November 2023: A therapist in your pocket?

Shiffman S et al, Ecological Momentary Assessment: A Seminal review paper introducing the method, Annual Review of Clinical Psychology, Volume 4, 2008

“The idea of momentary treatment, delivering an intervention immediately on-the-spot and as needed in real-world settings—a “therapist in your pocket”—holds promise for addressing behavior at crucial moments in the patient’s life.”

Key Takeaways: 

• Ecological Momentary Assessment (EMA) allows for the repeated sampling of an individual's behavior or experiences over time or at strategically selected intervals in their natural environment. It provides many advantages over global retrospective self-reporting methods that clinical psychology commonly relies upon.
• EMA overcomes systematic bias in recalled data, recognizes the real-world context of behaviors, and allows for repeated assessments at varying frequencies.
• EMA uses technologies like smartphones as well as electronic diaries to collect data in real-time. 
• EMA modalities also create opportunities for intervention. A study by Newman et al. (1997) reported that a brief EMA intervention for panic disorder was equivalent in efficacy to longer therapist-administered treatment, showcasing the potential of EMA in revolutionizing clinical treatment.

Comment from the Center for Global Digital Health Innovation:
Ecological Momentary Assessments showcase great potential, not only for the collection of real-world data for research but also for effective interventions in clinical psychology. The availability of digital tools offers an opportunity for EMAs as they can provide immediate behavioral guidance as well as develop algorithms that tailor coping strategies to individual needs and experiences. However, it is crucial to take into account certain methodological considerations when using EMA methods, such as the burden on subjects due to the frequency of assessment, distress due to repeated “beeping” reminders, and the feasibility of using high-tech devices with special populations. The articles below delve further into digital EMA methods for assessment and explore some interventions that use these methodologies.

McQuoid J et al, A geographically explicit ecological momentary assessment (GEMA) mixed method for understanding substance use, Social Science and Medicine, 2018

“Visualizing and exploring self-reported data with participants can help generate hypotheses about the contexts of health behaviors, such as how and why in everyday life smoking is linked to stress for marginalized groups.”

Key Takeaways

• This paper presents a mixed-method study through the description of three individual cases. It combines Geographically-explicit Ecological Momentary Assessments (GEMA) and travel-diary-like interviews to understand the individual and situational factors that influence the use of tobacco among marginalized minority groups.
• GEMA combines the real-time collection of data by individuals in their natural environment with their geographical information via smartphone GPS technology.
• The integration of interviewing with GEMA helped provide an understanding of where and when individuals smoke, as well as how and why--insights needed to design effective interventions that address the higher rates of tobacco consumption among minority groups.
• Using real-time momentary assessments with modified travel-diary interviews helped address factors like recall bias in interview-only studies and further increased the feasibility of a longer sampling period.

Comment from the Center for Global Digital Health Innovation:
The combined methodology of EMAs and post-assessment interviews that inform and interpret the collected data provides insight into individual and contextual factors that determine health behaviors. This paired technique may inform the development of tailored interventions to address health disparities in high-risk groups.
 

Schueller SM et al, Ecological momentary interventions for depression and anxiety: Using EMA data to inform mental health interventions, Wiley Periodicals: Depression & Anxiety, Volume 34, Issue 6, 2017

“Advances in ecological interventions are likely to take us one step closer to personal digital mental health assistants. These assistants will listen to people through sensed data, learn from people in the context of their daily lives, and guide people in directions that will support their mental health.”

Key Takeaways

• This article reviewed the design and evaluation of ecological momentary interventions (EMI) as well as their potential to engage and adapt to individual needs and preferences through technological advancements, which can bring interventions from clinical settings into an individual’s daily life. 
• The authors propose classifying these interventions by complexity: 1) low-level interventions that are the same for all users; 2) mid-level interventions that change in response to users; and 3) high-level interventions that evolve, individualizing responses for a particular user.
• “Just-in-time adaptive interventions” adapt over time by using the data collected about an individual or their environment to tailor interventions to individual needs. They harbor great potential for the treatment of depression and anxiety.
• With depression and stress management, such interventions should be integrated with human care. 
• Micro-randomized trials are a promising methodology to see how intervention results change over time and which variables help decide when and how to effectively intervene.

Comment from the Center for Global Digital Health Innovation:
EMIs provide a novel solution to the rising incidence of mental health conditions, creating an opportunity to develop adaptive solutions that meet the individual needs of patients and are available “just in time.” At the moment, end-users must initiate these interventions. Looking forward, researchers and practitioners should explore the use of sensors or machine learning algorithms and utilize passively collected data to tailor interventions to individuals for optimum outcomes.

Beres LK et al, Mobile Ecological Momentary Assessment and Intervention and Health Behavior Change Among Adults in Rakai, Uganda: Pilot Randomized Controlled Trial, JMIR Formative Research, Volume 5, Issue 7, 2021

“Compared with traditional, in-person assessments and interventions, ecological momentary assessments and interventions may offer more user-driven, cost-effective, and ecologically and temporally relevant strategies, and may generate more accurate data than traditional retrospective questionnaires, which are subject to recall bias.”

Key Takeaways

• This paper discusses the results of a pilot randomized trial in Rakai, Uganda, that aimed to study the feasibility of Ecological Momentary Assessment and Interventions and its estimated effect on health-related behaviors.
• The study assessed behavior change pertaining to five areas of interest: (1) fruit consumption; (2) vegetable consumption; (3) alcohol use; (4) cigarette smoking; and (5) sex with a nonmarital or non–long-term partner without a condom. 
• One arm of the trial received Ecological Momentary Interventions (EMI) in the form of ‘behaviorally responsive interventional health messaging’ after EMAs as compared to those submitting EMA data only.
• The findings included:
  • The high retention of participants in the intervention and control groups indicated that these strategies are feasible.
  • Most health behaviors were affected by these assessments and interventions; for instance, people receiving the momentary intervention increased their vegetable consumption. 
• Larger trials with more robust strategies should account for the social desirability bias due to self-reporting of behaviors.

Comment from the Center for Global Digital Health Innovation:
EMAs can facilitate the collection of real-time health behavior data in a lower-middle-income setting. When coupled with EMIs that respond to data collected for each individual, these assessments can promote behavior change remotely through mobile technologies. While this study highlights the feasibility and estimated effect of such interventions, further research can help determine their effectiveness and cost-effectiveness in comparison to traditional approaches and methods of overcoming the self-reporting bias in Ecological Momentary Assessments and Interventions.