Your smartphone vibrates and reminds you to do your daily relaxation exercise. A friendly message appears on the chat window inviting you to do the “Breath counting” exercise. After a brief confirmation and a click on “Play”, a chime sounds and you're ready to go: Straighten your upper body, close your eyes, breathe in and count to five in your mind – breathe out and count to five again.
The aim is to bring more relaxation into your everyday life by maintaining a steady rhythm and focusing your attention on your breathing. This three-minute exercise is one of several, predominantly compassion-oriented exercises that are suggested to the 92 participants in the EMIcompass study in an app during the six-week study phase. At a previously agreed time, they can integrate these exercises into their everyday lives independently using their smartphones.
Hardly any scientific evidence
The app is part of a study that is scientifically investigating the use of so-called mHealth or mobile health interventions. EMI stands for Ecological Momentary Intervention, i.e. a digital intervention. “Many lifestyle and health applications have been developed for smartphones in recent years, but we have hardly any scientific evidence for the safety and effectiveness of such applications,” says Prof. Dr. Ulrich Reininghaus, Head of the Public Mental Health Department at the CIMH. To change this, Reininghaus and his team have initiated numerous studies to investigate how effective digital interventions are.
“For the EMIcompass study, we were looking for people between the ages of 14 and 25 who feel stressed in their everyday lives, have a higher risk of mental illness or have the first symptoms of an illness,” explains Dr. Anita Schick, research associate in the Public Mental Health department. Especially young women in education were among the participants.
The researchers asked the participants six to eight times a day via the study app about their mood, their feelings, what they were currently doing, whether they were alone or with others. The further context, for example whether a stressful event has occurred, is also determined via the app. These queries are referred to as Ecological Momentary Assessment (EMA) and provide valuable data that can be used in the app to tailor the training to the respective person and offer certain exercises at appropriate times.
Improving stress reactivity
“In EMIcompass, we were particularly interested in how the participants react to stress, how much their mood changes negatively and how negative feelings arise,” explains Schick. By collecting data in everyday life before and after the six-week study phase, it is possible to see, for example, whether and how the reaction to stress changes. “We know from other studies that stress reactivity is significantly higher in people with psychosis or other mental illnesses than in the control group,” says Schick.
The researchers have therefore compiled exercises in the EMIcompass app that promote relaxation and calming and are based on compassion-focused therapy. The aim is to strengthen the ability to accept oneself and develop compassion for oneself and others in order to create a feeling of safety and security.
Acceptance and effectiveness of the exercises
The individual exercises take no longer than five minutes so that they can be done during a break in everyday life. “An exercise is explained in a short video and participants can practise for a week. With compassion-oriented exercises, it takes a while to master the exercise,” says Schick.
“Based on the data from the EMA mood surveys, we were able to see whether someone was currently very stressed and the app then suggested a corresponding exercise that could help them get out of their negative mood,” says Schick. In EMIcompass, the acceptance of using the exercises was very high. It can often make sense to combine the use of such apps with on-site sessions, as this is when participants are most motivated to actually do the exercises regularly.
Digital interventions as a low-threshold offer
Digital health applications offer many opportunities. “We have a significant proportion of people in the population who are under severe mental stress. We know that three quarters of young people in particular develop a mental illness before the age of 25. On the other hand, we have the problem that young people in particular take a very long time to enter our psychiatric care system,” emphasizes Ulrich Reininghaus. In the case of psychosis, for example, it sometimes takes more than ten years before therapy is sought for the very first time. “We have barriers and, of course, long waiting lists for psychotherapeutic treatment. Digital interventions can therefore be a way of making an initial, low-threshold offer at an early stage,” says Reininghaus.
Smartphone as a constant companion
“As everyone always has their cell phone to hand in everyday life, it offers the opportunity to practice exactly when the exercises are needed most,” says Schick. This is also one of the advantages of digital applications.
The two researchers are encouraged by the fact that a number of EMIcompass participants significantly exceeded a predetermined minimum number of exercises. “We can see that there is a high level of acceptance for app-based training,” says Schick. Further studies now need to clarify, among other things, how the motivation of participants can be strengthened, how much freedom users need or how many exercises are necessary to achieve an effect. The researchers also want to use interviews to find out more about how the exercises affected the participants, how they themselves perceived possible effects and where barriers and obstacles lie.
Challenges in data collection
Data collection is sometimes time-consuming. In studies, six to ten sentiment surveys per day are often common, meaning that the smartphone responds with a query around every two hours. The questions are always the same and a certain routine is established when answering them. Nevertheless, not all queries are always answered. “Around 60 percent of the mood queries are answered,” says Schick. Of course, it can also happen that participants feel under a lot of pressure from the questions. Adjustments are then necessary. “If a person consistently reports a negative mood and hardly anything changes over time, this can lead to the person feeling even more helpless,” explains Schick. Other therapeutic help is then required.
The strength of EMA and EMI
The strength of EMA and EMI lies in being close to people in everyday life. A mood diary can of course also be kept on paper. However, when an app is used in combination with therapy, the EMA data is immediately available to the therapist and can provide valuable information for an intervention and serve as targeted preparation for a therapy session.
Nevertheless, it always remains a challenge to capture the important moments that actually provide information about a person's mood. “It may be that the person is stressed at the moment and therefore doesn't respond to the query on the smartphone,” Schick points out. In such a case, it is helpful to collect additional data, such as movement data or physiological parameters, in order to identify additional contextual factors and offer targeted exercises and support.
Future studies
Digital interventions can be designed as health promotion, prevention or therapy and can be aimed at healthy, stressed or mentally ill people. “We cover all of these areas in our department,” says Ulrich Reininghaus. The EMIcompass study has a preventative approach. People who are under stress or have an increased risk of mental illness are more likely to develop negative feelings under stress. The app-based training is designed to strengthen the participants and improve their stress reactivity. “We were able to show that the app-based training is helpful and has a positive effect on the way people react to stress,” summarizes Schick. In order to answer further questions, the next study is already being planned, which will involve a larger number of participants and be conducted at several locations.