Background: Non-suicidal self-injury (NSSI) is a serious mental health problem characterized by rapid within-person fluctuations in thoughts and urges. Yet, treatments rely on retrospective and static approaches for assessments and interventions. Ecological Momentary Assessment (EMA) and Ecological Momentary Interventions (EMIs) may enable more dynamic support in real time. This study examined the perceived utility and scope of these new digital modalities from the perspectives of treatment-seeking individuals and mental health professionals. Methods: Semi-structured interviews were conducted with 30 treatment-seeking individuals engaging in NSSI, after completing a four-week EMA period, and with 14 professionals who used EMA in treatment. Interviews explored experiences with EMA and perspectives on EMIs and were analyzed using reflexive thematic analysis. Results: Three themes were identified. First, EMA and EMIs were perceived as extending therapeutic support by enhancing awareness, reflection, and skill use in daily life. Second, participants emphasized that EMIs must be tailored to changing needs in function of changing risk. This informed the development of a Needs-Based Dynamic Risk and Intervention Model for NSSI, distinguishing needs and interventions through a traffic-light analogy across low (i.e., mental health promotion), moderate (i.e., vulnerability regulation), and high (i.e., behavioral interruption) risk states. Third, EMIs were viewed as valuable when embedded in blended care and implemented through shared decision-making, balancing system- and user-initiated support. Conclusion: Integrating EMA and EMIs into treatment has potential to provide needs-tailored support for individuals who self-injure. Future work should focus on empirically validating the proposed dynamic model and co-designing EMI components that address fluctuating needs in daily life.

BACKGROUND AND HYPOTHESIS:Sex differences in psychosis are reported across the psychosis spectrum, including in subclinical stages. An important factor in understanding these variations is the subjective experience of everyday social interactions (SI). We investigated whether the presence of psychotic experiences (PEs), as well as associated distress, differs between men and women. We focused on the role of daily-life SI quality and whether its association with PEs varies by sex. STUDY DESIGN:We included adolescents from SIGMA, a general youth population study in Flanders, Belgium (n = 344; mean age = 18.7; 63.4% female). Psychotic experiences were measured using the PQ-16. We used Experience Sampling Methodology to assess daily-life SI. A multilevel model and multiple linear regressions were used to assess, respectively, the relationship between sex and SI quality and whether PEs and their association with SI quality differ between young men and women. STUDY RESULTS:The results of the multilevel linear regression model indicate that the prevalence of and distress associated with PEs were higher in women. No significant difference was observed in the subjective quality of daily SI. Social interaction quality was strongly related to PEs. This association did not seem to vary for the prevalence of PEs, though women's distress about PEs appeared to be more affected by SI quality. CONCLUSIONS:Present findings highlight the role of the subjective quality of SI in subclinical psychosis. More research is needed to investigate the mechanisms through which SI quality relates to PEs, and whether these differ between young men and women.

Numerous studies have substantiated the efficacy of slow-paced breathing (SPB) in decreasing anxiety and increasing vagally-mediated heart rate variability (vmHRV). Given its effectiveness and simplicity, SPB is a promising candidate for a just-in-time adaptive intervention (JITAI). This study examined the efficacy of SPB, triggered by increased anxiety and perseverative cognition (PC), on reducing these symptoms and increasing vmHRV at macro, micro, and immediate levels. Eighty individuals with subclinical anxiety from the Flemish general population were randomized into experimental (EC) or passive control (CC) conditions. Anxiety symptoms were evaluated at baseline and after 15 days. Participants underwent a control period (CP; 6 days) and an intervention period (IP; 6 days), during which they reported momentary anxiety and PC via a mobile application while wearing a portable electrocardiogram. EC participants received SPB training between CP and IP and were prompted to use SPB exercises during IP when anxiety/PC increased. Analyses revealed a significant effect of SPB on reducing retrospectively reported anxiety (p < .05), but not on average daily-life anxiety and PC or vmHRV assessed throughout the IP. Micro-level analyses indicated that SPB was associated with a decrease in PC (p < .05) but not anxiety at the subsequent daily-life assessment. Anxiety and PC decreased substantially from immediately before to immediately after SPB (< 0.001). The effect of SPB on vmHRV remains inconclusive due to methodological concerns in measuring vmHRV in ambulatory settings. The results provide mixed evidence for the efficacy of SPB as a JITAI, indicating the need for replication studies to further evaluate its potential.

Background: Elevated levels of distress, anxiety and depression are associated with increased risk for developing mental disorders. Ecological momentary interventions (EMIs) constitute a highly scalable, low-barrier approach for early intervention. In this study, a micro-randomized trial was conducted to investigate the proximal (short-term) and distal (longer-term) effects of different EMIs based on positive psychology, cognitive behavioral therapy (CBT), and acceptance and commitment therapy (ACT). Methods: 72 participants at increased risk for developing mental disorders comprised the sample (67.6% female). They completed a 16-day intervention phase during which they received four pre-ecological momentary assessments (pre-EMA) at semi-random moments each day assessing proximal outcomes negative (NA) and positive affect (PA). Each day, two randomly-selected pre-EMAs were immediately followed by an EMI. Thirty minutes following each pre-EMA, NA and PA were assessed again. Before and after the intervention phase, distal outcomes symptoms of depression, anxiety and well-being were assessed. Results: Multilevel models showed proximal improvements in PA following EMIs based on positive psychology and ACT. NA decreased following positive psychology; ACT specifically improved NA during moments of higher NA at pre-EMA. The CBT-based EMI neither improved NA nor PA. Distal improvements in symptoms of depression, anxiety and well-being were observed. Discussion: This study provides support for the beneficial immediate effects of EMIs based on positive psychology and ACT on affect; symptoms of psychopathology and well-being improved on a distal level. Future research should further investigate the benefits of different EMIs in crucial moments (e.g., high momentary NA) to develop adequate just-in-time support.

Research using self-reports hinges on the assumption that participants pay sufficient attention to questionnaires to provide valid data. This assumption is particularly tenuous in experience sampling method (ESM) studies, where participants complete questionnaires in daily life across a range of potentially distracting situations. Previous research suggests that participants may be particularly distracted when responding to ESM questionnaires in social situations, especially when engaging in social interactions. Yet, the effects of these environmental distractions on response behavior and, consequently, data quality remain poorly understood. We investigated the effects of distracting environments on disturbance and response behavior across various social and non-social situations. ESM data from three young adult samples (combined N = 293) and a general population youth sample (N = 1903) was analyzed with multilevel (logistic) regressions. In line with previous research, adults were significantly more disturbed by assessments when in company compared to when alone, especially when also interacting with their company. In addition, we found small but significant differences in response behavior between social settings in adults, with changes pointing towards lower data quality when in company. Interestingly, patterns were different–in some cases even reversed–in school-going adolescents. While our findings suggest that the distraction of social settings affects participant burden and response behavior, the influence on data quality was minor. Differences across samples suggest that the setting of the social experience (in vs outside school) needs to be considered. Preparing participants for sampling in distracting (social) environments may help safeguard data quality and reduce participant burden.

Key symptoms of anxiety include experiencing unpleasant emotions and hyperarousal. Growing evidence suggests that delayed affective recovery (DAR) from daily stressors plays a role in their maintenance and development on a day-to-day basis. We examined whether DAR is linked to current and future anxiety symptoms, independently of depressive symptoms. Self-reported anxiety and depressive symptoms were assessed at Wave 1 (N = 1,031) and approximately 2.5 years later at Wave 2 (N = 171) in a community sample of Flemish adolescents. Additionally, at Wave 1, the experience sampling method was used to obtain assessments of momentary affect and to infer stressful occurrences, with data collected 10 times a day, for 6 days. Using affective experience sampling method data, we constructed two variables, that is, affective valence and arousal, reflecting the (un)pleasantness and (hyper)arousal associated with emotions. The time interval for recovery was estimated using parametric survival analysis. Prospective associations were tested with multiple regression. Slower valence recovery was associated with higher concurrent anxiety symptoms. A similar association was present for the arousal recovery, however only when depressive symptoms were added to the model. We found no prospective association between the speed of valence nor arousal recovery at Wave 1 and anxiety symptoms at Wave 2. The results suggest that DAR is linked to current anxiety symptoms but does not predict their development 2.5 years later. Our findings provide insights into possible processes underlying the key features of anxiety and help identify the moments of vulnerability in the daily lives of youth.

ACT in Daily Life (ACT-DL) is a blended-care Ecological Momentary Intervention that extends ACT into the daily life of individuals, improving psychotic distress, negative symptoms, and global functioning. However, it remains unclear whether ACT-DL works equally for everyone. We investigated whether moderators (i.e., sociodemographic information, personality, and trauma history) determine clinical outcomes in individuals with early psychosis receiving ACT-DL. Seventy-one participants from the INTERACT trial, using ACT-DL, were analyzed. Outcomes included psychotic distress, negative symptoms, global functioning, and psychological flexibility. Using multivariate-multilevel models, we evaluated the effects of sociodemographics, personality, and childhood trauma across baseline, post-intervention, and six- and 12-month follow-ups. Sociodemographic characteristics and personality predicted clinical outcomes. Higher education demonstrated more substantial improvement in global functioning at 6- (B = 7.43, p = 0.04) and 12-FU (B = 10.74, p = 0.002) compared to lower education. Higher extraversion showed less improvement in negative symptoms at 12-FU (B = 1.24, p = 0.01) and more improvement in global functioning at post-intervention (B = 0.39, p = 0.046) and 6-FU (B = 1.40, p = 0.02) compared to lower extraversion. Higher negative affectivity showed more improvement in negative symptoms at 12-FU (B = −1.59, p = 0.001) and higher psychological flexibility at 12-FU (B = 8.38, p = 0.001) compared to lower negative affectivity. Our findings suggest that while ACT-DL improves clinical outcomes in individuals with early psychosis, the improvement rate is dissimilar for individuals and predictable by baseline characteristics. If replicated, these findings enable precision medicine approaches in allocating ACT-DL for early psychosis.

Mental health and well-being are one of the most challenging issues in modern so-ciety[1,2]. For example, moderate stress can help a person in many beneficial ways to confront a challenge [3]. On the other hand, excessive stress, a common phenomenon in our society, can cause overall negative health and well-being impact [4], such as increasing susceptibility to infection and illness[5-7], affecting a diverse range of physical, psychological, and behavioral conditions (i.e., anxiety, depression, sleep disorders, or decreasing job productivity)[8-11]. Furthermore, mental disorders such as depression and schizophrenia, if not monitored and treated timely, can lead to further degradation of the person's mental health and well-being. The ability to measure stress levels or mental health could enable better self-management of one's behavioral choices in ways that might be intervened timely.

During emotional events, people monitor the effectiveness of their emotion regulation (ER) to decide whether to keep using their current ER strategy, switch to a new strategy, or stop the regulation process. However, there is little empirical research on the monitoring phase of ER, particularly on which and how situational and individual factors influence this process. We tested situational and individual factors as predictors of real-life ER monitoring decisions. 155 young adults responded to 5 prompts per day in a 7-day experience sampling protocol. At each prompt they described an emotional event, rated the intensity of event, their current emotions and perceived success in ER, and reported their decision to simply stop using their current ER strategy or to switch to a new strategy during the event. Multilevel modeling results showed the decision to stop using the current ER strategy was predicted by perceived success in ER after both positive and negative events, and by depressive and anxiety symptoms after positive events. The decision to switch to a new strategy was more likely when there were high negative affect after a negative event, and less likely when there was perceived success after a positive event. These findings suggest that situational and individual factors affect people’s decisions about how to regulate emotion. Interventions addressing excessive regulatory stopping in response to positive events and their underlying causes may benefit individuals with depression or anxiety.

BACKGROUND AND AIMS:Studies show that higher levels of positive affect (PA) and lower levels of negative affect (NA) are related to craving and alcohol consumption at a daily level in men, but little is known on these associations at a momentary level, and whether they are present in women. This study measured the dynamics of within-person NA and PA surrounding craving, non-heavy alcohol use and binge drinking in women with alcohol use disorder (AUD) and female controls without AUD. METHODS:53 female patients with AUD and 75 female controls, all recruited in Belgium, were included in an experience sampling study where they reported on momentary NA, PA, craving and alcohol use in daily life over a period of 12 months. Assessments occurred eight times a day on Thursdays, Fridays and Saturdays in seven bursts of three weeks. RESULTS:Within-person NA at a previous assessment (t-1) predicted craving at the current assessment (t0) in patients with AUD in a positive linear [β = 0.043; 95% confidence interval (CI) = 0.002, 0.057; P = 0.041] and quadratic fashion (β = 0.034; CI = 0.011, 0.057; P = 0.004). Within-person PA at t-1 predicted craving at t0 in patients with AUD with a positive quadratic relation (β = 0.042; CI = 0.08, 0.065; P < 0.001). Within-person NA at t-1 negatively predicted non-heavy alcohol use at t0 in a linear fashion in controls (β = -0.495; CI = -0.677, -0.312; P < 0.001) and patients with AUD (β = -0.276; CI = -0.421, -0.132; P < 0.001). Within-person PA at t-1 significantly predicted non-heavy alcohol use at t0 with a positive linear term (β = 0.470; CI = 0.329, 0.610; P < 0.001) in controls, but with a positive linear term (β = 0.399; CI = 0.260, 0.454; P < 0.001) and a positive quadratic term (β = 0.203; CI = 0.060, 0.347; P = 0.003) in patients with AUD. Within-person NA at t-1 predicted binge drinking at t0 in patients with AUD with a significant quadratic term (β = 0.236; CI = 0.060, 0.412; P = 0.008), but not for controls. Within-person PA at t-1 predicted binge drinking at t0 in patients with AUD with a significant quadratic term (β = 0.378; CI = 0.215, 0.542; P < 0.001), and this was also the case for controls (β = 0.487; CI = 0.158, 0.770; P < 0.001). Non-heavy alcohol use at t0 predicted lower levels of NA at t+1 in both patients with AUD (β = -0.161; SE = 0.044; CI = -0.248, 0.074; P = 0.001) and controls (β = -0.114; CI = -0.198, -0.029; P = 0.010). Non-heavy alcohol use at t0 also predicted higher levels of PA at t+1 in both patients with AUD (β = 0.181; CI = 0.088, 0.274; P < 0.001) and controls (β = 0.189; CI = 0.101, 0.278; P < 0.001). CONCLUSIONS:The momentary relation between affect and craving or alcohol use seems to be non-linear in female patients with alcohol use disorder, whereby a worse mood predicts subsequent alcohol use, though more for binge drinking than for non-heavy alcohol use.

BackgroundPsychotic experiences (PEs) and social isolation (SI) seem related during early stages of psychosis, but the temporal dynamics between the two are not clear. Literature so far suggests a self-perpetuating cycle wherein momentary increases in PEs lead to social withdrawal, which, subsequently, triggers PEs at a next point in time, especially when SI is associated with increased distress. The current study investigated the daily-life temporal associations between SI and PEs, as well as the role of SI-related and general affective distress in individuals at clinical high risk (CHR) for psychosis.MethodsWe used experience sampling methodology in a sample of 137 CHR participants. We analyzed the association between SI, PEs, and distress using time-lagged linear mixed-effects models.ResultsSI did not predict next-moment fluctuations in PEs, or vice versa. Furthermore, although SI-related distress was not predictive of subsequent PEs, general affective distress during SI was a robust predictor of next-moment PEs.ConclusionsOur results suggest that SI and PEs are not directly related on a moment-to-moment level, but a negative emotional state when alone does contribute to the risk of PEs. These findings highlight the role of affective wellbeing during early-stage psychosis development.

Background and Hypotheses Affective recovery, operationalized as the time needed for affect to return to baseline levels after daily stressors, may be a putative momentary representation of resilience. This study aimed to investigate affective recovery in positive and negative affect across subclinical and clinical stages of psychosis and whether this is associated with exposure to childhood trauma (sexual, physical, and emotional abuse).Study Design We used survival analysis to predict the time-to-recovery from a daily event-related stressor in a pooled sample of 3 previously conducted experience sampling studies including 113 individuals with first-episode psychosis, 162 at-risk individuals, and 94 controls.Study Results Negative affective recovery (ie, return to baseline following an increase in negative affect) was longer in individuals with first-episode psychosis compared with controls (hazard ratio [HR] = 1.71, 95% confidence interval [CI; 1.03, 2.61], P = .04) and in at-risk individuals exposed to high vs low levels of emotional abuse (HR = 1.31, 95% CI [1.06, 1.62], P = .01). Positive affective recovery (ie, return to baseline following a decrease in positive affect) did not differ between groups and was not associated with childhood trauma.Conclusions Our results give first indications that negative affective recovery may be a putative momentary representation of resilience across stages of psychosis and may be amplified in at-risk individuals with prior experiences of emotional abuse. Understanding how affective recovery contributes to the development of psychosis may help identify new targets for prevention and intervention to buffer risk or foster resilience in daily life.

Background Acceptance and commitment therapy (ACT) is promising in the treatment of early psychosis. Augmenting face-to-face ACT with mobile health ecological momentary interventions may increase its treatment effects and empower clients to take treatment into their own hands. Objective This study aimed to investigate and predict treatment engagement with and acceptability of acceptance and commitment therapy in daily life (ACT-DL), a novel ecological momentary intervention for people with an ultrahigh risk state and a first episode of psychosis. Methods In the multicenter randomized controlled trial, 148 individuals with ultrahigh risk or first-episode psychosis aged 15-65 years were randomized to treatment as usual only (control) or to ACT-DL combined with treatment as usual (experimental), consisting of 8 face-to-face sessions augmented with an ACT-based smartphone app, delivering ACT skills and techniques in daily life. For individuals in the intervention arm, we collected data on treatment engagement with and acceptability of ACT-DL during and after the intervention. Predictors of treatment engagement and acceptability included baseline demographic, clinical, and functional outcomes. Results Participants who received ACT-DL in addition to treatment as usual (n=71) completed a mean of 6 (SD 3) sessions, with 59% (n=42) of participants completing all sessions. App engagement data (n=58) shows that, on a weekly basis, participants used the app 13 times and were compliant with 6 of 24 (25%) notifications. Distribution plots of debriefing scores (n=46) show that 85%-96% of participants reported usefulness on all acceptability items to at least some extent (scores ≥2; 1=no usefulness) and that 91% (n=42) of participants reported perceived burden by number and length of notifications (scores ≥2; 1=no burden). Multiple linear regression models were fitted to predict treatment engagement and acceptability. Ethnic minority backgrounds predicted lower notification response compliance (B=–4.37; P=.01), yet higher app usefulness (B=1.25; P=.049). Negative (B=–0.26; P=.01) and affective (B=0.14; P=.04) symptom severity predicted lower and higher ACT training usefulness, respectively. Being female (B=–1.03; P=.005) predicted lower usefulness of the ACT metaphor images on the app. Conclusions Our results corroborate good treatment engagement with and acceptability of ACT-DL in early psychosis. We provide recommendations for future intervention optimization. Trial Registration OMON NL46439.068.13; https://onderzoekmetmensen.nl/en/trial/24803

BACKGROUND:Research suggests that most mental health conditions have their onset in the critically social period of adolescence. Yet, we lack understanding of the potential social processes underlying early psychopathological development. We propose a conceptual model where daily-life social interactions and social skills form an intermediate link between known risk and protective factors (adverse childhood experiences, bullying, social support, maladaptive parenting) and psychopathology in adolescents - that is explored using cross-sectional data. METHODS:N = 1913 Flemish adolescent participants (Mean age = 13.8; 63% girls) were assessed as part of the SIGMA study, a large-scale, accelerated longitudinal study of adolescent mental health and development. Self-report questionnaires (on risk/protective factors, social skills, and psychopathology) were completed during class time; daily-life social interactions were measured during a subsequent six-day experience-sampling period. RESULTS:Registered uncorrected multilevel linear regression results revealed significant associations between all risk/protective factors and psychopathology, between all risk/protective factors and social processes, and between all social processes and psychopathology. Social processes (social skills, quantity/quality of daily social interactions) were uniquely predicted by each risk/protective factor and were uniquely associated with both general and specific types of psychopathology. For older participants, some relationships between social processes and psychopathology were stronger. CONCLUSIONS:Unique associations between risk/protective factors and psychopathology signify the distinct relevance of these factors for youth mental health, whereas the broad associations with social processes support these processes as broad correlates. Results align with the idea of a social pathway toward early psychopathology, although follow-up longitudinal research is required to verify any mediation effect.

Background As mobile health (mHealth) studies become increasingly productive owing to the advancements in wearable and mobile sensor technology, our ability to monitor and model human behavior will be constrained by participant receptivity. Many health constructs are dependent on subjective responses, and without such responses, researchers are left with little to no ground truth to accompany our ever-growing biobehavioral data. This issue can significantly impact the quality of a study, particularly for populations known to exhibit lower compliance rates. To address this challenge, researchers have proposed innovative approaches that use machine learning (ML) and sensor data to modify the timing and delivery of surveys. However, an overarching concern is the potential introduction of biases or unintended influences on participants’ responses when implementing new survey delivery methods. Objective This study aims to demonstrate the potential impact of an ML-based ecological momentary assessment (EMA) delivery system (using receptivity as the predictor variable) on the participants’ reported emotional state. We examine the factors that affect participants’ receptivity to EMAs in a 10-day wearable and EMA–based emotional state–sensing mHealth study. We study the physiological relationships indicative of receptivity and affect while also analyzing the interaction between the 2 constructs. Methods We collected data from 45 healthy participants wearing 2 devices measuring electrodermal activity, accelerometer, electrocardiography, and skin temperature while answering 10 EMAs daily, containing questions about perceived mood. Owing to the nature of our constructs, we can only obtain ground truth measures for both affect and receptivity during responses. Therefore, we used unsupervised and supervised ML methods to infer affect when a participant did not respond. Our unsupervised method used k-means clustering to determine the relationship between physiology and receptivity and then inferred the emotional state during nonresponses. For the supervised learning method, we primarily used random forest and neural networks to predict the affect of unlabeled data points as well as receptivity. Results Our findings showed that using a receptivity model to trigger EMAs decreased the reported negative affect by >3 points or 0.29 SDs in our self-reported affect measure, scored between 13 and 91. The findings also showed a bimodal distribution of our predicted affect during nonresponses. This indicates that this system initiates EMAs more commonly during states of higher positive emotions. Conclusions Our results showed a clear relationship between affect and receptivity. This relationship can affect the efficacy of an mHealth study, particularly those that use an ML algorithm to trigger EMAs. Therefore, we propose that future work should focus on a smart trigger that promotes EMA receptivity without influencing affect during sampled time points.

Research increasingly highlights the importance of social disconnectedness for the development of psychosis. However, the perspective of individuals with psychosis remains largely underexplored. At present, there is also no comprehensive view of the role of social processes throughout different phases of psychosis development. The current study aims to investigate 1) how individuals with a psychotic disorder experience social disconnection and 2) the role of social disconnection We conducted two focus groups, with individuals diagnosed with a psychotic disorder (N = 8). The data were analyzed using interpretative phenomenological analysis. We structured the data according to three phases: pre-psychotic early life, development of psychotic symptoms and recovery. The first phase included following themes: "developing distrustful views of others through childhood interpersonal adversity" and "growing up socially isolated". The second phase had three themes: "increasing separation between common and individual reality perception", "struggling to share psychotic experiences due to stigma" and "losing relationships due to feeling misunderstood and decreased social functioning". The final phase encompassed: "accepting psychosis diagnosis through social support", "grounding influence of others" and "finding purpose through social integration". In general, individuals with psychosis viewed social disconnectedness as a highly important factor for understanding and treating psychosis.