Self-monitoring Using Mobile Phones in the Early Stages of Adolescent Depression: Randomized Controlled Trial
What follows is the discussion section of the above mentioned article. To read the article in its entirety, click here.
Authors:
Sylvia Deidre Kauer, BBehavSci (Hons); Sophie Caroline Reid, MPsych(Clinical), PhD; Alexander Hew Dale Crooke, BSocSc(Hons); Angela Khor, BA(Hons); Stephen John Charles Hearps, BPsych, PGDipPsych; Anthony Francis Jorm, PhD, DSc; Lena Sanci, MBBS, PhD, FRACGP; George Patton, MD, FRANZCP
Objectives:
"We tested two main hypotheses: (1) people who monitored their mood, stress, and coping strategies would have increased ESA ["emotional self-awareness"] from pretest to 6-week follow-up compared with an attention comparison group, and (2) an increase in ESA would predict a decrease in depressive symptoms."
References used and mentioned in the original article:
1. Preacher KJ, Kelley K. Effect size measures for mediation models: quantitative strategies for communicating indirect effects. Psychol Methods 2011 Jun;16(2):93-115.
2. Morris ME, Kathawala Q, Leen TK, Gorenstein EE, Guilak F, Labhard M, et al. Mobile therapy: case study evaluations of a cell phone application for emotional self-awareness. J Med Internet Res 2010;12(2):e10
3. Pennebaker JW, Zech E, Rime B. Disclosing and sharing emotion: psychological, social and health consquences. In: Stroebe MS, Stroebe W, Hansson RO, Schut H, editors. Handbook of Bereavement Research: Consequences, Coping and Care. Washington, DC: American Psychological Association; 2001:517-539.
4. Saari C. Emotional competence and self-regulation in childhood. In: Salovey P, Sluyter DJ, editors. Emotional Development and Emotional Intelligence: Educational Implications. New York, NY: Basic Books; 1997:35-66.
5. Prochaska JO, Diclemente CC. Transtheoretical therapy: towards a more integrative model of change. Psychotherapy (Chic) 1982;19(3):276-288.
6. Rickwood D, Cavanagh S, Curtis L, Sakrouge R. Educating young people about mental health and mental illness: evaluating a school-based programme. Int J Ment Health Promot 2004;6(4):23-32.
7. Tylee A, Haller DM, Graham T, Churchill R, Sanci LA. Youth-friendly primary-care services: how are we doing and what more needs to be done? Lancet 2007 May 5;369(9572):1565-1573.
8. Reid SC, Kauer SD, Hearps SJ, Crooke AH, Khor AS, Sanci LA, et al. A mobile phone application for the assessment and management of youth mental health problems in primary care: a randomised controlled trial. BMC Fam Pract 2011;12:131
9. Page MJ, French SD, McKenzie JE, O'Connor DA, Green SE. Recruitment difficulties in a primary care cluster randomised trial: investigating factors contributing to general practitioners' recruitment of patients. BMC Med Res Methodol 2011;11:35
10. Williamson MK, Pirkis J, Pfaff JJ, Tyson O, Sim M, Kerse N, et al. Recruiting and retaining GPs and patients in intervention studies: the DEPS-GP project as a case study. BMC Med Res Methodol 2007;7:42
11. Denholm JT, Gordon CL, Johnson PD, Hewagama SS, Stuart RL, Aboltins C, et al. Hospitalised adult patients with pandemic (H1N1) 2009 influenza in Melbourne, Australia. Med J Aust 2010 Jan 18;192(2):84-86.
12. Fritz MS, Mackinnon DP. Required sample size to detect the mediated effect. Psychol Sci 2007 Mar;18(3):233-239.
13. Hayes AF. Beyond Baron and Kenny: statistical mediation analysis in the new milennium. Commun Monogr 2009;76(4):408-420.
14. Spence SH, Sheffield JK, Donovan CL. Preventing adolescent depression: an evaluation of the problem solving for life program. J Consult Clin Psychol 2003 Feb;71(1):3-13.
What follows is the discussion section of the above mentioned article. To read the article in its entirety, click here.
Authors:
Sylvia Deidre Kauer, BBehavSci (Hons); Sophie Caroline Reid, MPsych(Clinical), PhD; Alexander Hew Dale Crooke, BSocSc(Hons); Angela Khor, BA(Hons); Stephen John Charles Hearps, BPsych, PGDipPsych; Anthony Francis Jorm, PhD, DSc; Lena Sanci, MBBS, PhD, FRACGP; George Patton, MD, FRANZCP
Objectives:
"We tested two main hypotheses: (1) people who monitored their mood, stress, and coping strategies would have increased ESA ["emotional self-awareness"] from pretest to 6-week follow-up compared with an attention comparison group, and (2) an increase in ESA would predict a decrease in depressive symptoms."
Discussion:
"The
current study examined the use of a mobile phone self-monitoring
program on ESA ["emotional self-awareness"] with young people who had mild or more depressive
symptoms, and supported the hypothesis that self-monitoring mood,
stress, and coping strategies increases awareness of emotions. The
second hypothesis that an increase in ESA would predict a decrease in
depressive symptoms was also supported. Based on Preacher and Kelley’s
proportion of the maximum possible indirect effect [1], there was a large effect of the intervention program on depressive symptoms indirectly via ESA.
This
study supports previous research suggesting that simple self-monitoring
techniques effectively increase self-awareness, in this case, awareness
of one’s own emotions [2,3]. Metacognitions, such as self-awareness, are developed during early adolescence [4],
and interventions can be developed that target young people’s ability
to recognize emotions, identify emotional states, understand the
contextualization of emotions, communicate this emotional knowledge, and
plan and make constructive decisions about emotions. Increasing ESA is a
core process in the early stages of therapy [5].
The current study demonstrates the potential for targeting ESA in
first-step intervention strategies for young people with mild or more
depressive symptoms. This randomized controlled trial was conducted with
a view of representing a wide variety of young people who visit GPs
with a range of medical and psychological problems and severity of
problems. Therefore, the results of this study are applicable to this
age group in general.
Self-monitoring techniques
may provide an alternative to watchful waiting as a first-step
intervention in the stepped-care approach. Mobile phones are ideally
suited to this purpose, as the mobiletype program can be downloaded to
patients’ own mobile phones to help young people understand and manage
mild depressive symptoms. Detailed information about patients’ mental
health in recent weeks is then uploaded to GPs in an easy-to-read
format, saving time in appointments and allowing progression to more
intensive second-step interventions when needed. Young people often do
not recognize mental health problems [6] and instead attend GP clinics for somatic complaints rather than mental health symptoms [7].
Using self-monitoring techniques with young people who present with
underlying somatic complaints may increase their ESA and help young
people initiate treatment for depression.
Our
secondary hypothesis that the intervention program participants would
have a decrease in rumination when compared with those in the comparison
program was not supported. Further research is needed to determine
whether there is an inverse relationship between rumination and ESA.
Nevertheless, rumination decreased over time as did depressive symptoms [8], further supporting the positive relationship between depression and rumination.
Primary care is a particularly difficult setting in which to conduct randomized controlled studies [9,10].
In this study, recruitment was delayed and ceased before the
anticipated sample size was recruited due to the H1N1 influenza
pandemic, first detected in Melbourne on May 9, 2009 [11],
and during school holidays. These delays resulted in uneven numbers in
the two groups. We strongly recommend allocating extra time for
recruitment in primary care compared with other settings, particularly
in youth-focused studies. The intervention program had no direct effect
on depressive symptoms. One interpretation of these results is that
there was reduced power for a direct effect given that depressive
symptoms decreased significantly over time in both groups. It is
possible that both groups had a decrease in depressive symptoms due to
the resources, training, and support given to the GPs; however, a larger
sample size, or a wait-list control group, would be needed to determine
whether depressive symptoms differed between the groups [12,13]. Finally, Reid et al [8]
detail other limitations: a cluster randomized controlled trial, in
which GPs rather than patients are randomly allocated, may have been
more appropriate but was rejected during the study design due to the
difficulty in blinding GPs and participants to the randomization
procedure; and participant heterogeneity in illness type, severity, and
familiarity with their GP due to broad inclusion criteria needed in an
effectiveness trial is likely to have reduced the overall power of the
study.
To our knowledge, this is the first
randomized controlled trial examining the use of a mobile phone
self-monitoring program as an intervention tool for young people with
depressive symptoms. Self-monitoring was shown to effectively decrease
depression via the mechanism of ESA, suggesting that self-monitoring
programs that focus on increasing ESA may provide a useful framework for
first-step care in depression. The program provided GPs with
information about a young person’s daily activities and can be used to
detect early signs of mental health problems, such as elevated negative
mood, stress and causes of stress, maladaptive coping strategies,
isolation from peers, diet, and exercise, as well as other risk and
protective factors. The mobile phone self-monitoring program has the
advantage of being low cost, quick, and easy to use.
In
summary, mobile phones are well suited to first-step interventions,
providing an alternative to watchful waiting and allowing young people
to provide accurate information to their GPs about their mood and stress
[14], as well as
shortening the length of time it would take to relay this information to
GPs in a usual appointment. Mobile phone self-monitoring programs
should be considered as a first-step low-cost intervention with young
people who are at risk of mental health problems. Self-monitoring has
the advantages of helping young people increase their ESA while gaining
more information about their mental health symptoms in order to direct
them to the best intervention."
References used and mentioned in the original article:
1. Preacher KJ, Kelley K. Effect size measures for mediation models: quantitative strategies for communicating indirect effects. Psychol Methods 2011 Jun;16(2):93-115.
2. Morris ME, Kathawala Q, Leen TK, Gorenstein EE, Guilak F, Labhard M, et al. Mobile therapy: case study evaluations of a cell phone application for emotional self-awareness. J Med Internet Res 2010;12(2):e10
3. Pennebaker JW, Zech E, Rime B. Disclosing and sharing emotion: psychological, social and health consquences. In: Stroebe MS, Stroebe W, Hansson RO, Schut H, editors. Handbook of Bereavement Research: Consequences, Coping and Care. Washington, DC: American Psychological Association; 2001:517-539.
4. Saari C. Emotional competence and self-regulation in childhood. In: Salovey P, Sluyter DJ, editors. Emotional Development and Emotional Intelligence: Educational Implications. New York, NY: Basic Books; 1997:35-66.
5. Prochaska JO, Diclemente CC. Transtheoretical therapy: towards a more integrative model of change. Psychotherapy (Chic) 1982;19(3):276-288.
6. Rickwood D, Cavanagh S, Curtis L, Sakrouge R. Educating young people about mental health and mental illness: evaluating a school-based programme. Int J Ment Health Promot 2004;6(4):23-32.
7. Tylee A, Haller DM, Graham T, Churchill R, Sanci LA. Youth-friendly primary-care services: how are we doing and what more needs to be done? Lancet 2007 May 5;369(9572):1565-1573.
8. Reid SC, Kauer SD, Hearps SJ, Crooke AH, Khor AS, Sanci LA, et al. A mobile phone application for the assessment and management of youth mental health problems in primary care: a randomised controlled trial. BMC Fam Pract 2011;12:131
9. Page MJ, French SD, McKenzie JE, O'Connor DA, Green SE. Recruitment difficulties in a primary care cluster randomised trial: investigating factors contributing to general practitioners' recruitment of patients. BMC Med Res Methodol 2011;11:35
10. Williamson MK, Pirkis J, Pfaff JJ, Tyson O, Sim M, Kerse N, et al. Recruiting and retaining GPs and patients in intervention studies: the DEPS-GP project as a case study. BMC Med Res Methodol 2007;7:42
11. Denholm JT, Gordon CL, Johnson PD, Hewagama SS, Stuart RL, Aboltins C, et al. Hospitalised adult patients with pandemic (H1N1) 2009 influenza in Melbourne, Australia. Med J Aust 2010 Jan 18;192(2):84-86.
12. Fritz MS, Mackinnon DP. Required sample size to detect the mediated effect. Psychol Sci 2007 Mar;18(3):233-239.
13. Hayes AF. Beyond Baron and Kenny: statistical mediation analysis in the new milennium. Commun Monogr 2009;76(4):408-420.
14. Spence SH, Sheffield JK, Donovan CL. Preventing adolescent depression: an evaluation of the problem solving for life program. J Consult Clin Psychol 2003 Feb;71(1):3-13.