Diagnosis 2.0 Towards a new paradigm for personalized mental health care. Marieke Wichers, Psychiatry & Psychology, Maastricht

Transcription

1 Diagnosis 2.0 Towards a new paradigm for personalized mental health care Marieke Wichers, Psychiatry & Psychology, Maastricht

2 Tijd voor een nieuw paradigma in de psychiatrie 1. Van focus op het negatieve naar focus op het positieve, herstel en kracht 2. Van traditionele statische denkwijze naar complex dynamische manier van denken over psychiatrie 3. Van werken met groepsresultaten naar persoons-specifieke mechanismen

3 Experience Sampling Methodology 1. Multiple assessments 2. Real world 3. In het moment 4. Evaluation of context ESM procedure Dag 1 Dag 2 Dag 3 Dag 4 Dag 5 Een ESM dag uur Prospective!!!

4 1. ESM as a clinical tool: a focus on positive emotions NEW TECHNOLOGICAL DEVELOPMENTS!!! Data immediately available and opportunities for implementation in mental health care

5 Therapeutic application of ESM 7 6 positive affect Moments of resilience against depression? Context

6 ESM intervention in depression: RCT N=102 depressive patients Experimental n=33 Pseudo-experimental n=36 Controle n=33 6 weeks TAU+ESM+feedback 6-weeks TAU+ESM TAU Depressive 1 week, 1,2,3 & 6 months Kramer, Simons, et al, World Psychiatry, 2014

7 ESM intervention: Feedback protocol Type of Activities Activity & Positive Affect PA per type of activity active relaxation doing nothing/resting talking eating/drinking household activities passive relaxation work/study self care on the way active relaxation passive relaxation doing nothing/resting work/study talking self care eating/drinking on the way household not at all much PA Kramer, Simons, et al, World Psychiatry, 2014

8 Efficacy Depression * Clinical: HDRS Self-report: IDS Intervention Follow-up * * * * * * * Kramer, Simons, et al, World Psychiatry, 2014

9 17 ESM intervention in depression: RCT HDRS sum score predicted control group predicted pseudoexperimental predicted experimental Time since pre-assessment (weeks) Kramer, Simons, et al, World Psychiatry, 2014

10 Results Costs over 32 weeks ESM-I (n=33) Pseudo (n=35) TAU (n=33) Health care perspective Societal perspective Intervention alone No differences in costs between the groups Utilities over 32 weeks ESM-I Pseudo TAU EuroQol 0.17 (0.06) 0.13 (0.08) 0.12 (0.07) ESM-I better than TAU. B=0.03, p=0.047 HDRS at 32 weeks ESM-I Pseudo TAU HDRS 10.8 (7.1) 13 (7.12) 15.3 (8.3) Symptomatic remission 11 (45.8) 9 (32.1) 5 (20.0) ESM-I subjects more in remission than TAU. OR=2.8, p=0.09 HDRS results see introduction

11 22 Figure 1. Cost-effectiveness acceptability curve of the base-case 32 week follow-up costutility analysis with the bootstrapped societal costs and EQ-5D-based QALYs 100% Probability cost-effective 80% 60% 40% % CNTR PSEU INTERV 20% 0% Cost-effectiveness threshold Healthy Maximum

12 2. ESM: zooming in to smallest building blocks: mechanisms and diagnostics 1. Multiple assessments 2. Real world 3. In het moment 4. Evaluation of context ESM procedure Dag 1 Dag 2 Dag 3 Dag 4 Dag 5 Een ESM dag uur

13 ESM: micro-level processing may produce a cascase of effects Insecure down cheerful suspicious content Wichers 2013, Psychological Medicine

14 Dynamiek op micro-niveau LAGE connectiviteit in het netwerk HOGE connectiviteit in het netwerk Wichers, Wigman, Myin-Germeys, submitted

15 Diagnostics: TOP DOWN network approach Healthy people (n=207) Depressed people (n=129) Cheerful Cheerful Suspicious Content Suspicious Content Down Insecure Down Insecure Wigman et al, submitted

16 Diagnostics: TOP DOWN approach Psychotic people (n=263) Depressed people (n=129) Cheerful Cheerful Suspicious Suspicious Content Content Down Insecure Down Wigman et al, submitted Insecure

17 BOTTOM UP APPROACH TOP-DOWN BOTTOM UP Category 1 Category 2 Category 3 Empirical approach

18 Subgroeps of individuals? Or subgroups of network parts?

19 BOTTOM UP APPROACH 1. Impact of positive emotions 2. Impact of feeling down 3. Healthy suspicion 4. Balance between active and passive positive emotions 5. Impact of feeling insecure 6. Negative mood reactivity 7. Unhealthy suspicion

20 t 0 stress NA PA social active behaviour behaviour genes Stress genes t 1 1 t 2 PA 2 3 NA t 3 genes t 4 t 5 4 Social interaction 5 Active behaviour genes Wichers 2013, psychological medicine

21 Stress in the network : real data! Sample: 129 individuals with residual symptoms of major depression ESM: 5 days, 10 measurements a day with an average of 90 minutes in between Baseline assessment of MBCT trial Social stress Positive affect Negative affect Social engagement 4 5 Active engagement Wichers 2013, psychological medicine

22 MINDMAASTRICHT: RCT Sample: 130 participants with residual symptoms of depression, not currently depressed 6 days Experience Sampling Questionnaires Mindfulness Training (8 weeks) + TAU TAU 6 days Experience Sampling Questionnaires 4 5 Geschwind N, Peeters F, Drukker M, van Os J, Wichers M. J Consult Clin Psychol Oct;79(5): FU 6 months FU 12 months

23 MBCT impacts on PA related outcomes Geschwind et al, J. Consulting & Clinical Psychology, 2011

24 Increase in Positive Affect is associated with change in depressive symptoms Geschwind et al 2011 J Clin Consult Psychol

25 3. ESM: person-specific assessment of early warning signals Personalized analyses

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27 Predicting critical transitions in complex dynamical systems Scheffer et al, Nature

28 van der Leemput, Wichers et al, PNAS Early warning signals if close to transition: - increased variance - Increased autocorrelation t t+1 t t+1 - Increased connectivity Cramer et al, submitted

29 Prediction of future shifts in a single system with ESM data Case-experiment in an individual on antidepressants. Can I stop taking antidepressants? Wichers, Groot et al, in preparation

30 Change point analyses package ecp in R

31 2,8 depressive symptoms SCL-90 Time period before transition Time window of transition Time period directly following transition 2,6 2,4 2,2 2 1,8 1,6 1,4 1, ,4 negative affect autocorrelation 0,35 0,3 0,25 0,2 Wichers, Groot, Scheffer ( ) Borsboom, in preparation 0,15 0,1 0,

32 Prediction of future shifts with changes in the network Increased connectivity? Wichers, Groot, Scheffer ( ) Borsboom, in preparation

33 suspicion Positive affect 1. Before experiment Mental unrest 2. Double-blind: no reduction AD worry Negative affect 3. Double-blind: reduction AD 4. After reduction; before shift

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35 Diagnose 2.0: de inzet van ESM in mentale gezondheidszorg Focus op kracht, weerbaarheid en eigen betrokkenheid bij herstel Complementaire manier om gedetailleerd de kleinste betrokken bouwstenen van psychopathologie te observeren Complementaire persoons-specifieke informatie over mechanismen en risico voor transitie

36 Mobile app en web-app Patient makes own diagnosis Patient assesses change Learning about mood in relation to daily life circumstances Implicit mood patterns made explicit (life or delayed feedback) Patient and clinician share the outcome of the assessment information: it collaboratively leads to informed decisions improved patient engagement & empowerment

37 We have: Support for (cost-)effectiveness in RCT Research supporting underlying theories regarding vision on diagnostics, positive affect and complex dynamics Statistical tools to deal with complexity: time series, network analyses Proof of principle for single case monitoring ESM-I implementation - large pragmatic observational trial - GP, primary, specialized care (cost)effectiveness in mental health care?

38 Met dank aan: Denny Borsboom Peter Groot Marten Scheffer Kenneth Kendler Hanneke Wigman Jim van Os Philippe Delespaul Inez Myin-Germeys en de onderzoeksgroep div Mental Health, Maastricht

39 Table S1. Mean ratings on the Use of the Psymate debriefing questionnaire addressing the feasibility of the PsyMate as an experience sampling device Use of the PsyMate Acceptance of the PsyMate Mean (min-max) (Scale 1-7) N (subje cts) SD All groups Was the text on screen well readable? 5.8 (2-7) Was it difficult to switch PsyMate on? 1.6 (1-6) Was the PsyMate difficult to control? 1.4 (1-5) Were the verbal instructions you received about using the PsyMate clear? 6.6 (3-7) Were the written instructions you received with the PsyMate clear? 6.5 (1-7) Were the questions you answered on the PsyMate difficult or unclear? 2.6 (1-6) Did you find it annoying or stressful to use the PsyMate? With respect to the number of s per day 3.1 (1-7) With respect to the time it took to answer the questions for a single 2.5 (1-7) With respect to the noises/sound volume 2.0 (1-7)