded. Actor-Partner Interdependence Models indicate that, among those with greater PTSD symptom severity, partners' caring, understanding, and validation were associated with increased negative emotions, particularly fear. Among those with greater PTSD severity, provision of caring was associated with decreased anger, guilt, and sadness. Therefore, the receipt of intimacy was associated with increased negative emotions among individuals with elevated PTSD symptoms while provision of intimacy was associated with decreased negative emotions. Existing treatments for PTSD should consider the emotional context of provision and receipt of intimacy to more fully address relationship problems among couples dealing with PTSD.

The differential diagnostic accuracy of the PTSD Checklist among men versus women in a community sample.

We evaluated the specific version of the PTSD Checklist (PCL-S) as a screening tool for the recruitment of community-residing men and women with diverse trauma experiences. We administered the PCL-S via telephone in the context of participant recruitment, as well as in a laboratory setting preceding administration of the Clinician Administered PTSD Scale (CAPS), the gold standard PTSD assessment tool. In the laboratory, the PCL-S performed reasonably well for men and women, yielding overall diagnostic efficiency (ODE) values (representing percentage of cases accurately identified) of 0.78 and 0.73, respectively, for our recommended cut-points of 42 for men and 49 for women. In contrast, as a recruitment tool, the PCL-S yielded an acceptable ODE of 0.79 for men at the recommended cut-point of 47, but only an ODE of 0.56 (representing diagnostic efficiency no greater than chance) for women at the recommended cut-point of 50. A recruitment cut-point of 57 for women yields a similarly modest ODE of 0.61, but with substantial cost to sensitivity. These findings suggest that use of the PCL-S to screen for PTSD among potential study participants may lead to gender biased study results, even when separate diagnostic cut-points for men and women are used.

Gender differences in the impact of posttraumatic stress disorder symptoms on community couples' intimacy behaviors.

Problems in intimate relationships frequently occur among individuals with posttraumatic stress disorder (PTSD). This study includes examination of whether deficits in the intimacy process occur among couples affected by PTSD, and whether gender differences exist in the association between PTSD symptom severity and intimate behaviors. Heterosexual community couples in which at least 1 partner was experiencing elevated symptoms of PTSD were video-recorded while discussing positive and negative aspects of their relationship. Each partner's intimacy behaviors (i.e., self-disclosure and support provision) were coded. Results of an actor-partner interdependence model indicate that husbands, but not wives, with greater PTSD symptom severity provided less support (i.e., expressions of understanding, validation, and caring) to their partners during discussions of negative aspects of their relationship. This finding supports prior literature while increasing generalizability beyond samples of male combat veterans and addressing a possible confound of prior research that has exclusively relied on self-reported intimacy. In addition, wives' PTSD symptom severity was associated with husbands engaging in more self-disclosure when discussing negative aspects of their relationship, which may have represented husbands' expression of more negative thoughts and feelings in this context. Overall, women appeared to be resilient against the potential negative impact of PTSD symptoms on their ability to continue providing intimacy behaviors to their partners.

Validating measures of real-world outcome: the results of the VALERO expert survey and RAND panel.

BACKGROUND: People with schizophrenia demonstrate considerable discrepancy between self-reported functioning and informant reports. It is not clear whether these discrepancies originate from the instruments used or from the perspectives of different informants. The goal of the Validation of Everyday Real-World Outcomes (VALERO) Study is to enhance the measurement of real-world (RW) outcomes in the social, residential, and vocational domains through selection of optimal scales and informants using a multistep process similar to the Measurement and Treatment Research to Improve Cognition in Schizophrenia (MATRICS) initiative. METHODS: Forty-eight experts provided their opinion regarding the best scales measuring RW outcomes. Fifty-nine measures were nominated. The investigators selected the 11 scales that were the most highly nominated, had the most published validity data, and best represented the domains of interest. Information was provided to other experts who served as RAND panelists. Panelists rated each measure for its suitability across multiple a priori domains. Discrepant ratings were discussed until consensus was reached. RESULTS: Following the RAND Panel, the 2 scales that scored highest across the various criteria for each of the classes of scales (hybrid, social functioning, and everyday living skills) were selected for use in the first substudy of VALERO. The scales selected were the Quality-of-Life Scale, Specific Levels of Functioning Scale, Social Behavior Schedule, Social Functioning Scale, Independent Living Skills Schedule, and Life Skills Profile. DISCUSSION: The results show that although there are significant limitations with current scales used for the assessment of RW outcome in schizophrenia, a consensus is possible. Further, several existing instruments were rated as useful for measuring social, residential, and vocational outcomes.

Psychometric properties of performance-based measurements of functional capacity: test-retest reliability, practice effects, and potential sensitivity to change.

Performance-based measures of the ability to perform social and everyday living skills are being more widely used to assess functional capacity in people with serious mental illnesses such as schizophrenia and bipolar disorder. Since they are also being used as outcome measures in pharmacological and cognitive remediation studies aimed at cognitive impairments in schizophrenia, understanding their measurement properties and potential sensitivity to change is important. In this study, the test-retest reliability, practice effects, and reliable change indices of two different performance-based functional capacity measures, the UCSD Performance-Based Skills Assessment (UPSA) and Social Skills Performance Assessment (SSPA) were examined over several different retest intervals in two different samples of people with schizophrenia (n's=238 and 116) and a healthy comparison sample (n=109). These psychometric properties were compared to those of a neuropsychological assessment battery. Test-retest reliabilities of the long form of the UPSA ranged from r=63 to r=80 over follow-up periods up to 36 months in people with schizophrenia, while brief UPSA reliabilities ranged from r=66 to r=81. Test-retest reliability of the NP performance scores ranged from r=77 to r=79. Test-retest reliabilities of the UPSA were lower in healthy controls, while NP performance was slightly more reliable. SSPA test-retest reliability was lower. Practice effect sizes ranged from .05 to .16 for the UPSA and .07 to .19 for the NP assessment in patients, with HC having more practice effects. Reliable change intervals were consistent across NP and both FC measures, indicating equal potential for detection of change. These performance-based measures of functional capacity appear to have similar potential to be sensitive to change compared to NP performance in people with schizophrenia.

Determinants of everyday outcomes in schizophrenia: the influences of cognitive impairment, functional capacity, and symptoms.

Deficits in everyday living skills and social skills are associated with the pervasive disability seen in schizophrenia. Cognitive impairments are determinants of these skills deficits and it is known that positive and negative symptoms add to the influence of cognitive impairments for prediction of real-world outcomes. This study examined the relative importance of cognitive impairments measured with a neuropsychological battery, performance-based measures of social and everyday living skills, and positive and negative symptoms for the prediction of real-world outcomes in social and residential domains. In contrast to most previous studies, we examined the importance of individual symptoms, as well as total subscale scores, for predicting clinician rated outcomes in 194 older outpatients with schizophrenia. Symptoms were rated with the Positive and Negative Syndrome Scale; everyday living skills were measured by the UCSD Performance-based Skills Assessment; and social skills were measured with the Social Skills Performance Assessment. For prediction of real-world social outcomes, blunted affect and passive-apathetic social withdrawal accounted for all of the predicted variance, while social competence and cognitive impairments did not enter the final equation. For residential functioning, everyday living skills were the most important predictor, followed by lack of spontaneity. The positive symptoms of hallucinatory behavior and suspiciousness also predicted real-world residential outcomes. These results suggest that real-world disability is the product of a complex array of ability deficits and symptoms, indicating interventions will need to be carefully targeted. For social and everyday living outcomes, variance accounted for by the entire array of predictive variables was less than 40%, suggesting that other factors, such as social and cultural influences, are involved as well.