# 20211120 All about EMA and EMI #hope-s Reference [[List of EMA EMI SYSTEMS]] [[Systematic Review of Digital Interventions Project]] ## Introduction to Ecological Momentary Assessment Research methods that examine this landscape from 10,000 feet cannot shed light on how this landscape is shaped at ground level” (Shiffman 2005, p. 1743)[[Ecological Momentary Assessment. Saul Shiffman, Arthur A. Stone, and Michael R. Hufford#^4a81d8]] Diagnosis of psychopathology are based on functional impairments expressed in real-world settings yet behavior are seldom studied, assessed or observed in real world. Usually done by interviews, self-reporting [[Ecological Momentary Assessment. Saul Shiffman, Arthur A. Stone, and Michael R. Hufford#^2119c3]] Asking patient to recall past behavior, emotions do not convey the whole complex interactions of different factors, or allow us to notice the changes that have taken place [[Ecological Momentary Assessment. Saul Shiffman, Arthur A. Stone, and Michael R. Hufford#^f47f75]] EMA are quick assessment methods to provide us with snap shots of the changes in patient's mood, behavior, experience in the real world across time. [[Ecological Momentary Assessment. Saul Shiffman, Arthur A. Stone, and Michael R. Hufford#^fd7ce5]] EMA collect data from the real world environment of subjects, thus "ecological". The assessments focuses on subjects moment to moment experiences (which reduces recollection bias). EMA can be time-based (i.e tracking mood state throughout the day), or event-based (e.g Whenever there is an hallucination, smoke, alcohol use, panic attack) depending on study interests, thus when subject complete the multiple assessments, it provide a picture of how experiences, behavior varied across time and situations. [[Ecological Momentary Assessment. Saul Shiffman, Arthur A. Stone, and Michael R. Hufford#^531865]] ## EMA is not new. Ecological Momentary Assessment (EMA) is a collection of methods of collecting subjects' behavior and experience in their natural environments repeatedly in real-time. [[Ecological Momentary Assessment. Saul Shiffman, Arthur A. Stone, and Michael R. Hufford#^2d038d]] EMA is not new, traditionally, it was written diaries for research. Observation of behavior throughout the day in natural environment, beeping people at random time to record activity, mood/thoughts. [[Ecological Momentary Assessment. Saul Shiffman, Arthur A. Stone, and Michael R. Hufford#^1b0b1a]] - The oldest is the use of written diaries for research (Verbrugge 1980), which was systematically deployed in clinical re- search in the 1940s.  - Self-monitoring of particular behaviors or experiences (Korotitsch & Nelson-Gray 1999) - Self-monitoring of particular targets; a prominent example is the Rochester Interaction Record (Reis & Wheeler 1991), which subjects used to record every social interaction.  - Kansas School of Ecological Research (Barker 1978) on continuous observation of behavior through the day in the natural environment. - ethnographic method of describing individuals’ allocation of time, often to describe differences among societies (Szalai 1966). - Czikszentmihalyi and colleagues (DeVries 1992, Hektner et al. 2007) of the Experience Sampling Method,  using pagers to “beep” people at random times to prompt them to complete diary cards reporting their activity, mood, and/or thoughts.  - wearable cardiac monitors, has been used for several decades as a means of understanding the link between experience and cardiovascular health (Turner et al. 1994). - physiological monitoring to other parameters, such as galvanic skin response, temperature, motion, and others (Wilhelm et al. 2003) - EMA assessment of behaviors (e.g., pill taking; Cramer et al. 1989) and even of the physical environment (e.g., air sampling; Saito et al. 2005). ![[Article - Mood disorders in everyday life#^53041f]] ## Why use EMA? How is this different from survey, or interview methods? Interviewing methods, or Surveys depends on the subjects' memory of events that happened in the past. 1. There will be Recall Bias, as recollection is reconstruction of memories. [[Ecological Momentary Assessment. Saul Shiffman, Arthur A. Stone, and Michael R. Hufford#^13c86f]] 2. Subjects use a variety of cognitive heuristics to estimate what interviewers are asking. [[Ecological Momentary Assessment. Saul Shiffman, Arthur A. Stone, and Michael R. Hufford#^549a0c]] 3. Person's current context and mental state affect recollection of memory. When the person experience negative mood, they will recall more negative information. [[Ecological Momentary Assessment. Saul Shiffman, Arthur A. Stone, and Michael R. Hufford#^c36c7e]] 4. Recollection is influenced by what we know or believe rather than actually recall. Memory are "reorganized" to fit into coherent script or theory of events. [[Ecological Momentary Assessment. Saul Shiffman, Arthur A. Stone, and Michael R. Hufford#^40537b]] 5. When comparing results from Recall-Based data and EMA, recall-based data tend to yield higher results. i.e Subject recall more frequent, more intense, longer lasting symptoms. [[Ecological Momentary Assessment. Saul Shiffman, Arthur A. Stone, and Michael R. Hufford#^79f0df]] 6. Behavioral frequency overestimated in recall. [[Ecological Momentary Assessment. Saul Shiffman, Arthur A. Stone, and Michael R. Hufford#^d8fe20]] ## Types of EMA Uses [[202201271525 Types of EMA]] ^441bba 1. In understanding individual differences EMA can be use in comparing individual pre and post intervals. E.g Before and After interventions, and tracking intensity of distress. [[Ecological Momentary Assessment. Saul Shiffman, Arthur A. Stone, and Michael R. Hufford#^0d29eb]] 2. In understanding natural history, EMA can be used to follow a subject across time to understand the course of symptoms. [[Ecological Momentary Assessment. Saul Shiffman, Arthur A. Stone, and Michael R. Hufford#^304ff2]] 3. It allow examination temporal sequences of events or experiences, and it's effect on consequences of events or behavior. E.g Patient's affect before and after experience of hallucinations. [[Ecological Momentary Assessment. Saul Shiffman, Arthur A. Stone, and Michael R. Hufford#^7296d3]] 4. To examine contextual associations or interaction between two (or more) phenomena that co-occur in time. (This is most interesting to me!) [[Ecological Momentary Assessment. Saul Shiffman, Arthur A. Stone, and Michael R. Hufford#^e0dfd1]] 1. _Myin-Germeys et al. (2001) examined emotions accompanying stressful events as a way to test a diathesis-stress model of schizophrenia. They postulated that vulnerability to schizophrenia would be reflected in excess emotional responses accompanying stress. Schizophrenics, their first-degree relatives (who are genetically vulnerable), and normal controls were assessed 10 times daily about stressful events and mood. An examination of individual differences in average mood showed that the schizophrenics reported more negative affect and more stressful events, whereas vulnerable individuals and normal controls did not differ. But a look at stressor-mood associations revealed that the first-degree relatives reacted more strongly than did controls. Thus, examination of the association between stressors and mood at particular moments was key to understanding what vulnerabilities might be conferred by a genetic predisposition to schizophrenia._ 2. _whether positive and negative emotions are polar opposites or are independent dimensions and can be experienced simultaneously. Feldman- Barrett & Russell (1998) used EMA data to address the argument that although one could be both happy and distressed over some interval of time, in a particular moment, one could be either happy or distressed but not both._ 3. _Although most designs examine associations between different variables within the same person, an interesting variation considers how one person in a relationship affects the other (Bolger & Laurenceau 2005). For example, Larson & Richards (1994) asked members of families to track their experience in parallel and examined how the mood of each affected the other. They found, for example, that a hus- band’s mood when he comes home from work significantly influences his wife’s mood, but not vice versa._ This is particularly interesting for me, from a systemic perspective, illness are symptoms of relational issues. Often it got something to do with familial/relational dynamics. If we can have this kind of contextual associations analyses from different family members. How each EMA interacts with each other. We can make the "invisible visible" and perhaps even intervene. ## Can EMA be predictive? I don't really understand. - EMA-based measures of job strain predicted progression of arterial occlusion - Heart rate assessed by EMA in the natural environment also independently predicted progression of carotid blockage, whereas heart rate measured in the lab did not. - Smokers who engaged in "negative affect smoking" (They have negative mood before smoking) tend to relapse after they quit smoking. [[Ecological Momentary Assessment. Saul Shiffman, Arthur A. Stone, and Michael R. Hufford#^bb9429]] ## How to design EMA? [[202201271526 How to design EMA?]] EMA can be divided into event-based sampling and time-based sampling schemes. ^e07bb7 ### Event-Based Sampling [[Ecological Momentary Assessment. Saul Shiffman, Arthur A. Stone, and Michael R. Hufford#^40d433]] It could be instances of a relapse of drinking, violence, panic attacks. It is user defined. User determine if that event has occurred Recording of events can show frequency and time distribution. User can press a button to log to start recording (other data such as duration, intensity, antecedent mood etc). There is no way to verify/assess compliance. Subject to poor compliance of falsification ### Time-Based Sampling [[Ecological Momentary Assessment. Saul Shiffman, Arthur A. Stone, and Michael R. Hufford#^61b581]] Used to monitor clinical phenomena such as pain, mood, which varied continuously. The frequency of time-based assessments is dependent on resolution the study needed. The intervals could be fixed intervals - common for blood pressure monitoring, or varied intervals. ^9f1738 Will have to consider the subject burdens in responding to EMAs.  Should be during waking day, 10-10pm etc ^2048f6 ### Combination Sampling Design [[Ecological Momentary Assessment. Saul Shiffman, Arthur A. Stone, and Michael R. Hufford#^49a069]] Depending on the nature of the study, time and event based design can be combined. Such as panic attacks (Margraf et al. 1987), binge eating episodes Engel et al. 2007 -- does negative affect come before binge eating?, Smoking cessation, Pain relief after taking medicine, Drinking habits. Some studies also include some degree of retrospection. Thus researcher must consider the biases even for a short interval. Even though we may have assessed their mood 12 times in a day, and found them happy each time, it is possible that they experienced moments of misery in between the assessments.  Combine objective (passive data) to compliment active EMA to cover the whole day. [[Ecological Momentary Assessment. Saul Shiffman, Arthur A. Stone, and Michael R. Hufford#^bf81e9]] ## Using EMA in Clinical Setting [[202201271528 EMA can be use to understand antecedent or precipitating events to an event]] - In Assessments: EMA could also prove useful in shedding light on processes and mediators of psychotherapy-induced change (i.e “Let’s figure out what led up to your anxiety attack so we can understand it and think about how to prevent it”)[[Ecological Momentary Assessment. Saul Shiffman, Arthur A. Stone, and Michael R. Hufford#^00b4c3]] For interventions: EMA-based momentary intervention (EMI) remains a promising, but only partly proven, idea. EMA-based treatment can provide behavioral guidance or other interventions (e.g., relaxation stimuli) throughout a patient’s day as well as just at the moment they are needed. This is the idea we have for HOPE-S. [[202201271530 EMA can help patients increase Emotional Self-Awareness (ESA)]] EMA questions have to make sense both from investigator's and subject's perspective. [[Ecological Momentary Assessment. Saul Shiffman, Arthur A. Stone, and Michael R. Hufford#^f7ed21]] Seeing the same questions repeatedly a few times a day can be annoying [[Ecological Momentary Assessment. Saul Shiffman, Arthur A. Stone, and Michael R. Hufford#^553d23]] EMA are still a form of self-reporting, thus there is still the question of validity and reliability to think about. [[Ecological Momentary Assessment. Saul Shiffman, Arthur A. Stone, and Michael R. Hufford#^ad3a62]] Ideas: Illness and Symptom Monitoring [[Article Ecological Momentary Assessment and Intervention in the Treatment of Psychotic Disorders A Systematic Review#^21aa86]] Self-Management and Psychosocial Functioning [[Article Ecological Momentary Assessment and Intervention in the Treatment of Psychotic Disorders A Systematic Review#^f0ca6c]] ## Methodological Considerations ^e1a9af ### Reactivity Behavior or experience can potentially be affected by the act of assessing it. Reactivity is not universal. It may only be present in some kind of phenomenon. But we don't know when it occur. [[Ecological Momentary Assessment. Saul Shiffman, Arthur A. Stone, and Michael R. Hufford#^bcdbcc]] ### Compliance Another challenge/consideration is how to ensure subjects comply with answering EMA? For diary base EMA, subjects may backfiling the entries. Falsification. That result in inaccuracies. [[Ecological Momentary Assessment. Saul Shiffman, Arthur A. Stone, and Michael R. Hufford#^fc071f]] ### Special Population Another consideration is whether children, elderly, mental patients are suitable for EMA. Concerns also arise about whether some clinical populations might be unable to perform in EMA studies precisely because of their psychopathology. But should be OK [[Ecological Momentary Assessment. Saul Shiffman, Arthur A. Stone, and Michael R. Hufford#^bac39f]] ### Selection Bias Those to sign up for study, and hardworking enough to complete demanding EMA are not representative of the populations. [[Ecological Momentary Assessment. Saul Shiffman, Arthur A. Stone, and Michael R. Hufford#^6d5f47]] What EMA questions do other ask? ## What will be the guiding principles of designing EMA, and EMI. #Conceptual_Framework [[List of EMA EMI SYSTEMS#^9c825a]] #stress_vulnerability_model #cognitive_model ## Domains of interests 1. Five General Domains: #medication_adherence Adherence, Mood Regulation, Sleep, Social Functioning/ #socialization , Coping with #auditory_hallucinations [[List of EMA EMI SYSTEMS#^65ee57]], [[List of EMA EMI SYSTEMS#^b83479]] 4. What are the different EMIs, and level of complexities? 5. Evidence so far? [[202111201646 20211120 What are Ecological Momentary Assessments (EMA)]] [[Use of Ecological Momentary Assessment and Intervention in Treatment With Adults]] Although additional, rigorous research is needed to understand when and how to maximize the efficacy of EMA and EMI, these techniques may be useful adjuncts for psychotherapy. In the framework of CBT, the notion of bringing the therapy material into the patient’s natural environment fits with the concept of generalization (or the application of learning outside of the context in which it initially occurs). The use of EMA may help to enhance the clinician’s understanding of the topography and function of a given behavior or thought pattern in the client’s usual environment and in the flow of his or her usual routine. This functional understanding may be further enhanced when data about location are collected either actively (respondent input) or passively (through the device’s GPS function). EMA also provides a window into the client’s life that is somewhat unfettered by the usual threats to the validity of autobiographical recall. Typically, when clinicians query about a patient’s week, the information that the client provides may be influenced by memory limitations or by the client’s current mood or cognitive state (13). Furthermore, systematic memory biases associated with depression or anxiety may further influence responding retrospectively (34). In other words, EMA offers a method for the client and therapist to collaboratively investigate behavior in context in real time, circumventing the problems of hindsight bias or inaccurate reporting that may result from retrospective recall. EMA can be used to develop a better understanding of the functional antecedents and correlates of a given behavior pattern that could, in turn, be used in planning interventions. EMI can take this a step farther: Therapists capitalizing on EMI technology have a rare opportunity to expand the context in which therapeutic learning can occur from the therapy room to the patient’s real-world environment. # EMI approaches Reference: [[An overview of and recommendations for more accessible digital mental health services]] ![[An overview of and recommendations for more accessible digital mental health services#^1836ba]] 1. Guided Interventions 2. Self-directed Interventions 3. [[202202171123 Blended Approach EMIs]] Ema use in suicide prevention