Adherence to a Six-Week Study of Wearable Digital Mood and Cognitive Assessments in Depression: Qualitative Insights

Background

Digital technology has promise in delivering insights into psychiatric conditions such as depression by enabling assessment of mood and cognitive symptoms in patients’ daily life. The utility of these methods may be limited by patient adherence with frequent testing or wear of sensing technology. Here we describe qualitative data which aimed to enhance our understanding of participants’ experiences of longer-term use of digital cognitive assessments with wearable technology. We explored why participants choose to engage with digital health assessments, and motivations and factors influencing adherence to a daily testing regimen over six weeks.

 

Methods

• Thirty adults age 19-63 with mild to moderate single or recurrent Major Depressive Episode prescribed antidepressant monotherapy were enrolled.
• A single-arm, 6-week prospective observational feasibility study, designed to assess the feasibility and compliance with a novel method for assessing mood and cognition in participants with MDD.
• Brief cognitive (Cognition Kit n-back) and mood assessments were administered through the Cognition Kit application on Apple Watch (Figure 2).

 

Results

Compliance with Daily Assessment

Compliance results are shown in Figures 3 and 4, plotting individual participants (y axis), by daily compliance during the 6-week study period (x-axis), yellow squares show days with completed assessments, black where they are missed.

Daily mood assessments:

• Self-reported mood was available to complete once per day.
• 50% of participants achieved 100% compliance, completing all assessments. overall compliance was 94.6%.
• There was no significant change in severity of depression symptoms over the course of the study, measured either through the Cognition Kit Apple watch app or PRO measures. 

Daily cognitive assessments:

• Participants completed up to three Cognition Kit n-back sessions per day. A median of two assessments were completed daily
• 70% of participants achieved 100% compliance. Cognitive assessment was completed on 96% of study days.
• In Week 5, compliance reached 100%, with all study participants completing at least one Cognition Kit n-back session daily.

 

Qualitative Insights 

• Participants adhered to the testing regimen with varying degrees of ease, enjoyment and perceived benefit. We identified four main themes contributing to participants’ continued adherence. These included ⁽¹⁾ Context ⁽²⁾; Motivation; ⁽³⁾ Study features; and ⁽⁴⁾ Impact.
• Adherence was influenced by contextual factors, including moods, daily routines, and social and physical environment.
• Many patients expressed personal motivations of enhancing knowledge of depression or gaining self-insight. The in-app feedback functionality, which displayed scores after each cognitive assessment, supported this aim of self-insight and served as a motivator.
• Participants were motivated by the luxury status of the device, although short battery life was an obstacle to adherence. The technology was experienced as discreet, quick and easy to use.
• Assessment burden was deemed acceptable over the 6-week time-frame, helped by the brevity of each individual assessment.
• Study participation had diverse effects on participant wellbeing, with some feeling increased anxiety, others a sense of accomplishment. The extent to which people reported a benefit was overall linked to their expectations for self-insight, behaviour change, and their personal use of the trial data.

 

Conclusions

• Our study suggests good acceptability of wearable cognitive and mood assessment using the Apple Watch.
• The qualitative themes identified show some overlap with previous research in smartphone-based digital health assessments, with discretion of the wearable technology as well as desirability of the smartwatch providing additional motivation in the current study.
• Usability of health technology has been noted as a major contributor to engagement, and a primary predictor of drop-out. Optimising the balance between assessment burden and a monitoring schedule which captures the measures and processes of interest is of importance for supporting adherence in high-frequency assessment studies. The current results have implications for digital health development and design, identifying factors and features supporting patient adoption, motivation and engagement.

 

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Tags : cognition | digital health | cognitive testing | digital tools | cognitive science | technology | depression