Communication and Regulation in Psychotherapy

This commentary considers the Nock et al. review article (this issue) and provides additional perspectives pertaining to current concerns about Soldier suicides. The review article is relevant to the current Army STARRS research project, which is one of the most significant scientific undertakings in the history of suicide research. The review is an outstanding and thorough consideration of psychosocial risk and protective factors that may be related to Soldier suicide. While Army STARRS is a landmark effort, the author does note the need for innovation and alternative approaches to addressing alarming increases in Soldier suicides. Indeed, the dramatic increase seen in Soldier suicides over the past several years poses one of the more vexing challenges that the field of suicidology has faced to date. To this end, the author explores some alternative considerations that were not particularly featured in the review article. Some of these considerations include perspectives on military culture in relation to conventional suicide prevention as well as exciting developments emerging from clinical trial treatment research using suicidal military samples. It is argued that the magnitude of the current problem requires both innovative approaches and a sound scientific foundation to meaningfully impact and reduce the unprecedentedly high rates of Soldier suicide.     

Ecological Momentary Assessment in Eating Disorder and Obesity Research: a Review of the Recent Literature

Our current understanding of the etiology and maintenance of eating disorders and obesity continues to be far from complete. Similarly, our understanding of determinants of both successful and unsuccessful weight loss surgery is also quite limited. While a number of research methodologies have been applied to these areas, one methodology that has recently seen a rise in popularity is the use of ecological momentary assessment (EMA). EMA allows one to study a variety of variables of interest in the natural environment. The study of eating disorders, obesity, and bariatric surgery has all been conducted using EMA recently. The current study is a review of these areas and summarizes the recent literature (past 3 years) in eating disorders, obesity, and bariatric surgery using EMA methodology.     

Feasibility and acceptability of post-hospitalization ecological momentary assessment in patients with psychotic-spectrum disorders

BackgroundUp to 50% of patients with psychotic-spectrum disorders are medication nonadherent. The use of real-time assessment via ecological momentary assessment (EMA) on mobile devices might offer important insights into adherence behaviors that cannot be measured in the clinic. However, existing EMA studies have only studied acutely ill patients during hospitalization or more stable patients in the community.MethodsFeasibility and acceptability of EMA in 65 patients with psychotic-spectrum disorders who were recently discharged from the hospital were assessed. EMA was administered for four weeks via study-provided mobile devices. Feasibility was measured by study recruitment/retention rates, patients' connectivity, and completion rates. Quantitative and qualitative acceptability data were collected.ResultsParticipants completed 28–31% of offered EMA assessments. The only significant predictor of reduced EMA completion was recent cannabis use. EMA completion was maintained from weeks 1 to 3 but significantly dropped at the fourth week. Patient acceptability feedback was generally positive; negative comments related primarily to technological problems.ConclusionsThis was the first study to use EMA in recently discharged patients with psychotic-spectrum disorders. EMA is feasible and acceptable in this population, but completion rates were lower than in more stable samples. Future research should consider limiting the assessment period, screening for substance use, and integrating assessment with intervention elements to increase EMA engagement.     

An electronic memory aid to support prospective memory in patients in the early stages of Alzheimer's disease: a pilot study

The use of an electronic memory aid (EMA) for patients with mild-to-moderate probable Alzheimer disease is examined in five outpatients aged 58-79 years. The ability to remember to carry out seven tasks at a particular time was evaluated in three experimental conditions: recall without an external memory aid, recall with a written list and recall with support available from an EMA. The use of an EMA significantly improved patients' prospective memory, while the written list and free recall were not useful. Future research that examines the value of using an EMA to help with tasks that are associated with prospective memory with a larger sample of patients within their own home context is suggested.     

Ecological momentary assessment in aging research: A critical review

Ecological momentary assessment (EMA) gathers respondent data on affective, behavioral, and contextual experiences as close in time to those experiences as possible. Potential advantages of EMA in aging research include reducing memory biases and gathering intra-individual data, yet there is little understanding about implementation. The goal of this critical review was to assess the feasibility and applications of EMA in psychological and behavioral research on aging. Through a comprehensive search of the online electronic databases, Psycinfo and Pubmed, for English-language peer-reviewed journals published between 1990 and 2007, we identified 40 articles using EMA methods in older adults. Studies sampled participants between five times per day over one day to once a week for 210 days. Samples were generally not cognitively impaired, evenly split between healthy and clinical populations, and only 6 of 40 studies focused on psychiatric diagnoses. The most common assessment content solicited ratings on affect (n = 15), activities of daily living (n = 12), physical activities (n = 10), and social exchanges (n = 8). A total of 90% of the studies that reported compliance reported rates over 80%. Uses of EMA varied widely, with research goals including validation of global measures, detection of subtle treatment effects, and for testing hypotheses about causal intra-individual relationships. Although these measures appear feasible and useful in aging research, recommendations for future studies include adapting measures to enable data collection among older participants with cognitive impairments and/or psychopathology, along with greater use of electronic data capture to improve compliance and increase ease of implementation.     

Ecological momentary assessment versus standard assessment instruments for measuring mindfulness,depressed mood,and anxiety among older adults

As mobile data capture tools for patient-reported outcomes proliferate in clinical research, a key dimension of measure performance is sensitivity to change. This study compared performance of patient-reported measures of mindfulness, depression, and anxiety symptoms using traditional paper-and-pencil forms versus real-time, ambulatory measurement of symptoms via ecological momentary assessment (EMA). Sixty-seven emotionally distressed older adults completed paper-and-pencil measures of mindfulness, depression, and anxiety along with two weeks of identical items reported during ambulatory monitoring via EMA before and after participation in a randomized trial of Mindfulness-Based Stress Reduction (MBSR) or a health education intervention. We calculated effect sizes for these measures across both measurement approaches and estimated the Number-Needed-to-Treat (NNT) in both measurement conditions. Study outcomes greatly differed depending on which measurement method was used. When EMA was used to measure clinical symptoms, older adults who participated in the MBSR intervention had significantly higher mindfulness and significantly lower depression and anxiety than participants in the health education intervention at post-treatment. However, these significant changes in symptoms were not found when outcomes were measured with paper-and-pencil measures. The NNT for mindfulness and depression measures administered through EMA were approximately 25–50% lower than NNTs derived from paper-and-pencil administration. Sensitivity to change in anxiety was similar across administration modes. In conclusion, EMA measures of depression and mindfulness substantially outperformed paper-and-pencil measures with the same items. The additional resources associated with EMA in clinical trials would seem to be offset by its greater sensitivity to detect change in key outcome variables.     

Experience sampling and ecological momentary assessment for studying the daily lives of patients with anxiety disorders: A systematic review

Anxiety disorders are highly prevalent. Symptoms may occur unpredictably (e.g., panic attacks) or predictably in specific situations (e.g., social phobia). Consequently, it may be difficult to assess anxiety and related constructs realistically in the laboratory or by traditional retrospective questionnaires. Experience sampling methods (ESM) and ecological momentary assessment (EMA) can deepen the understanding of the course of anxiety disorders by frequently assessing symptoms and other variables in the natural environment. We review 34 ESM/EMA studies on adult panic disorder, generalized anxiety disorder, social phobia, post-traumatic stress disorder, and obsessive–compulsive disorder, as well as anxiety disorders in youth. Benefits of ESM/EMA for the study of anxiety disorders include generating insight into the temporal variability of symptoms and into the associations among daily affect, behaviors, and situational cues. Further, ESM/EMA has been successfully combined with ambulatory assessment of physiological variables and with treatment evaluations. We provide suggestions for future research, as well as for clinical applications.     

Feasibility and validity of ecological momentary assessment in adolescents with high-functioning autism and Asperger's disorder

Ecological Momentary Assessment (EMA) may increase accuracy of data compared with retrospective questionnaires by assessing behaviours as they occur, hence decreasing recall biases and increasing ecological validity. This study examined the feasibility and concurrent validity of an EMA tool for adolescents with High-Functioning Autism Spectrum Disorders (HFASD). Thirty-one adolescents with HFASD completed a mobile phone EMA application that assessed stressors and coping for two weeks. Parents and adolescents also completed retrospective measures of the adolescent's coping/stressors. Moderate compliance with the EMA tool was achieved and some concurrent validity was established with the retrospective measure of coping. Concordance was found between the types of stressors reported by parents and adolescents but not the quantity. The results suggest adolescents with HFASD are capable of reporting on their stressors and coping via EMA. EMA has the potential to be a valuable research tool in this population.     

Characteristics of Recent Suicide Attempts by Inmates in Maximum Security Correctional Centers

The research examined inmates' subjective perceptions of the reasons for suicide attempts and the psychological, sociological and criminological factors associated with such attempts. The sample comprised 60 male inmates who had made a recent suicide attempt. The methods of examination were semi-structured interviews with the inmates and analysis of their psychological and criminological files. The results showed that the examined group was not totally homogeneous. Methods of suicidal attempts divided the sample into two groups: those who had made a non-life-threatening (NLT) suicide attempt (58%) and those who made a life-threatening (LT) attempt (42%). Several factors significantly differentiated NLT and LT groups. Four of these factors were combined in regression models to clarify the relationships between the variables and to predict, in retrospect, whether an inmate had made a NLT or LT suicide attempt. The results are discussed in relation to previous findings on suicidology and to practical implications in correctional settings.     

Consultations for research in suicidology

Science means research. Current research in suicidology, however, needs development. Therefore, a task force was established by the International Academy for Suicide Research (IASR) to make recommendations for future study of suicide. These consultations are offered only as current thoughts to assist, not only in research, but also to aid in preventing suicide.     

Social anxiety and cannabis use: an analysis from ecological momentary assessment

Individuals with elevated social anxiety appear especially vulnerable to cannabis-related problems, yet little is known about the antecedents of cannabis-related behaviors among this high-risk population. The present study used ecological momentary assessment (EMA) to examine the relations among social anxiety, cannabis craving, state anxiety, situational variables, and cannabis use in the natural environment during ad-lib cannabis use episodes. Participants were 49 current cannabis users. During the two-week EMA period, social anxiety significantly interacted with cannabis craving to predict cannabis use both cross-sectionally and prospectively. Specifically, individuals with higher social anxiety and craving were most likely to use cannabis. There was a significant social anxiety x state anxiety x others' use interaction such that when others were using cannabis, those with elevations in both trait social anxiety and state anxiety were the most likely to use cannabis.     

Historical Perspectives on Suicide and Suicide Prevention in Sweden

The suicide panorama is not static but continually changing with the development of society. In this article changes in suicide rates and attitudes towards suicide in Sweden from pre-modern to modern time are described, with suicidal murders as an interesting transitional form. The rates of homicide have decreased, while those of suicide have increased. Changes in attitudes towards suicide have reached different groups in society at different times, leading to very heterogeneous suicide patterns. With increasing social homogeneity there now seems to exist a tendency back towards larger homogeneity of suicide as well. In order to develop suicide prevention into a vital branch of public-health services humanistic, linguistic and social research in suicidology must be encouraged.     

User profiles of an electronic mental health tool for ecological momentary assessment: MEmind

Ecological momentary assessment (EMA) is gaining importance in psychiatry. This article assesses the characteristics of patients who used a new electronic EMA tool: the MEmind Wellness Tracker. Over one year, 13811 adult outpatients in our Psychiatry Department were asked to use MEmind. We collected information about socio‐demographic data, psychiatric diagnoses, illness severity, stressful life events and suicidal thoughts/behavior. We compared active users (N = 2838) and non‐active users (N = 10,973) of MEmind and performed a Random Forest analysis to assess which variables could predict its use. Univariate analyses revealed that MEmind‐users were younger (42.2 ± 13.5 years versus 48.5 ± 16.3 years; χ² = 18.85; P < 0.001) and more frequently diagnosed with anxiety related disorders (57.9% versus 46.7%; χ² = 105.92; P = 0.000) than non‐active users. They were more likely to report thoughts about death and suicide (up to 24% of active users expressed wish for death) and had experienced more stressful life events than non‐active users (57% versus 48.5%; χ² = 64.65; P < 0.001). In the Random Forest analysis, 31 variables showed mean decrease accuracy values higher than zero with a 95% confidence interval (CI), including sex, age, suicidal thoughts, life threatening events and several diagnoses. In the light of these results, strategies to improve EMA and e‐Mental Health adherence are discussed.     

Suicide risk: where, why and how is it generated?

In this editorial we will first use the findings of epidemiological research to show that the closer we get to brain dysfunction, the higher is the suicide risk (Where?). Secondly, a distinction will be made between the proximate and ultimate causation of suicide behaviour as a biological phenomenon (Why?). Using the evolutionary psychiatry approach, the ultimate causation of suicide could answer the question why does suicidal behaviour exist at all? Third, we will review the most attractive recent molecular genetic findings in the field of suicidology genetics (How?). These three perspectives will in turn lead us to summarise where, why and how suicide risk is generated?     

Consultations for research in suicidology

Abstract

Science means research. Current research in suicidology, however, needs development. Therefore, a task force was established by the International Academy for Suicide Research (IASR) to make recommendations for future study of suicide. These consultations are offered only as current thoughts to assist, not only in research, but also to aid in preventing suicide.     

Ecological momentary assessment in addiction

Numerous symptoms in psychiatry are subjective (e.g., sadness, anxiety, craving or fatigue), fluctuate and are environment dependent. Accurate measurement of these phenomena requires repeated measures, and ideally needs to be performed in the patient's natural environment rather than in an artificial laboratory environment or a protected hospital environment. The usual paper and pencil questionnaires do not meet these two conditions for reasons of logistics. A recently developed method, ecological momentary assessment (EMA), made it possible to implement these field assessments via ingenious use of various devices (most frequently an electronic diary) coupling an auditory signal with computerized data capture. The subject carries the device with him/her at all times, and data is recorded in vivo in real time. The programming of repeated measures in the form of a Likert scale or pull-down menu is easily achieved. A recall alarm system can help increase compliance. Compared with classical self-report, EMA improves the validity of the assessment of certain symptoms, which are the main evaluation criteria in clinical trials concerning certain pathologies (e.g., craving and treatment of addiction), where measurement was previously liable to bias. This article sets out to present this method, its advantages and disadvantages, and the interest it presents in psychiatry, in particular via three original applications developed by the authors including: measurement of reaction time without the knowledge of the subject in order to test certain cognitive models; use of a graphic solution for the data recorded for functional analysis of disorders; and the use of data collection via mobile phone and text messages, which also enables therapeutic interventions in real time by text messages, personalized on the basis of the situational data collected (e.g., in the case of craving, the associated mood, solitary or group consumption or concomitant occupations).     

The clinical concept of chronic pain

In this article, the authors present a rationale for considering pain to be a major health problem in the United States, based on epidemiologic data. They then define the nature of pain disorders in terms of their acute and chronic forms. By extending the definition of pain into a psychogenic/organic dichotomy, the authors introduce the concept of personality variables and psychodynamic considerations that have been attributed to patients with chronic pain. Finally, the overlap and evidence for depression as a coexisting variable with chronic pain is considered. Throughout the article, the authors are arguing implicitly for a multimodal approach to therapy.     

Group external memory aid treatment for mild cognitive impairment

Background: Although individuals with mild cognitive impairment (MCI) often live independently, instruction on compensatory strategies could assist individuals with complex daily tasks. External memory aids (EMA) are evidence-based compensatory strategies that support cognitive communication impairments. Often EMAs are included within multi-strategy-based interventions; however, limited research has examined solely training several EMAs to individuals with mild memory impairments and the long-lasting outcomes.

Aims: The aims of this study were to examine the effect of structured group EMA treatment for individuals with possible MCI on their: (1) functional use of EMAs to compensate for memory impairments compared to before treatment; (2) cognitive skills post-treatment; and (3) do these changes maintain for 6 weeks and 18 months following intervention.

Methods & Procedures: The researchers employed an experimental pre-/post-group treatment design and collected 6-week and 18-month follow-up data. Six participants were divided into two groups. Participants completed 6 weekly group treatment sessions training three categories of EMAs. Group 1 began treatment immediately and Group 2 started treatment following the conclusion of treatment for Group 1.

Outcomes and Results: Participants increased their functional EMA use following treatment on a Role Play Activity. Group mean scores on the Montreal Cognitive Assessment (Nasreddine et al., 2005) increased following treatment. Inconsistent retention of skills was documented for both functional EMA use and cognitive skills during follow-up assessment.

Conclusions: With treatment, individuals with possible MCI learned to use EMAs during functional activities. Mixed results related to retention of skills indicated the potential importance of booster treatment to reinforce EMA use. Future research should aim to investigate additional methods to measure functional EMA use prior to and following intervention.     

The Aarhus Neuromodulation Database

Objectives: Spinal cord stimulation (SCS) is increasingly gaining widespread use as a treatment for chronic pain. A widely used electronic registry could play a pivotal role in improving this complex and cost‐intensive treatment. We aimed to construct a comprehensive, universally available data base for SCS. Materials and Methods: The design considerations behind a new online data base for SCS are presented; basic structure, technical issues, research applications, and future perspectives are described. Results: The Aarhus Neuromodulation Database covers core SCS treatment parameters, including procedure‐related details and complications, and features recording of key success parameters such as pain intensity, work status, and quality of life. It combines easy access to patient information with exhaustive data extraction options, and it can readily be adapted and expanded to suit different needs, including other neuromodulation treatment modalities. Conclusions: We believe that the data base described in this article offers a powerful and versatile data collection tool suited for both clinicians and researchers in the field. The basic data base structure is immediately available on a no‐cost basis, and we invite our colleagues to make use of the data base as part of the efforts to further the field of neuromodulation.