# Changing Mental Health and Positive Psychological Well-Being Using Ecological Momentary Interventions- A Systematic Review and Meta-analysis Anke Versluis1, MSc; Bart Verkuil2, PhD; Philip Spinhoven2,3, PhD; Melanie M van der Ploeg1, MSc; Jos F Brosschot1, PhD [[Changing Mental Health and Positive Psychological Well-Being Using Ecological Momentary Interventions- A Systematic Review and Meta-analysis (1).pdf]] [[Ecological Momentary Interventions]] #EMI ## Conclusions To conclude, the meta-analysis found a small to medium effect of EMIs on mental health, and this effect did not differ across the different outcome types. Furthermore, the effect appeared to be larger when the EMI was supported by an MHP. It is important that future research determines how support by an MHP can best be implemented and if this support is a necessity for everyone. In addition, new research studies should investigate what the active features of an EMI are. Overall, the use of EMIs for improving mental health is supported; EMIs offer great potential for providing easy and cost-effective strategies to improve mental health and positive psychological well-being in the population. **The need and value of "self-management" because mental health problem is highly prevalent.** - Mental health problems are highly prevalent, and there is need for the self-management of (mental) health. Ecological momentary interventions (EMIs) can be used to deliver interventions in the daily life of individuals using mobile devices. **What are the effect of EMI on anxiety, depression, and perceived stress and positive psychological outcomes? This is important, because perceived stress may cause relapse.** - **Objectives:** The aim of this study was to systematically assess and meta-analyze the effect of EMI on 3 highly prevalent mental health outcomes (anxiety, depression, and perceived stress) and positive psychological outcomes (eg, acceptance). ## Introduction **There are many people who need help, using technology to reach more people, thus the need for ecological momentary interventions (EMI), seems promising.** - One method that can be used to enhance health self-management is ecological momentary interventions (EMIs) [6]. The key to these interventions is that they can be tailored to the individual and be implemented in real time (ie, daily life). Mobile or electronic devices can be used to provide these interventions in the daily lives of individuals. With a Web-based survey, Proudfoot et al [7] showed that 76% of the general population is interested in using mobile technology for either self-monitoring or self-management of health (ie, if the service was free). Using EMIs has numerous advantages such as the ability to reach large populations at lower costs [8,9]. **EMI allow the user to learn new strategies/behavior right in their natural environment, compare to being in a clinical setting which is not "natural".** - Training people in situ could be highly relevant for learning new, healthy behaviors, considering that people under stress typically switch from _goal-directed behavior_ to _habit behavior_ [10-13]. In other words, when a person experiences stress, that person is more likely to rely on the “old” behavior routine than display the newly learned behavior routine. In line with this, it might make more sense to learn a new behavioral routine in daily life compared with an artificial surrounding (eg, the therapist’s office) that generally does not resemble daily life. Indeed, research shows that although new behaviors can be effectively learned in artificial surroundings, this knowledge does not always generalize to real-life settings [14]. **When people in their natural environment (context), they revert back to their old style of coping (behavior). Thus if people can be retrained in their usual context, it may be more effective.** - According to Neal et al [15], this is understandable, given that the association between context and the maladaptive behavior may still be in place after traditional treatment. As a consequence, the context (eg, setting or time of day) can still trigger the maladaptive behavior. Therefore, EMIs may provide a more effective way to train people in daily life than conventional treatment, by training people in the very context in which the maladaptive behavior occurs. As a result, this could lead to the (faster) formation of a new and more adaptive association between context and behavior. This systematic review and meta-analysis therefore attempts to expand the current knowledge by including both mental health outcomes (ie, perceived stress, anxiety, or depressive symptoms) and positive psychological outcomes (eg, positive affect or acceptance).  ## Discussion ## ### Principal Findings **A total of 33 studies, but study quality generally low due to bias caused by attrition, self-report measures, and not blinded to researcher.** - The systematic review and meta-analysis was a first attempt to examine whether mobile technologies can be used to provide an effective intervention for mental health and under which circumstances this is the case. A total of 33 studies (_n=_ 1301) were used to answer this question, and the included studies varied considerably in terms of study and intervention characteristics. The quality assessment indicated that the reported study quality was generally low. Specifically, the studies were at risk for bias caused by attrition, reliance on self-report measures, and the failure to blind personnel. Moreover, only a few studies reported using strategies to randomly allocate participants to conditions. **When EMI is used with human intervention effect is larger then just EMI alone** - In the within-subject studies (n=1008), a significant medium effect size (Hedges’ _g_) of 0.58 was found. The estimated effect size did not significantly differ per outcome type (ie, anxiety, depression, perceived stress, acceptance, relaxation, and quality of life), although no significant effect was found for relaxation. Moderation analysis suggested that the effect on mental health was 62% larger when the EMI was part of a treatment package that included support of an MHP compared with stand-alone EMI.  Moreover, this moderation analyses showed that the effect of EMI was smaller, but significant, in the population that had access to care as usual while using the EMI (eg, inpatient or outpatient setting). **But the group who require more human interventions may also mean they are harder to change, or human interventions makes more difference?** - It is possible to speculate about what caused this difference in effect; however, a clear comparison of the groups is complicated by the fact that the groups (and included studies) are very diverse. More specifically, the group that received EMIs while also having access to care as usual consisted largely of patients with severe complaints that might be less susceptible to change (eg, schizophrenia or schizoaffective disorders, borderline personality disorder, and substance abuse). **Human interventions with EMI is better, human can encourage increase adherence and motivation. But not sure what's the level of support needed. (This is why IMH doesn't have fully self-help system, need a psychologist involved)** - The finding that the effect of EMIs was stronger when support by an MHP was included is in line with findings from research on Internet interventions (eg, [68,69]). Therefore, although fully automated EMIs can have a positive effect on mental health, it is additionally beneficial to include contact between researcher (or therapist) and participant. This contact could be a helpful tool to increase adherence and motivation, which in turn could result in a stronger effect. Unfortunately, it is currently unknown what levels of support are needed to optimize the effectiveness of EMIs.  - Future studies should differentiate what kind of contact is necessary for improvement. Not only is it important that we learn how much contact is required, but the _when_ (eg, beginning or during intervention), _how_ (eg, via mobile phone, email, or face-to-face), and _what_ (eg, should support focus on adherence or on the intervention) questions are also worth asking when developing evidence-based interventions [69]. In addition, it is worthwhile to consider which individuals stand to benefit from the support and if support is necessary for everyone.  **This is similar to the graded system mentioned elsewhere, EMI as the first line of treatment.** Link to : [Article : Ecological momentary interventions for depression and anxiety](evernote:///view/463671/s5/7c0e4ea9-3922-f1ce-b241-b8551b6dc0a9/c24bc1f0-1ab8-482a-b3ed-5d0ab50ef081/) (Different level of complexity and intervention) - To specify, EMIs can be a valuable (first) step to treat the “worried well” and individuals with mild symptoms. Using EMIs to treat this group could be economically efficient, as mild problems constitute a major part of all reported mental health problems [70]. Treating this group using the cost-effective EMI methodology, frees resources (such as therapists) for those individuals who are in greater need of more intensive interventions. Moreover, it could help to improve the access to and quality of psychological care. Ideally, the progress of the individuals using the EMIs could be monitored so that alternative intervention options can be recommended when an EMI fails to be effective. Alternative intervention options could entail extra support (while using the EMI), an Internet intervention, or face-to-face intervention. Incorporating EMI in a stepped-care program could help in providing intensive intervention only when needed [71]. **Conclusions** To conclude, the meta-analysis found a small to medium effect of EMIs on mental health, and this effect did not differ across the different outcome types. Furthermore, the effect appeared to be larger when the EMI was supported by an MHP. It is important that future research determines how support by an MHP can best be implemented and if this support is a necessity for everyone. In addition, new research studies should investigate what the active features of an EMI are. Overall, the use of EMIs for improving mental health is supported; EMIs offer great potential for providing easy and cost-effective strategies to improve mental health and positive psychological well-being in the population.