Background
Major depressive disorder (MDD) is a highly prevalent mental disorder with large disease burden for patients, their relatives, and society [
1,
2]. Due to its intermittent course, where remission is often followed by relapse [
3] or persistence of depressive complaints, there is a large and growing need to improve treatment outcome. This is particularly the case for those who have been unresponsive, or insufficiently responsive, to stepwise protocolized pharmacological and psychotherapeutic treatments [
4]. These patients are considered difficult-to-treat and further personalization of treatment is needed. Clinicians typically personalize psychological treatment through (re-)investment in a patientۥ s case conceptualization [
5]. In case conceptualization patients and clinicians develop a holistic working theory about the patient’s psychopathology.
The core feature of case conceptualization is the active participation of both the patient and clinician. In close collaboration, both combine their unique expertise to describe and explain the patient’s psychopathology in a holistic theory, or case concept. In short, case conceptualization involves: i) describing the presenting patient’s psychopathology, ii) providing a working hypothesis about the psychological mechanisms that drive or maintain a patient’s psychopathology, iii) organizing and integrating patient information based on the judgment of the clinician, and iv) informing diagnosis and treatment [
5]. However, although well-established, there is no gold standard for the methodology and theoretical basis of case conceptualization [
5‐
7]. This results in a lack of consensus on the essential features of case conceptualization and low inter-rater reliability between case concepts of different clinicians [
8,
9]. Contributing factors might be that a case concept is based on retrospective information and depends on the questions asked by a particular clinician. These issues can be addressed by systematic momentary monitoring in a patient’s normal daily-life and subsequently providing feedback on this information during a subsequent regular consult. A scientific method to obtain this goal is the experienced sampling method (ESM).
ESM involves repeated sampling of momentary affect, cognitions, and/or behavior, typically via a patient’s own smartphone [
10]. Prolonged ESM monitoring (i.e., weeks, months) results in time-series data, which can reveal the dynamic course of psychopathology in individuals [
11,
12]. ESM holds the promise to advance the case conceptualization process for notable reasons: i) ESM provides patients and clinicians access to momentary information, thereby reducing retrospective bias [
10,
13,
14]; ii) ESM promotes the patients’ reflections and insights in his/her own psychopathology by intensive self-monitoring [
15]; and iii) ESM derived time-series data can be summarized into personalized feedback reports with intuitive visualizations of the course of the data (e.g., [
16]). Such feedback may be further improved through more sophisticated analyses on the time-series data. A method that may hold particular promise for case conceptualization are person-specific network models [
17,
18]. Proof-of-principle studies showed that results from such network models may be used as a starting point for a dialog between the patient and clinician during regular consults (e.g. [
16,
19,
20].
The efficacy of ESM-based feedback as a therapeutic tool in decreasing depressive symptoms in outpatients diagnosed with depression was first shown in a pioneer randomized controlled trial (RCT,
n = 102 [
21];). The treatment as usual (TAU) condition primarily consisted of pharmacotherapy, with less than 10% of the patients receiving additional psychotherapeutic treatment. In the experimental condition of this study, patients received TAU and monitored their momentary positive affect for 6 weeks. Every week a feedback report was generated from the collected time-series data by a clinical researcher, who discussed the feedback with the patient and his/her clinician. In another, more recent pragmatic RCT in patients indicated for treatment for depression (
n = 161, [
22,
23]), efficacy of ESM-based feedback added to pharmacological and/or psychotherapeutic TAU was not established. In this study, patients monitored their momentary positive and negative affect for 4 weeks. ESM monitoring started after the intake procedure while the patient was waiting for psychotherapeutic treatment, continued monitoring during treatment and weekly feedback was emailed to the patient. The fourth feedback report was discussed with the patient and a research assistant. The authors concluded that, while ESM-based feedback in depression treatment was highly appreciated by both patients and clinicians in their study, its promise to augment the efficacy of regular depression treatment was not met. However, they cannot rule out that it advanced other domains (e.g. acquire better self-insight), or provided a more efficient way of delivering care (i.e. more patients may be treated when combining face-to-face sessions with ESM compared to full face-to-face treatment). Besides notable differences between the two ESM studies outlined above [
21,
23], they have in common that ESM was neither personalized nor fully integrated into patient’s psychotherapeutic treatment.
Interestingly, recent research findings from patients and clinicians stress the importance of personalizing ESM assessment and feedback [
15]. Furthermore, Bos and colleagues recommended that ESM should be implemented by an interdisciplinary team of patients, clinicians, researchers, and information technology specialists. These recommendations are in line with the clinical process of case conceptualization outlined above. The present study follows these recommendations by implementing them in a new ESM-based intervention: the Therap-i module. In Therap-i fixed ESM items will be supplemented with personalized items to cover core elements of the case concept of each individual. Patients and their clinicians will collaborate, together with the researcher, in personalizing ESM and, discussing ESM-derived feedback results in feedback sessions to advancing the case conceptualization process. Therap-i feedback includes graphs on daily fluctuations of scores on the ESM items, their associations, and contextual information (e.g. notes on (un) pleasurable events, company and activities). Researchers will assist patients and their clinicians during the entire procedure. This approach may anchor the case concepts more robustly in the patient’s narrative during psychotherapeutic treatment.
Study aims
We aim to test the efficacy of the Therap-i module as a supportive tool in psychotherapeutic TAU in MDD patients, who have been insufficiently responsive to protocolized treatments for depression. We hypothesize that the Therap-i module is effective in these patients in i) decreasing depressive symptom severity (primary outcome), ii) increasing general functioning, iii) increasing the therapeutic working alliance, and iv) improving illness perception (more specifically, increased illness insight, increased personal control over the illness, increased control through treatment, and reduces emotional representation of the illness). After treatment, self-management strategies will be examined and the Therap-i module will be evaluated by both patients and clinicians with quantitative and qualitative instruments. This paper provides a detailed overview of the patient inclusion procedure, instruments, and ESM protocol used in the Therap-i study. Furthermore, potential pitfalls and promises of the module are discussed.
Discussion
The ongoing global digitalisation influences the possibilities to monitor and manage our health and behaviours, and holds potential to improve outpatient mental healthcare. While routine outcome monitoring is being used to evaluate and compare treatment outcomes and process variables [
57], the use of more frequent repeated measurements to assess psychopathological complaints has been limited. Currently existing monitoring routines are not fully taking advantage of the potential of these repeated measurements to obtain a fine-grained view on triggers and perpetuating factors of psychopathology. ESM offers the possibility to bring relevant information from outpatients’ daily life into regular consultations, enhancing a systematic personalized characterization of a patient’s psychopathology. In order to fulfil its promise to support precision psychiatry, ESM monitoring needs to be implemented in clinical practice, become part of the treatment process, and allow for personalization [
58]. Until now, personalized ESM monitoring during psychotherapeutic treatment has not been researched as a supportive tool and with our pragmatic RCT study we aim to fill this gap. The unique contribution of our study is the integration of personalized ESM into regular outpatient treatment for depression. Quantitative and qualitative outcome variables will be combined to examine the added value of the Therap-i module. Specifically, the use of qualitative methods complements interests in clinical practice, since recovery and empowerment of patients are concepts which are difficult to grasp with quantitative measures. Data collection has started and will continue for at least another year. In short, the intent of the Therap-i module is to support the case conceptualisation process by increasing insight in a patient’s complaints and motivating change in behaviour through informed treatment strategies. As such the module may advance treatment efficacy for depression and the quality and duration of recovery from depression.
The following potential challenges should be mentioned. First, when interpreting our results, we have to take into account the selection bias of who was willing to enrol in the study. Not all patients and clinicians will be able, or are motivated, to invest time and effort needed to successfully participate. However, enrolment will show an accurate impression of the level of adoption of the module in this particular sample in clinical practice. Second, the study tests a combination of potentially active components in the Therap-i module: focus on resilience (via the resilience interview), ESM monitoring, the feedback rapport, and the collaborative discussion of the feedback results. Clear conclusions about the active ingredients are not warranted and more research will be needed for detailed insight into this matter. However, through our, quantitative and specifically qualitative evaluation of the Therap-i module, we gather information on these separate components to aid further testing and development. Third, the trial is “pragmatic” because it is designed to fit into regular clinical practice, which involves some flexibility in the procedure (e.g., different types and dose of TAU, different centers and therapists, a range of different comorbidities). The resulting heterogeneity may reduce statistical power and hide a potential effect of the Therap-i module. However, the fact that the trial is pragmatic also is a testament to the possibility to implement the module in clinical practice. Fourth, in case we find evidence that the Therap-i module is effective and a valuable contribution to the treatment of MDD patients, the findings cannot be generalized to other patient groups without additional study. Fifth, future large-scale clinical implementation of the Therap-i module would likely differ from this study because ideally patients and clinicians are able to implement the module independently without involvement of a researcher. To this end, therapists need to be trained and intuitive software needs to be developed.
1
Despite these limitations, the Therap-i study will provide valuable insights into the promise of personalized ESM and ESM-based feedback in clinical practice. Currently, it is acknowledged that severe depressive problems are seldom fully cured as residual complaints often remain and that those affected have life-long vulnerabilities for relapse [
59]. For this reason, the ultimate ambition behind our Therap-i module is to contribute to putting patients “back into the driver’s seat” and relieving them from the feeling that their depression is overpowering their lives.
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