Mobile devices for the remote acquisition of physiological and behavioral biomarkers in psychiatric clinical research

Psychiatric disorders are linked to a variety of biological, psychological, and contextual causes and consequences. Laboratory studies have elucidated the importance of several key physiological and behavioral biomarkers in the study of psychiatric disorders, but much less is known about the role of these biomarkers in naturalistic settings. These gaps are largely driven by methodological barriers to assessing biomarker data rapidly, reliably, and frequently outside the clinic or laboratory. Mobile health (mHealth) tools offer new opportunities to study relevant biomarkers in concert with other types of data (e.g., self-reports, global positioning system data). This review provides an overview on the state of this emerging field and describes examples from the literature where mHealth tools have been used to measure a wide array of biomarkers in the context of psychiatric functioning (e.g., psychological stress, anxiety, autism, substance use). We also outline advantages and special considerations for incorporating mHealth tools for remote biomarker measurement into studies of psychiatric illness and treatment and identify several specific opportunities for expanding this promising methodology. Integrating mHealth tools into this area may dramatically improve psychiatric science and facilitate highly personalized clinical care of psychiatric disorders

Clinical Decision-Making Following Disasters: Efficient Identification of PTSD Risk in Adolescents

The present study aimed to utilize a Receiver Operating Characteristic (ROC) approach in order to improve clinical decision-making for adolescents at risk for the development of psychopathology in the aftermath of a natural disaster. Specifically we assessed theoretically-driven individual, interpersonal, and event-related vulnerability factors to determine which indices were most accurate in forecasting PTSD. Furthermore, we aimed to translate these etiological findings by identifying clinical cut-off recommendations for relevant vulnerability factors. Our study consisted of structured phone-based clinical interviews with 2,000 adolescent-parent dyads living within a 5-mile radius of tornados that devastated Joplin, MO, and northern Alabama in Spring 2011. Demographics, tornado incident characteristics, prior trauma, mental health, and family support and conflict were assessed. A subset of youth completed two behavioral assessment tasks online to assess distress tolerance and risk taking behavior. ROC analyses indicated four variables that significantly improved PTSD diagnostic efficiency: Lifetime depression (AUC=.90), trauma history (AUC=.76), social support (AUC=.70), and family conflict (AUC=.72). Youth were 2–3 times more likely to have PTSD if they had elevated scores on any of these variables. Of note, event-related characteristics (e.g., property damage) were not related to PTSD diagnostic status. The present study adds to the literature by making specific recommendations for empirically-based, efficient disaster-related PTSD assessment for adolescents following a natural disaster. Implications for practice and future trauma-related developmental psychopathology research are discussed

Taxometric Investigation of PTSD: Data From Two Nationally Representative Samples

Current psychiatric nosology depicts posttraumatic stress disorder (PTSD) as a discrete diagnostic category. However, only one study has examined the latent structure of PTSD, and this study suggested that PTSD may be more accurately conceptualized as an extreme reaction to traumatic life events rather than a discrete clinical syndrome. To build on the existing literature base, the present research examined the latent structure of posttraumatic stress reactions by applying three taxometric procedures (MAXEIG, MAMBAC, and L-Mode) to data collected from large nationally representative samples of women (ns = 2684 and 3033) and adolescents (n = 3775). Results consistently provided evidence for a dimensional PTSD solution across samples and statistical procedures. These findings have important implications for the theory, assessment, and investigation of posttraumatic stress reactions

How should we screen for depression following a natural disaster? An ROC approach to post-disaster screening in adolescents and adults

The present study’s aim was to provide the foundation for an efficient, empirically based protocol for depression screening following a natural disaster. Utilizing a Receiver Operating Characteristic (ROC) analytic approach, the study tested a) what specific disaster-related stressors (i.e., property damage, loss of basic services) and individual-related constructs (i.e., PTSD symptoms, trauma history, social support) conveyed the greatest risk for post-natural disaster depression, b) specific cutoff scores across these measures, and c) whether the significance or cutoff scores for each construct varied between adolescents and adults

Reducing substance use risk and mental health problems among sexually assaulted adolescents: A pilot randomized controlled trial.

The current study reports results from a pilot randomized controlled trial evaluating the feasibility and efficacy of Risk Reduction through Family Therapy (RRFT) for reducing substance use risk and trauma-related mental health problems among sexually assaulted adolescents. Thirty adolescents (aged 13–17 years; M=14.80; SD=1.51) who had experienced at least one sexual assault and their caregivers were randomized to RRFT or treatment as usual (TAU) conditions. Participants completed measures of substance use, substance use risk factors (e.g., family functioning), mental health problems (i.e., posttraumatic stress disorder, depression, and general internalizing/externalizing symptoms) and risky sexual behavior at four time points (baseline, post-treatment, and 3- and 6-month follow-up). Mixed-effects regression models yielded significantly greater reductions in substance use, specific substance use risk factors, and (parent-reported) PTSD, depression, and general internalizing symptoms among youth in the RRFT condition relative to youth in the TAU condition. However, significant baseline differences in functioning between the two conditions warrant caution in interpreting between-group findings. Instead, emphasis is placed on replication of feasibility findings and within-group improvements over time among the RRFT youth

Adolescent Substance Use Following a Deadly U.S. Tornado Outbreak: A Population-Based Study of 2,000 Families

Despite conceptual links between disaster exposure and substance use, few studies have examined prevalence and risk factors for adolescent substance use and abuse in large, population-based samples affected by a recent natural disaster. We addressed this gap using a novel address-based sampling methodology to interview adolescents and parents who were affected by the 4th deadliest tornado outbreak in U.S. history. Postdisaster interviews were conducted with 2,000 adolescent–parent dyads living within a 5-mile radius of the spring 2011 U.S. tornadoes. In addition to descriptive analyses to estimate prevalence, hierarchical linear and logistic regression analyses were used to examine a range of protective and risk factors for substance use and abuse. Approximately 3% reported substance abuse since the tornado. Greater number of prior traumatic events and older age emerged as consistent risk factors across tobacco and alcohol use and substance abuse since the tornado. Tornado incident characteristics, namely, greater loss of services and resources after the tornado and posttraumatic stress disorder since the tornado, were associated with greater alcohol consumption. Service loss increased risk for binge drinking, whereas, for substance abuse, posttraumatic stress disorder increased risk and parent presence during the tornado decreased risk. Greater family tornado exposure was associated with a greater number of cigarettes smoked in female but not male teen participants. Both trauma and non-trauma-related factors are relevant to postdisaster substance abuse among adolescents. Future research should examine the role of broader ecological systems in heightening or curtailing substance use risk for adolescents following disaster exposure

Hybrid type 1 randomized controlled trial of a tablet-based application to improve quality of care in child mental health treatment

The quality of child mental health care is highly variable in community practice settings. Innovative technology-based solutions may be leveraged to improve quality of care and, in turn, treatment outcomes. This is a protocol paper that describes an innovative study design in which we rigorously evaluate the effectiveness of a tablet-assisted intervention, Supporting Providers and Reaching Kids (SPARK). SPARK consists of a collection of interactive games and activities that are designed to improve provider fidelity and child engagement in evidence-based psychotherapies. The methodology also allows us to explore the implementation and sustainability of a technology-enhanced intervention in more than two dozen community practice settings. This paper includes a description and justification for sample selection and recruitment procedures, selection of assessment measures and methods, design of the intervention, and statistical evaluation of critical outcomes. Novel features of the design include the tablet-based toolkit approach that has strong applicability to a range of child mental health interventions and the use of a hybrid type 1 effectiveness-implementation trial that allows for the simultaneous investigation of the effectiveness of the intervention and the implementation context. Challenges related to the implementation of a technology-enhanced intervention in existing mental health clinics are discussed, as well as implications for future research and practice

Elucidating the Neurobiologic Etiology of Comorbid PTSD and Substance Use Disorders

Early childhood maltreatment and other traumatic event experiences (“trauma”) are common among youth, including those with substance use problems including substance use disorders (SUD). Particularly, interpersonal violence is associated with high rates of comorbidity between posttraumatic stress disorder (PTSD) and SUD, and these comorbid disorders exhibit high levels of overlapping symptomatology. Theoretical models proposed to explain the bidirectional relationship between PTSD and SUD include the self-medication hypothesis and susceptibility hypothesis. In this article, we explore neurobiologic changes associated with trauma, PTSD, and SUD that underly dysregulated stress response. Examining lessons learned from recent translational and clinical research, we propose that further elucidating the neurobiologic etiology of comorbid PTSD and SUD will require a collaborative, interdisciplinary approach, including the integration of preclinical and clinical studies, exploration of biologic markers in clinical studies, and accumulation of larger studies and longitudinal studies with the power to study PTSD and SUD. Such research can transform the field and ultimately reduce high rates and costly impairment of co-occurring PTSD and SUD across the lifespan

Youth Offspring of Mothers with Posttraumatic Stress Disorder have Altered Stress Reactivity in Response to a Laboratory Stressor

Parental Posttraumatic Stress Disorder (PTSD), particularly maternal PTSD, confers risk for stress-related psychopathology among offspring. Altered hypothalamic–pituitary–adrenal (HPA) axis functioning is one mechanism proposed to explain transmission of this intergenerational risk. Investigation of this mechanism has been largely limited to general stress response (e.g., diurnal cortisol), rather than reactivity in response to an acute stressor. We examined cortisol reactivity in response to a laboratory stressor among offspring of mothers with a lifetime diagnosis of PTSD (n = 36) and age- and gender- matched control offspring of mothers without PTSD (n = 36). Youth (67% girls; mean age = 11.4, SD = 2.6) participated in a developmentally sensitive laboratory stressor and had salivary cortisol assessed five times (one pre-stress, one immediate post-stress, and three recovery measures, spaced 15 min apart). Results were consistent with the hypothesis that offspring of mothers with PTSD would exhibit a dysregulated, blunted cortisol reactivity profile, and control offspring would display the expected adaptive peak in cortisol response to challenge profile. Findings were maintained after controlling for youth traumatic event history, physical anxiety symptoms, and depression, as well as maternal depression. This finding contributes to the existing literature indicating that attenuated HPA axis functioning, inclusive of hyposecretion of cortisol in response to acute stress, is robust among youth of mothers with PTSD. Future research is warranted in elucidating cortisol reactivity as a link between maternal PTSD and stress-related psychopathology vulnerability among offspring

Development and Usability Testing of an mHealth Tool for Trauma-Informed Prevention of Substance Use, HIV Acquisition, and Risky Sexual Behaviors Among Adolescents: Mixed Methods Study

BackgroundYouth who experience traumatic events are at a substantially higher risk of engaging in substance use and sexual risk behaviors and problems (eg, HIV acquisition) than their non–trauma-exposed counterparts. Evidence-based substance use and risky sexual behavior prevention may reduce the risk of these outcomes. Trauma-focused mental health treatment provides a window of opportunity for the implementation of such preventive work with these youth. However, overburdened clinicians face challenges in adding prevention content while implementing evidence-based treatments. Mobile health (mHealth) tools can help reduce this burden in delivering prevention curricula. Trauma-Informed Prevention for Substance Use and Risky Sexual Behavior (TIPS) is an mHealth app that was developed to aid trauma-focused cognitive behavioral therapy (TF-CBT) clinicians in the implementation of an evidence-based risk behavior prevention curriculum. ObjectiveThe goal of this paper is to describe the rationale for and development of the TIPS app and present the results of a mixed methods approach for the initial evaluation of its usability. MethodsParticipants included clinicians (n=11), adolescents (n=11), and caregivers (n=10) who completed qualitative interviews and an adapted version of the Website Analysis and Measurement Inventory. ResultsIn total, 4 overarching themes emerged from the participants’ answers to the qualitative interview questions, demonstrating a generally positive response to the app. The themes were (1) strength of app content, (2) suggestions about app content, (3) esthetics and usability, and (4) benefits to the patient and session implementation. Clinicians, adolescents, and caregivers all agreed that the content was very relevant to adolescents and used examples and language that adolescents could relate to. All 3 groups also discussed that the content was comprehensive and addressed issues often faced by adolescents. All 3 groups of users made suggestions about the esthetics, which mostly comprised suggestions to change the font, color, or pictures within the app. Of all the groups, adolescents were most positive about the esthetics and usability of the app. Results from the Website Analysis and Measurement Inventory further illustrated the users’ favorable reaction to the TIPS app, with 100% (11/11) of clinicians, 100% (10/10) of caregivers, and most adolescents (7/11, 64%) selecting strongly agree or somewhat agree to the following statement: “This app has much that is of interest to me.” Adolescents generally found the app easier to use than did caregivers and clinicians. ConclusionsThe TIPS app shows promise as an mHealth tool for TF-CBT clinicians to integrate evidence-based substance use, risky sexual behavior, and HIV prevention during treatment. Future research, including a randomized controlled trial comparing TF-CBT implementation with and without the inclusion of the app, is necessary to evaluate the feasibility and efficacy of the app in reducing the risk of substance use and risky sexual behavior among trauma-exposed adolescents. Trial RegistrationClinicalTrials.gov NCT03710720; https://clinicaltrials.gov/study/NCT0371072