#hope-s # Ecological Momentary Assessment and Intervention in the Treatment of Psychotic Disorders: A Systematic Review [Ecological Momentary Assessment and Intervention in the Treatment of Psychotic Disorders- A Systematic Review.pdf](https://drive.google.com/file/d/1JV8u4gB3xUcu8Op-_gHtHd0CI1p7z_wh/view) Imogen H. Bell, [B.Sc](http://B.Sc). (Hons), Michelle H. Lim, Ph.D., Susan L. Rossell, Ph.D., Neil Thomas, [D.Clin.Ps](http://D.Clin.Ps)y. --- **In summary, great potential to the future of psychiatry. Results are mixed, and not strongly conclusive.** EMI stands for ecological momentary intervention Across the included studies, a total of 459 participants with a psychotic disorder were included. Participants’ mean6SD age was 36.968.15, and ages ranged from 27.0 to 48.7. Most studies included samples of patients diagnosed as having schizophrenia or schizoaffective disorder (44–48). Two studies included additional patients with acute poly- morphic psychotic disorder (15% of the sample) (50,51), and another study included patients with nonspecific psychotic spectrum disorders (8% of the sample) (49). **EMA can be use for :** ## Illness and Symptom Monitoring ^21aa86 Four studies involved remote monitoring of the prodromal warning signs of relapse among patients with a diagnosis of a psychotic disorder to prevent hospitalization by using an intervention called Information Technology–Aided Relapse Prevention Program in Schizophrenia (ITAREPS) [[List of EMA EMI SYSTEMS#^18f01a]](43,45,50,51). Patients and caregivers completed the Early Warning Signs Questionnaire (52) weekly, which was uploaded to an online system, or the results were reported to managing nurses and were monitored by the treatment team. The response to patients who were assessed to be at risk of relapse was heightened monitoring and increased medication. The inclusion of this intervention required a broad definition of EMA, given that the assessments were conducted weekly and do not assess momentary phenomena. However, these studies were included in this review to demonstrate the potential application of remote monitoring of illness by using EMA for the purpose of clinical management. _Feasibility and acceptability._ Adherence to the monitoring protocol by patients and caregivers was relatively low in the two initial ITAREPS trials (50,51). In the randomized controlled trial (RCT), patient and caregiver adherence in- creased; however, only 39% of alerts were responded to by the treatment team in accord with the protocol (45). The low rate was mainly attributed to conflicts between protocol- indicated medication increases and psychiatrists’ clinical judgement (65% of cases). To account for this, Komatsu and colleagues (43) engaged nurses to conduct assessments by telephone and to monitor medication responses, which in- creased adherence to the response protocol. - **False Positive of relapses picked up by the weekly Questionnaire? So, they changed it to human assessment by phone** _Clinical outcomes_. The initial ITAREPS trials showed reductions in hospitalization events and total hospital days for the treatment group (sustained at follow-up), compared with the control groups, particularly for participants and treatment teams that adhered to the monitoring and responding protocol (50,51). Because the subsequent RCT suffered from a low rate of adoption and adherence by the treatment team, it was difficult to assess efficacy (45). Reductions in hospitalization events and total hospital days were noted for the group in which the treatment team adhered to the protocol, compared with the nonadherent group. In the later trial by Komatsu and colleagues (43), in which better clinician adherence was achieved, greater reductions in hospitalization and severity of relapse were observed; however, no follow-up data were reported. A cost-benefit analysis conducted by Spaniel and colleagues (45) showed that the cost of treatment was lower in the group of patients with protocol-adhering treatment teams.  - **I don't understand this part.** ## Self-Management and Psychosocial Functioning ^f0ca6c _Intervention characteristics._ Five of the nine studies targeted self-management and psychosocial and daily function- ing for patients with a psychotic disorder. The app-based FOCUS [[List of EMA EMI SYSTEMS#^c674e5]] and SMS-delivered Mobile Assessment and Intervention for Schizophrenia (MATS) [[List of EMA EMI SYSTEMS#^8507f8]] involved EMIs targeting illness self-management through the delivery of repeated prompts to users throughout the day. These prompts provided medication reminders and momentary intervention items based on therapeutic models for challenging cognitions, coping, and promotion of healthy behaviors. Both FOCUS and MATS involved initial interviews with participants regarding treatment targets and sub- sequent personalization of intervention components. The FOCUS app also includes resources for participants to access on demand (62% of use), as well as prompts (38% of use) (46). - **Quite similar. Giving interventions. But not sure what are those "momentary intervention items"** The remaining three studies focused on compensating for cognitive difficulties through promoting goal achievement and daily living activities, such as attending appointments, managing medications, and inhibiting undesirable behavior. The Skills Training and Empowerment Program trial was a pilot study aimed at enhancing the efficacy of a face-to-face intervention for patients with schizophrenia while shortening the intervention’s duration through regular phone calls (47). The app-based Mobus trial (44) and the SMS-based EMI designed by Pijnenborg and colleagues (49) involved programming of personalized daily living activities and goals to remind patients to complete these in daily life. In the Mobus trial, caregivers were engaged to work with the patient to identify goals and keep track of their progress by using the system (44). - **Sound like more behavioral modification based interventions. Setting a goal, doing them.** _Feasibility and acceptability._ The mean dropout rate across the EMI studies was 15%, with a range from 0% (47) to 36% (44). Reasons for dropout included loss of device, severity of illness, loss of interest, and intervention nonengagement. Mean response rates to the prompting components of the EMIs across the studies was 80% (rates were not reported in Pijnenborg and colleagues [49]). Ben-Zeev and colleagues (46) found no association between response rates and cognitive functioning or symptom severity. However, they found that the percentage of days on which the app was used was lower among participants who had a greater reduction in depressive symptoms over the course of the intervention (r=2.36). In the MATS trial, the participants who stopped responding to the intervention had more severe negative symptoms, more impaired daily living skills, and lower premorbid IQ (48). Participants with more severe paranoia in the Mobus trial were unable to engage with the intervention because of suspiciousness of the monitoring nature of the device (44). No other studies reported reasons for response rates. Technical is- sues were reported in three of the five trials (44,46,48), and specific issues related to confidentially and risk of carrying cell phones in public settings were mentioned by participants. Overall acceptability ratings for the interventions were moderate to high. In the MATS trial, partici- pants reported increasing helpfulness of the app over time; however, some technical issues were reported that were re- lated to the usability of the phone response and navigation functions (48). _Clinical outcomes_. The three trials targeting cognitive impairments or daily living skills found improvements in the percentage of goals achieved over the intervention (49), improvements in daily living skills (44,47), and evidence for improved cognitive capacity (44,49). The only study that conducted a follow-up (two weeks postintervention) did not find evidence for sustained increase in goals achieved in the treatment group (49). Four of the five EMI studies also included outcome measures related to change in psychotic symptoms. The Mobus (44) and MATS (48) studies did not detect pre-post changes in symptoms; however, the latter found improvements over time in medication adherence and attitudes, increased socialization, and positive effects on hallucinations (decreased occurrence and severity and controllability). The FOCUS study found significant reductions in depression and in total and positive symptoms but not in negative symptoms (46). Although Pijnenborg and colleagues (49) did not report symptom changes as over- all outcomes, they noted that the group of participants classified as “responders” to the intervention (.20% in- crease in goal achievement over the intervention) showed pre-post reductions in negative symptoms but not in positive symptoms. - Can we use borrow ideas from the three trials to help our patients? But not sure if effect sustain over time. - Did not improve symptoms, but increase medication adherence, attitudes? - Reduction in depressive but not negative symptoms? - I think the result is mixed.. **DISCUSSION** We should interpret the result cautiously. - Four of the five EMI studies conducted analysis to evaluate changes in clinical outcomes, although these should be interpreted cautiously because most trials were uncontrolled. Two of these four studies found improvements in overall and positive symptoms (46) and in negative symptoms (49). The remaining two EMI studies did not find significant pre-post changes to symptoms (44,48), although Granholm and colleagues (48) found improvements in medication adherence, auditory hallucinations, and socialisation over the course of the intervention. Three of the five EMI studies found improvements in cognitive impairments, goal achievement (44,49), and daily living skills (44,47). The only intervention identified that made use of EMA-based methods (43,45,50,51) found that remote monitoring of illness states minimized relapse and hospitalization.  **Broad definition of EMI and EMA. Different studies uses EMA and EMI differently shows that there are many possibilities** - Another use of EMA and EMI has been referred to as an “ecological interventionist–causal model approach” (53). This approach involves testing interventions by linking their specific effects to the putative mechanisms and the targeted outcome (for example, psychotic symptoms). This innovative approach offers a highly reliable method of investigating the causal relationship between intervention and putative psychological mechanisms, which may ultimately lead to enhanced and more sustained effectiveness. What is this?? - ([Reininghaus U, Depp CA, Myin-Germeys I: Ecological interventionist causal models in psychosis: targeting psychological mechanisms in daily life. Schizophrenia Bulletin 42:264–2](evernote:///view/463671/s5/f1ba78a4-efaf-ee4b-67f7-d15501157da1/c24bc1f0-1ab8-482a-b3ed-5d0ab50ef081/)69, 2016 ) **Another project similar to ours is the EMPOWER trial** - The use of EMA for monitoring and detecting signs of relapse clearly has clinical utility; however, future research may benefit from approaching this from a more empowering perspective by allowing users to self-monitor and direct their own needs for intervention. An example of this is the EMPOWER trial (ISRCTN99559262), which is an ongoing study examining the use of a smartphone app in self-monitoring for early warning signs of relapse. This approach emphasizes user control over responses; users are able to notify their case coordinator and nominated caregiver if they choose, and the app suggests strategies for self-management.