Mobile Phone-Based Unobtrusive Ecological Momentary Assessment of Day-to-Day Mood: An Explorative Study (2016)

Asselbergs, J., Ruwaard, J., Ejdys, M., Schrader, N., Sijbrandij, M. & Riper, H. (2016). Mobile Phone-Based Unobtrusive Ecological Momentary Assessment of Day-to-Day Mood: An Explorative Study. J Med Internet Res 2016;18(3):e72 DOI: 10.2196/jmir.5505 [Open access at journal site ]

Background: Ecological momentary assessment (EMA) is a useful method to tap the dynamics of psychological and behavioral phenomena in real-world contexts. However, the response burden of (self-report) EMA limits its clinical utility.

Objective: The aim was to explore mobile phone-based unobtrusive EMA, in which mobile phone usage logs are considered as proxy measures of clinically relevant user states and contexts

Methods: This was an uncontrolled explorative pilot study. Our study consisted of 6 weeks of EMA/unobtrusive EMA data collection in a Dutch student population (N=33), followed by a regression modeling analysis. Participants self-monitored their mood on their mobile phone (EMA) with a one-dimensional mood measure (1 to 10) and a two-dimensional circumplex measure (arousal/valence, –2 to 2). Meanwhile, with participants’ consent, a mobile phone app unobtrusively collected (meta) data from six smartphone sensor logs (unobtrusive EMA: calls/short message service (SMS) text messages, screen time, application usage, accelerometer, and phone camera events). Through forward stepwise regression (FSR), we built personalized regression models from the unobtrusive EMA variables to predict day-to-day variation in EMA mood ratings. The predictive performance of these models (ie, cross-validated mean squared error and percentage of correct predictions) was compared to naive benchmark regression models (the mean model and a lag-2 history model).

Results: A total of 27 participants (81%) provided a mean 35.5 days (SD 3.8) of valid EMA/unobtrusive EMA data. The FSR models accurately predicted 55% to 76% of EMA mood scores. However, the predictive performance of these models was significantly inferior to that of naive benchmark models.

Conclusions: Mobile phone-based unobtrusive EMA is a technically feasible and potentially powerful EMA variant. The method is young and positive findings may not replicate. At present, we do not recommend the application of FSR-based mood prediction in real-world clinical settings. Further psychometric studies and more advanced data mining techniques are needed to unlock unobtrusive EMA’s true potential.

Online Structured Writing Therapy for Post-traumatic Stress Disorder and Complicated Grief (2016)

Ruwaard, J. & Lange, A. (2016). Online structured writing therapy for post-traumatic stress disorder and complicated grief. In N. Lindefors and G. Andersson (eds), Guided Internet-Based Treatments in Psychiatry. Switzerland, Springer International Publishing. doi:10.1007/978-3-319-06083-5_7 [ Chapter at publisher’s site ]


Post-traumatic stress disorder (PTSD) and complicated grief are related disorders for which well-described and effective cognitive-behavioural therapeutic procedures exist that are firmly rooted in theoretical work. As a result, several research groups have been able to successfully translate these procedures into e-mental health applications for the prevention, detection and treatment of the disorders. This chapter reviews online structured writing therapy (oSWT), a standardised therapist-guided Internet-based cognitive-behavioural treatment (ICBT) for post-traumatic stress disorder and complicated grief, which can be fully delivered online, without face-to-face contact between the patient and therapist. This protocol integrates three principal elements of trauma-focused therapy: (1) exposure through self-confrontation, (2) cognitive reappraisal and (3) strengthening of social support. A unique characteristic of oSWT is that it implements these three elements through writing assignments. In the past two decades, oSWT has been validated in a series of controlled studies and in routine clinical practice, with positive results. This chapter reviews these efficacy and effectiveness trials, elaborates on the details of the therapeutic procedures of the treatment protocol and identifies future research themes.

Gelezen: Andersson, G. (2014). The Internet and CBT: A Clinical Guide.

Ruwaard, J. (2015). Andersson, G. (2014). The Internet and CBT: A Clinical Guide (Boek Recensie). Tijdschrift voor Psychiatrie, 41(5). Manuscript | Published URL

Wie start met online hulpverlenen, koopt een boek. Vaak wordt dat het ‘Handboek Online Hulpverlening’ van stichting (Schalken e.a., 2012). Een prima keuze, maar daarin komen behandelinhoudelijke overwegingen en de wetenschappelijke onderbouwing maar beperkt aan de orde. Gerhard Andersson, een bekende Zweedse eMental Health expert, vult dit gat met zijn boek ‘The Internet and CBT: A Clinical Guide’. Cognitieve gedragstherapie via het internet: wat is dat, werkt dat, zo ja, voor wie dan en waar moet ik op letten in de behandelkamer? Andersson vat twee decennia onderzoek naar deze vragen samen. Dat is ambitieus: u kent de kloof tussen wetenschap en praktijk. Maar Andersson schreef een constructieve aanvulling op het beschikbare aanbod. Misschien net iets te constructief, maar dat kan aan mij liggen.

Wild West eHealth: Time to hold our horses? (2015)

Ruwaard, J. & Kok, R.N. (2015). Wild West eHealth: Time to hold our horses? The European Health Psychologist, 171), 45-49. Full Text

In reviews of the eMental health field, the Netherlands are often hailed as a forerunner nation, a shining example for the rest of the European Union. All that glitters, however, may not be gold. Dutch eMental health upscaling efforts are currently characterized by one of the most dubious mottos of the old Wild West, ‘Shoot first, ask questions later’. Pressed into action by financial incentives from health insurance companies, mental health organisations hastily implement untested e-health interventions on an increasing scale. On introduction, the efficacy and cost-effectiveness of these interventions is simply asserted or assumed. Efficacy trials start after implementation, if ever at all. Arguments do exist for this disconcerting twist in the preferred order of things, but we argue that these do not hold up to closer scrutiny. Large-scale dissemination of unvalidated e-health may kick-start a quality-sacrificing, cost-driven downward spiral in mental health care. It is time to hold our horses.

Web-based psychotherapy for posttraumatic stress disorder in war-traumatized Arab patients (2015)

Knaevelsrud, C., Brand, J., Lange, A., Ruwaard, J., & Wagner, B. (2015). Web-based psychotherapy for posttraumatic stress disorder in war-traumatized Arab patients: a parallel group randomized controlled trial. Journal of medical Internet research. doi:10.2196/jmir.3582 Full Text

Background: In recent years, armed conflicts in the Middle East have resulted in high rates of exposure to traumatic events. Despite the increasing demand of mental health care provision, ongoing violence limits conventional approaches of mental health care provision. Internet-based interventions for posttraumatic stress disorder (PTSD) have proved feasible and effective in Western countries, but their applicability and efficacy in war and conflict regions remains unknown.

Objective: This study investigated the efficacy of a cognitive behavioral Internet-based intervention for war-traumatized Arab patients, with focus on Iraq.

Methods: A total of 159 individuals with PTSD participated in a parallel group randomized trial. Participants were randomly allocated by a computer-generated sequence to a treatment group (n=79) or a waiting list control group (n=80). The treatment group received 2 weekly 45-minute cognitive behavioral interventions via Internet over a 5-week period (10 sessions in total). The primary outcome was recovery from posttraumatic stress symptoms.

Results: Posttraumatic stress symptoms were significantly reduced from baseline to posttreatment (intention-to-treat analysis) in the treatment group relative to the control group (F1,157=44.29, P<.001, d=0.92). Treatment effects were sustained at 3-month follow-up. Completer analysis indicated that 29 of 47 patients (62%) in the treatment group had recovered from posttraumatic stress symptoms at posttreatment (reliable change and Posttraumatic Stress Diagnostic Scale score <20) versus 1 patient (2%) in the control group (OR 74.19, 95% CI 9.93-585.8, P<.001) indicating that the chance of recovering was 74.19 times higher in the treatment than in the control group.

Conclusions: The results indicate, even in unstable and insecure settings with ongoing exposure to human rights violations through war and dictatorships, people with posttraumatic stress symptoms benefit from a cognitive behavioral treatment provided entirely through the Internet. This method of delivery could improve patients’ access to humanitarian aid in the form of e-mental health services.