Emotional self-awareness and depressive symptoms (PDF)

EMOTIONAL SELF-AWARENESS AND DEPRESSIVE SYMPTOMS: AN INVESTIGATION OF AN EARLY INTERVENTION MOBILE PHONE SELF-MONITORING PROGRAM FOR ADOLESCENTS Sylvia D Kauer Submitted in total fulfillment of the requirements of the degree of Doctor of Philosophy Produced on archival quality paper June, 2012 School of Psychological Sciences University of Melbourne  i Abstract Up to 30% of adolescents experience depressive symptoms before 18 years of age and are at risk of developing severe recurrent depression. There is, however, a lack of appropriate treatments available for these young people. Self-monitoring is often used in therapy to increase awareness about mood and distress, and is likely to decrease depressive symptoms. Furthermore, self-monitoring has potential as an early intervention tool for young people at risk of depression, particularly when mobile phones are used as a medium. Using both qualitative and quantitative methods, this thesis investigates the concept of emotional self- awareness (ESA) and its mediating role in the relationship between self-monitoring and depressive symptoms. To this end, several studies were conducted. First, a systematic literature review examining the benefits of ESA was conducted. A review of 50 publications found five common themes throughout the literature regarding ESA: (a) becoming aware of an emotional experience; (b) the ability to define and distinguish specific feelings; (c) identifying the contextual factors surrounding emotions; (d) communication of emotional knowledge; and (e) analysing emotional events to make decisions. Second, a post-hoc qualitative study examined secondary school students’ general feedback about ESA after self-monitoring. Spontaneous feedback from 20% of participants reported at least one ESA theme after completion of the self-monitoring program. Third, following from the post-hoc study, in-depth qualitative interviews were conducted with 37 young people after self-monitoring, specifically targeting ESA. This study provided rich descriptive detail about the themes of ESA from young people’s perspectives. Fourth, a preliminary measure of ESA was developed and tested with 22 young people with subclinical depressive symptoms, recruited from two general practitioners in a rural setting. This small-scale mixed-methods study combined an in-depth qualitative interview and a quantitative measure of ESA. Young people with high scores on the ESA measure had a different qualitative experience than those with low scores. Last, a randomised controlled trial examined the effects of self-monitoring on depressive symptoms when mediated by ESA. Young people with mild or more depressive symptoms were recruited from primary care settings and randomised into an intervention group (n = 68) or an attention-comparison group (n = 46). Mediation analysis demonstrated that self- monitoring significantly increased ESA in the intervention group when compared with the comparison group and that an increase in ESA significantly decreased depressive symptoms.  ii Furthermore, there was a medium size of indirect effect (κ2 = 0.44) for depressive symptoms per week indirectly through ESA when compared with the comparison group. In summary, a useful model of ESA was developed in this thesis and tested across the studies suggesting that self-monitoring can increase ESA, which in turn, decreases depressive symptoms. Mobile phones are well suited to early intervention programs, providing an alternative to watchful waiting. Mobile phone self-monitoring programs should be considered as a first-step low-cost early intervention for young people who are at-risk of mental health problems. Self-monitoring has the advantages of helping young people increase their ESA while gaining more information about their mental health symptoms, which can also direct them to suitable interventions.  iii Declaration This is to certify that: I, Sylvia Kauer, declare that the research reported in this thesis was conducted in accordance with the principles of ethical treatment of human participants as approved for this research by the Royal Children’s Hospital Human Research Ethics Committee and further registrated with the University of Melbourne Human Research Ethics Committee. Sylvia Deidre Kauer June 2012 1) the thesis comprises only my original work towards the PhD except where indicated in the Preface, 2) due acknowledgement has been made in the text to all other material used, 3) the thesis is less than 100,000 words in length, exclusive of tables, maps, bibliographies and appendices.  iv Preface The studies in this thesis were conducted by a team of researchers. The lead investigator for all studies was Dr Sophie Reid. The candidate was responsible for writing ethics applications for all studies in this thesis and responsible for recruitment, data entry and follow-up for the studies described in Chapters 4, 5 and 6. Mr Alex Crooke was employed as a research assistant for the studies described in Chapters 5 and 6, which involved recruiting participants and data entry. Mr Crooke was also the primary research assistant responsible for recruitment, data entry, and conducting follow-ups for the study described in Chapter 7. Ms Angela Khor also assisted with recruitment for the studies described in Chapters 5 and 6 and follow-ups in the study described in Chapter 7. The candidate did all the data analyses for the Chapters in this thesis with the exception of the secondary analysis of rumination described in Chapter 7 (p. 251), which was conducted by Mr Stephen Hearps. The candidate was also responsible for the writing of the thesis in it’s entirety except for the methods sections and some of the demographics in the results sections which were jointly written by Dr Sophie Reid, Mr Stephen Hearps and the candidate. The data collection for Chapter 4 was conducted by the candidate before commencement of this PhD in her role as a research assistant on the mobiletype project and formed the conceptualisation of this research topic. Parts of this thesis were presented by the candidate at several conferences. Abstracts and posters are presented in Appendix A for the following conference presentations: Kauer, S. D., (2011). Using mobile phones in the prevention of adolescent depression: A randomised controlled trial examining emotional self-awareness as a mediating variable. Presented at the International Society for Research on Internet Interventions Conference: Sydney, Australia and the European Psychiatric Society Congress: Vienna, Austria. Kauer, S. D., (2010). Emotional self-awareness: Preliminary analyses of an RCT using a mobile phone self-monitoring program (mobiletype) to decrease early symptoms of depression (Poster Presentation). Australasian Society of Psychiatric Research: Bondi Beach, Australia.  v Kauer, S. D., (2008). Emotional self-awareness: A qualitative exploration of the mechanism underlying a mobile phone self-monitoring program (mobiletype). Presented at the Adolescent Health Conference: Melbourne, Australia and the Australasian Society of Psychiatric Research: Melbourne, Australia. Kauer, S. D., (2007). The phenomenon of insight and preliminary findings for preventing depression: self-monitoring via mobile phones (Poster Presentation). Australasian Society of Psychiatric Research: Sydney, Australia. Elke Power copy-edited this thesis in accordance with the Editing of Research Thesis by Professional Editors guidelines. A publication based on the analyses conducted in Chapter 7 is currently in press: Kauer, S. D., Reid, S. C., Crooke, A. H. D., Khor, A., Hearps, S. J. C., Jorm, A. F., Sanci, L. & Patton, G., accepted, August 2011 ). Self-monitoring using mobile phones in the early stages of adolescent depression: randomised controlled trial with an attention comparison group to examine the mediating effect of emotional self-awareness. Journal of Medical Internet Research. The candidate was primary author and responsible for planning, preparation and execution of this publication. Co-authors provided assistance with data collection, comments and suggestions. The signed Contribution to Authorship Form is on the following pages.  vi Contribution to Published Work The following conditions apply to the publication included in Chapter 7 of the published work: Publication: Kauer, S.D., Reid, S.C., Crooke, A.H.D., Khor, A., Hearps, S.J.C., Jorm, A.F., Sanci, L. & Patton, G. (accepted, August 2011). Self-monitoring using mobile phones in the early stages of adolescent depression: Randomized controlled trial with an attention comparison group to examine the mediating effect of emotional self-awareness. Journal of Medical Internet Research. Declaration by candidate My contribution to the published work included planning, preparation, data collection, data analysis, writing and editing. My contribution to the published work constituted at least 80%. • The candidate contributed to more than 50% of the content of the publication and is the primary author, meaning the one who is primarily responsible for the planning, execution and preparation of the work for publication. • The initial draft of the paper was written by the candidate and subsequent editing in response to co-authors and editors has been performed by the candidate. • Author contributions are acknowledged in the ‘Preface’ and detailed on this ‘Contribution to Published Work’ form. • The publication was accepted for publication in a peer-reviewed journal prior to submission of the thesis. • The publication directly pertains to the thesis topic.  vii Declaration by co-authors The undersigned hereby authorise the inclusion of this published work in the candidate’s PhD thesis and certify that: 1) the above declaration correctly reflects the nature and extent of the candidate’s contribution to this work; and 2) the candidate contributed the proportion of the content in the publication declared above and is primary author.  viii Acknowledgements First and most importantly my thanks to Dr. Sophie Reid for all her help, support and friendship during the past five years. Although not my primary supervisor on record, Sophie has been my primary supervisor in every other way and entirely responsible for me starting, continuing and finishing this thesis. I feel like we’ve been through a lot together in the last five years, including four studies and three babies (two for her, one for me) and look forward to many more papers and collaborations in the future. Many thanks also to my panel of supervisors: Profs. Henry Jackson and Tony Jorm, who provided me with valuable support and expert advice throughout my thesis as well as being supportive of my new role as a mother and the accompanying hurdles and delays. Prof. George Patton also helped me greatly, stepping in as replacement for Sophie when Sophie went on maternity leave for the second time during my PhD. My thanks to the mobiletype team, lead by Dr. Sophie Reid and including: Alex Crooke, Angela Khor and Stephen Hearps, who were the major force behind recruiting participants, setting up the studies and providing comic relief. Alex Crooke also assisted with the interrater agreement in Chapter 4. Thanks also to my fellow PhD student, Michelle Tollit, for her assistance intepreting the Mplus output used in Chapter 7, Elke Power for her amazing copy- editing skills, and the young people who participated in the studies. Thanks also to my family, Andrew and Luke. Andrew has been eternally patient and supportive while I wrote what he mockingly calls my ‘essay’. Our beautiful boy, Luke, has constantly reminded me what’s important in life; namely, him! To my in-laws also, Patrick, Sue and Teresa, thank you for all your babysitting efforts, I would be completely senseless if I didn’t have you all to rely on. It has been so lovely to see the mutual bond that you and Luke share with each other develop. I am very lucky and grateful to have completed my PhD at MCRI with funding grants awarded to Sophie from various sources: beyondblue, Telstra Foundation, MCRI and the Shephard Foundation. Lastly, an enormous thank you to Australian Rotary Health for supporting me with the Ian Scholarship over the course of my PhD.  TABLE OF CONTENTS ix Table of Contents Abstract.............................................................................................................................. i Declaration.......................................................................................................................iii Preface ............................................................................................................................. iv Contribution to Published Work...................................................................................... vi Acknowledgements........................................................................................................viii List of Tables .................................................................................................................. xv List of Figures............................................................................................................... xvii CHAPTER 1. Overview of the Thesis......................................................................................1 CHAPTER 2. Emotions, Coping and Becoming Aware: .......................................................5 Background and Theory........................................................................................................5 Depression and Depressive Symptoms............................................................................. 6 Symptomology of depression................................................................................6 Prevalence of adolescent depression.....................................................................7 Life course of depression ......................................................................................8 Current Treatment for Major Depressive Disorder in Adolescents................................ 10 Stepped Care Model........................................................................................................ 14 Universal prevention programs ...........................................................................16 Selective prevention programs............................................................................17 Indicated prevention programs............................................................................18 Early intervention programs................................................................................19 Emotions and Emotion Regulation................................................................................. 20 Affective states....................................................................................................23 Adolescent development .....................................................................................23 Coping............................................................................................................................. 26 Problem-focused coping......................................................................................27 Emotion-focused coping......................................................................................28 Cognitive Processing of Affective States ....................................................................... 29 Reinforcement Sensitivity Theory.......................................................................30 Psychotherapeutic theory ....................................................................................33 Maladaptive processing in depression.................................................................34  TABLE OF CONTENTS x Activating cognitive processing of emotions......................................................37 Emotion-Focused Attention............................................................................................ 37 Past associations with worry and rumination......................................................38 Adaptive emotion-focused attention ...................................................................39 Early intervention with a Focus on Emotions................................................................. 40 CHAPTER 3. When Self-Awareness of Negative Emotions Leads to Beneficial Outcomes: A Systematic Review of Emotional Self-Awareness..........................................................42 Repetitive Thoughts ............................................................................................43 Adaptive emotion-focused attention ...................................................................46 Aims ....................................................................................................................50 Methodology................................................................................................................... 51 Approach .............................................................................................................51 Literature search..................................................................................................51 Selection of publications .....................................................................................53 Thematic analysis................................................................................................54 Results............................................................................................................................. 55 Screening process................................................................................................55 Cross-sectional studies ........................................................................................71 Longitudinal studies ............................................................................................71 Experimental studies ...........................................................................................73 Heterogeneous publications ................................................................................74 Beneficial outcomes ............................................................................................75 Emotional self-awareness....................................................................................79 Relationship between ESA and adaptive outcomes ............................................85 Discussion....................................................................................................................... 88 Comparison with previous research ....................................................................88 Theoretical implications of findings....................................................................89 Limitations of the review ....................................................................................91 Future research ....................................................................................................92 Practical Implications of the research .................................................................92 CHAPTER 4. Observations from a Mobile Phone Self-Monitoring Program Pilot Study: A Post-Hoc Analysis of Young People’s Feedback about Emotional Self-Awareness...94  TABLE OF CONTENTS xi Approaches to increase emotional self-awareness ..............................................96 Homework diaries in psychotherapy...................................................................98 The expressive writing paradigm ........................................................................99 Momentary sampling methodology...................................................................101 Momentary sampling methodology to increase emotional self-awareness.......104 Rationale for a focus on adolescence ................................................................105 Method.......................................................................................................................... 106 Participants........................................................................................................106 Materials............................................................................................................107 The mobiletype self-monitoring program..........................................................109 Procedure...........................................................................................................112 Qualitative data analysis....................................................................................113 Results........................................................................................................................... 116 Demographics....................................................................................................116 Emotional self-awareness..................................................................................117 Depression, anxiety and stress...........................................................................119 Adolescent coping scale....................................................................................120 Discussion..................................................................................................................... 120 CHAPTER 5. The Effects of Self-Monitoring on Young People’s Emotional Self- Awareness: An In-depth Qualitative Thematic Analysis ...............................................125 Qualitative methodologies.................................................................................127 Qualitative research to generate a model of emotional self-awareness.............129 Aims ..................................................................................................................130 Method.......................................................................................................................... 130 Participants........................................................................................................130 The mobiletype program 2.0..............................................................................131 Materials............................................................................................................137 Procedure...........................................................................................................138 Transcribing.......................................................................................................141 Data analysis......................................................................................................142 Results........................................................................................................................... 143 Demographics....................................................................................................143  TABLE OF CONTENTS xii Thematic analysis of emotional self-awareness................................................145 Thematic map....................................................................................................151 Reliability and frequency ..................................................................................153 Discussion..................................................................................................................... 154 Thematic analysis of emotional self-awareness................................................154 Limitations.........................................................................................................157 Future research ..................................................................................................159 Practical implication of the ESA model............................................................159 Summary ...........................................................................................................160 CHAPTER 6. Mixed Methods Exploration of Emotional Self-Awareness and Development of an ESA Scale ...........................................................................................161 Current measures of emotion-focused attention................................................163 Mixed methods..................................................................................................163 Limitations of the previous qualitative studies..................................................165 Method.......................................................................................................................... 166 Participants........................................................................................................166 The mobiletype program Version 2.1................................................................167 Materials............................................................................................................168 Procedure...........................................................................................................170 Data analysis......................................................................................................171 Results........................................................................................................................... 172 Demographic information .................................................................................172 Initial ESA scale................................................................................................174 Comparison of low and high ESA scores..........................................................177 Additional items in the emotional self-awareness scale from the qualitative interview............................................................................................................185 Mental health and coping outcome ...................................................................186 Discussion..................................................................................................................... 189 Comparison with previous research ..................................................................191 Limitations of the study.....................................................................................192 Implications of findings.....................................................................................192 Summary ...........................................................................................................194  TABLE OF CONTENTS xiii CHAPTER 7. A Randomised Controlled Trial Investigating the Use of a Mobile Phone Self-Monitoring Tool to Increase Young People’s Emotional Self-Awareness and Reduce Depressive Symptoms...........................................................................................195 Mediation...........................................................................................................198 Aims ..................................................................................................................199 Methods ........................................................................................................................ 200 Trial design........................................................................................................200 Sample...............................................................................................................201 The mobiletype program....................................................................................203 Measures............................................................................................................205 Procedure...........................................................................................................207 Data analyses.....................................................................................................212 Results........................................................................................................................... 214 Recruitment .......................................................................................................214 Demographics....................................................................................................216 Descriptive statistics..........................................................................................218 Emotional self-awareness..................................................................................218 Mental health outcomes.....................................................................................223 Parallel process latent growth curve model.......................................................224 Discussion..................................................................................................................... 234 CHAPTER 8. Emotional Self-Awareness Model and its Role in Mediating Self- Monitoring and Depressive Symptoms: Final Discussion ..............................................240 The Characteristics of Emotional Self-Awareness....................................................... 242 Qualitative Experience of Emotional Self-Awareness After Self-Monitoring............. 244 The Preliminary Emotional Self-Awareness Scale (ESAS) ......................................... 245 The Effects of Self-Monitoring on Emotional Self-Awareness.................................... 246 The Indirect Effect of ESA on Self-Monitoring and Depressive Symptoms ............... 248 Limitations of the Investigation.................................................................................... 251 Theoretical Implications of Findings............................................................................ 252 Practical Implications of the Research.......................................................................... 254 Future Research ............................................................................................................ 255 Conclusion .................................................................................................................... 257  TABLE OF CONTENTS xiv Reference List.....................................................................................................................259 Appendices..........................................................................................................................282 APPENDIX A. Abstracts and Posters from Conference Presentations............................ 283 APPENDIX B. Content of the different mobiletype programs ........................................ 287 Appendix C. Qualitative Codebook for Thematic Analysis in Chapters 4 and 6......... 305 Appendix D. Example of the summary report accessible to doctors............................ 307 Appendix E. Quantitative analysis of the Depression, Anxiety and Stress Scale and the Adolescent Coping Scale from Chapter 5..................................................................... 312 Appendix F. Interrater Discrepancies in Chapter 5 ...................................................... 316 Appendix G. High Risk Assessment for mobiletype Program...................................... 318 Appendix H. Publication from Chapter 7..................................................................... 319 Appendix I. Emotional Self-Awareness Scale.............................................................. 346 Appendix J. Preliminary Confirmatory Factor Analysis of the Emotional Self- Awareness Scale ........................................................................................................... 348 Appendix K. Additional Scales Used in Chapter 7 ...................................................... 354 Appendix L. All responses from the ‘High’ and ‘Low’ ESA Groups in Chapter 5 ..... 360