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Seminar on e-mental health training

This second Dutch eMEN seminar on April 10, 2018 in Haarlem, is about the development of e-mental health curricula and training  mental health education. With pitches from e-health training providers, workshops and expert keynote speakers.

More information: https://academy.arq.org/eMentalHealthConference2018curriculum

INDUCT: Dementia research and eHealth

Dementia is one of the most common causes of disability and dependency among older adults. Currently there are around 50 million of people living with dementia globally. The number of people living with dementia in Europe in 2015 was estimated in 7.5 million. This number is projected to increase to 14.3 million by 2050. During the last years, eHealth and eMental health have showed potential to reduce the impact of dementia at personal and societal levels.

INDUCT
In 2016 the Interdisciplinary Network for Dementia Utilising Current Technology (INDUCT) was launched, funded by the European Commission through an EU Marie Sklodowska-Curie action . The overall objectives of this initiative are
1 to determine practical, cognitive and social factors to improve the usability of technology
2 to evaluate the effectiveness of technology and
3 to trace facilitators and barriers for implementation of technology in dementia care. Besides these objectives INDUCT aims to provide future researchers with the necessary skills and training increasing the quality of research in the dementia eHealth field.

15 early stage researchers, based in different institutions around Europe including VU and VUmc, are developing, evaluating and/or implementing eHealth solutions in dementia care such as cognitive stimulation apps, promoting physical activity through virtual games (exergaming) for people with dementia, electronic medical records, etc.

iSupport: eMental Health for unpaid caregivers of people with dementia
About 75% of people with dementia live in their own home, cared by family members and/or other unpaid caregivers such as friends or neighbours. Although unpaid care often improves the quality of life of the people with dementia, the unpaid caregivers may experience negative mental health consequences derived from their carer role.

The WHO in collaboration with dementia organizations and a panel of experts developed an online intervention for unpaid caregivers of people with dementia called iSupport. The intervention is meant for caregivers who are not able to access to face-to-face psychological interventions. iSupport can decrease caregiver’s stress, burden, and symptoms of depression and anxiety. The (unguided) intervention consists of 5 modules and a total of 23 lessons providing information about topics related with the caregiver role as being a caregiver, ‘caring for me’, providing everyday care and dealing with challenging behaviour.

Adaptation and research in The Netherlands
We aim to adapt iSupport to the Dutch cultural context and determine the effectiveness. After the adaptation of the intervention, a superiority two-arm randomized controlled trial comparing the effects of iSupport will be carried out in The Netherlands (2018-2019). Unpaid caregivers (n=200) experiencing at least some stress or burden will be recruited. Those caregivers assigned to the experimental group will be provided with access to the intervention for 3 months. Online assessments will be done at baseline (t0), 3 months after baseline (post-intervention, t1), and 6 months after baseline (follow-up, t2).It is expected that iSupport will not only reduce the mental health problems of unpaid caregivers, but also provide them with more support and skills to improve their performance as caregivers and positively influence the quality of life of people living with dementia.

Acknowledgement
The research presented is being carried out as part of the Marie Curie Initial Training Network (ITN) action, H2020-MSCA-ITN-2015, under grant agreement number 676265

More information:
www.dementiainduct.eu
www.mantelzorgersdementie.nl (this link will be available when recruitment starts)
Contact: isupport.fgb@vu.nl

MSc. Ángel C. Pinto Bruno. Promovendus Section of Clinical Psychology, Amsterdam Public Health Research Institute, VU Amsterdam, The Netherlands

eMovit: increasing wellbeing while conducting research using an iPhone app

Eating healthier, exercising more – resolutions like these are easily made. Sticking to new habits, however, is much harder and all too often ends in quickly abandoned resolutions. To support those to whom this sounds awfully familiar in sticking to new habits, we have developed eMovit. eMovit is an iPhone app which not only helps you in developing new, positive behaviours but also gives you the opportunity to participate in innovative research while doing so.

How does eMovit work?

With eMovit, users can schedule positive activities by deciding on which days and at what time they would like to carry out an activity. Users can choose from numerous activities, ranging from small activities such as taking a break to bigger tasks such as eating a healthy meal, or they can create their own activities. Once an activity is planned, eMovit reminds users when it is time to carry out their activity. After doing an activity, users can rate how pleasant they found that activity and if users stick to their new activities over time they will be rewarded with trophies to celebrate their accomplishments.

Based on behavioural activation

eMovit is based on behavioural activation, an evidence-based treatment for depression. The idea of behavioural activation is to support people in engaging in positive, enjoyable activities, thereby reducing depressive symptoms related to inactivity and withdrawal. Behavioural activation strategies include structuring and planning daily activities, exploring new behaviours, and rating how pleasant a new activity was. Ultimately, eMovit may therefore be a useful tool for reducing depressive symptoms by increasing participation in pleasant activities in people with depressive disorders. At the same time, eMovit and its behavioural activation principles may also benefit people without depressive symptoms, by increasing their wellbeing as well.

How do users like eMovit?

To find out what iPhone users think of eMovit, we conducted a small usability study with four participants who tested eMovit for one week. During interviews at the beginning and end of the study and through written feedback throughout the week, we assessed what users like about eMovit, what they would like to see improved, and which problems they encountered.

Overall, participants liked the idea of eMovit and saw potential in the app.  Particularly the design received much positive feedback: participants described it as ‘aesthetically pleasing’ and found the pictures in the app next to the activities to be motivating. Participants also liked the selection of activities to choose from, enjoying especially smaller activities such as ‘give a compliment’ or ‘moment for yourself’. In general, participants liked the positivity of the app, in that it celebrated small accomplishments with them without making them feel guilty for any setbacks. In doing so, participants felt motivated by eMovit to keep sticking to their new behaviours and already celebrated their first small successes:  one participant reported that while testing eMovit she had given far more compliments than before.

 

 

What needs to be improved?

Participants also had various suggestions on how to improve eMovit. Firstly, participants did not find the introduction, which shows up when users first open eMovit, informative enough and would have liked more specific explanations on how to use the app. Moreover, participants did not always receive reminders for their scheduled activities. When scheduling activities, participants would have also liked the option of setting up time-specific reminders, such as Monday at 14:00. Currently, only broad parts of the day – morning, afternoon, and evening – can be chosen, during which a reminder is sent at a random time. Finally, participants would have liked a visual overview of their accomplishments, such as a graph showing the number of activities carried out per day or the days on which participants had done at least one activity. This, participants believed, would further motivate them to stick to their new behaviours.

Based on the feedback we gathered during our study, we are currently improving eMovit, to make it a motivating, easy to use app. Furthermore, we are working on also offering eMovit in German – currently the app is available in Dutch and English.

Conducting research with eMovit

eMovit was designed utilising the Apple ResearchKit (http://researchkit.org), an open-source framework launched in 2015 and designed for health and medical research. ResearchKit enables scientists to develop apps they can then gather participant data with.  A number of apps have already been developed, addressing topics such as asthma or diabetes, but eMovit is one of the first mental health-focused ResearchKit apps.

Once eMovit is updated, we plan on testing our research study built within the app in a larger study sample. Consenting app users will be able to participate in a three-week study by filling out three questions per day about their current mood and happiness and completing a short questionnaire at the beginning and end of the study. On top of that, participants anonymously share their user statistics (e.g., which activities they carried out) for the duration of the study. We aim to investigate whether app users are willing to participate in app-based research, how participants use eMovit, and whether the type and frequency of activities carried out is related to participants’ mood.

I you would like to try out eMovit, you can download the app here: https://itunes.apple.com/nl/app/emovit/id1208136061?mt=8

Embodied Conversational Agents in Clinical Psychology

Following an internet-based therapy can be an effective way to deal with a depression. While some of these therapies can be followed independently, most of them still include some form of support by a therapist or coach. Interventions that do not require support are potentially more accessible and scalable, but thus far supported interventions appear to be a bit more effective. In this project we aim to bridge the gap between guided and unguided interventions by automating human support, or part of it, with embodied conversational agents.

You might know embodied conversational agents (ECAs) under a different name, for example, avatar or virtual character. ECA is an academic term for the concept for which the website www.chatbots.org/ has already identified 161 synonyms, summarized as “humanlike conversational AI entities”. Since this does not exactly make things more clear, a definition is warranted. We are talking about computer programs that (1) have an embodiment, for example on a computer screen, (2) can communicate with users in a human-like manner, and (3) apply artificial intelligence (AI) to show intelligent behavior. Both the balance between these three elements, as well as the complexity with which they can be implemented can differ tremendously. Consider, for example, the difference between a chatbot, represented by a picture, that answers questions in an online store, and a very realistic video gaming character with whom a user can barely interact.

From ELIZA to Ellie
The classical example in psychology is chatbot ELIZA, developed back in 1966 by Joseph Weizenbaum, which simulates a Rogerian therapist. It is still possible to talk to ELIZA if you go to www.masswerk.at/elizabot/. One of the things ELIZA has a lot of trouble with, just like computers in the present, is interpreting semantics. For this reason we are probably still far removed from computers taking over the clinical interviews, and psychologists becoming obsolete. Nevertheless, the field has naturally progressed a lot over the past 50 years, and especially the following Youtube video of virtual counsellor ‘Ellie’ appeals to the imagination: https://www.youtube.com/watch?v=ejczMs6b1Q4. Can we use this kind of technology in routine clinical practice?

Literature review
In our first study we disclosed the research field with a review of the literature. We identified a total of 49 studies that used an ECA in an intervention for people with common mental health disorders. One of our primary interest was the level of evidence that supported the interventions that we found. Had they already been shown to be effective and safe for application in routine practice, was there perhaps some solution with which we could immediately get started, or would we have to follow our own path?

Relatively new
What we found was that most of the interventions were still in the development and piloting phases. The studies mostly dealt with trying out new ideas, and testing their feasibility. Few studies answered important questions that arise when we want to start using new technologies in routine practice: Do symptoms improve? Is it safe to use? What are the long-term effects? Are ECA interventions more effective than the interventions we already have? Of course, this is hardly surprising if we consider that we are dealing with a relatively new field of research; it was only after 2009 that we started seeing an increase in the number of studies that was published.

Simple but effective
Additionally, developing ECA systems such as Ellie is not a trivial task. First of all experts from different disciplines are necessary, for example, computer scientists and psychologists. Furthermore, it can take years to develop the different components that make up an ECA, such as dialog engines, or automated non-verbal behavior. Because the systems can grow very complex, it becomes harder to convince both ethical boards and practitioners to start testing them with real patients. In order to contribute to the evidence base in the limited time-span of a PhD trajectory, we decided to go with a more ‘low-tech’ approach; virtual characters that still match all three criteria mentioned before, but are a lot easier to develop than, for example, Ellie. Furthermore, we chose to limit ourselves to a task and outcome measure that are important in many of our interventions: Ecological Momentary Assessment (EMA), and adherence.

Ecological Momentary Assessment and Adherence
EMA refers to repeated measurements of people’s behavior or experiences, in their own environment, and in the current moment. A good example is the paper diary in which people with depression register their mood over the course of a week, for example, to see whether there might certain recurring events that trigger bad moods. These days paper diaries are being replaced by smartphone applications that are able to send reminders at specific times. In EMA, adherence, or compliance, is very concrete: people either respond or do not respond to the automated requests.

Motivation
This is what we looked at in our second study, in which we investigated whether we could increase adherence with a simple form of visual feedback, and whether we should take into account individual differences in people’s motivation. In a three-week smartphone study, participants reported their mood three times a day in an EMA app. Half of the participants were thanked for their response by an avatar that mirrored their self-reported mood state. Our goal was to see whether lowly motivated participants would become increasingly motivated by a system in which they could recognize themselves. Surprisingly, not the lowly motivated, but the highly motivated participants were the ones to benefit from the feedback in this sense. Thus, an important lesson we learned from this study is that merely giving feedback does not necessarily lead to the desired results, and that it could even work out the other way around.

The next step in this project is the development of a new and generic EMA application. Within this application there will be more room for experimenting with automated feedback, for example through personalization. Building on the paradigm of our second study, our goal is to find out whether inclusion of automated feedback can increase adherence.

Answers and challenges: Mastermind final conference

It already has been three years after the start of the Mastermind project. Now we can look back on the goals of Mastermind and evaluate whether they have been reached. Mastermind is a EU funded implementation project and had four goals:
1) to implement computerized Cognitive Behavioral Therapy and videoconferencing for depression in 15 European regions (http://mastermind-project.eu/partners/)
2) a two-wave implementation of cCBT
3) a systematic evaluation using the MAST framework and
4) to provide the services to at least 5000 patients. At the end guidelines should become available to help the implementation and upscaling in the participating and non-participating regions in Europe.

Differences
At the conference, a nice global overview of the goals and results was given by the project coordinator Claus Duedal Pederson. Mastermind indeed has boosted the use of cCBT and videoconferencing in the participating regions. The number of patients that have been included exceeded the goal and was 11.573. The second wave countries (e.g. some Spanish regions, Estonia, Italy) have adopted information and strategies from the first wave regions (e.g. The Netherlands, Germany, Scotland) and now have cCBT solutions in place. However, the systematic evaluation using the MAST framework is not yet ready, because data could be uploaded until the end of February. Some interesting results were already presented, for example about the differences between countries in the ways cCBT and videoconferencing is given, and about the differences regarding effectiveness, and safety (< 0.1 % suicide attempts). What conclusions can be drawn from these data is not yet clear, but will be presented in the final reports.

You Tube
During the conference more general aspects of innovation in Health care and especially eHealth for psychiatric disorders were discussed. Heleen Riper gave an interesting presentation about these developments. In a discussion panel the experiences in secondary care in the Netherlands were presented. A good moment to pay attention to the outpatient eHealth clinic that was started last year by GGZ inGeest (eHealth@Mind) The whole conference can be watched  on Youtube.

Challenge
The positive thing of Mastermind is clearly that the use of cCBT and videoconferencing was made more widely available. However, the percentages of the patients that are being reached by these services are still relatively low. Even in the Netherlands, where circumstances are very beneficial (the Minister of Health, Welfare and Sports is positive about eHealth, insurance companies reimburse eHealth treatments, mental health organizations have the technical solutions in place etc.) the percentages of cCBT for depression are low (mostly less than 10% of the treatments). Furthermore, it is still not yet clear what the effects of cCBT and videoconferencing are in real life practice, and what factors hinder or facilitate these services in the treatment of depressionMastermind will surely give some answers, but then it will be a challenge to use this knowledge to successfully fine-tune and upscale the use of cCBT and videoconferencing. That is why many of the participants in the Mastermind project will collaborate in another project, ImpleMentALL, which aims to pay attention in more detail to the implementation process in different organizations. Hopefully this successful consortium can add a next step in implementing eHealth for depression.