title: Mobile Sensing and Support for People With Depression: A Pilot Trial in the Wild.
abstract: BACKGROUND
  Depression is a burdensome, recurring mental health disorder with high prevalence. Even in developed countries, patients have to wait for several months to receive treatment. In many parts of the world there is only one mental health professional for over 200 people. Smartphones are ubiquitous and have a large complement of sensors that can potentially be useful in monitoring behavioral patterns that might be indicative of depressive symptoms and providing context-sensitive intervention support.
  
  
  OBJECTIVE
  The objective of this study is 2-fold, first to explore the detection of daily-life behavior based on sensor information to identify subjects with a clinically meaningful depression level, second to explore the potential of context sensitive intervention delivery to provide in-situ support for people with depressive symptoms.
  
  
  METHODS
  A total of 126 adults (age 20-57) were recruited to use the smartphone app Mobile Sensing and Support (MOSS), collecting context-sensitive sensor information and providing just-in-time interventions derived from cognitive behavior therapy. Real-time learning-systems were deployed to adapt to each subject's preferences to optimize recommendations with respect to time, location, and personal preference. Biweekly, participants were asked to complete a self-reported depression survey (PHQ-9) to track symptom progression. Wilcoxon tests were conducted to compare scores before and after intervention. Correlation analysis was used to test the relationship between adherence and change in PHQ-9. One hundred twenty features were constructed based on smartphone usage and sensors including accelerometer, Wifi, and global positioning systems (GPS). Machine-learning models used these features to infer behavior and context for PHQ-9 level prediction and tailored intervention delivery.
  
  
  RESULTS
  A total of 36 subjects used MOSS for ≥2 weeks. For subjects with clinical depression (PHQ-9≥11) at baseline and adherence ≥8 weeks (n=12), a significant drop in PHQ-9 was observed (P=.01). This group showed a negative trend between adherence and change in PHQ-9 scores (rho=-.498, P=.099). Binary classification performance for biweekly PHQ-9 samples (n=143), with a cutoff of PHQ-9≥11, based on Random Forest and Support Vector Machine leave-one-out cross validation resulted in 60.1% and 59.1% accuracy, respectively.
  
  
  CONCLUSIONS
  Proxies for social and physical behavior derived from smartphone sensor data was successfully deployed to deliver context-sensitive and personalized interventions to people with depressive symptoms. Subjects who used the app for an extended period of time showed significant reduction in self-reported symptom severity. Nonlinear classification models trained on features extracted from smartphone sensor data including Wifi, accelerometer, GPS, and phone use, demonstrated a proof of concept for the detection of depression superior to random classification. While findings of effectiveness must be reproduced in a RCT to proof causation, they pave the way for a new generation of digital health interventions leveraging smartphone sensors to provide context sensitive information for in-situ support and unobtrusive monitoring of critical mental health states.
authors.affiliation: ETH Zürich, Department of Management, Technology and Economics, Zürich, Switzerland.
authors.forename: Fabian
authors.identifier: http://orcid.org/0000-0003-1377-9239
authors.initials: F
authors.lastname: Wahle
authors.forename: Tobias
authors.identifier: http://orcid.org/0000-0001-5939-4145
authors.initials: T
authors.lastname: Kowatsch
authors.forename: Elgar
authors.identifier: http://orcid.org/0000-0002-4842-1117
authors.initials: E
authors.lastname: Fleisch
authors.forename: Michael
authors.identifier: http://orcid.org/0000-0003-4964-4213
authors.initials: M
authors.lastname: Rufer
authors.forename: Steffi
authors.identifier: http://orcid.org/0000-0001-5267-8217
authors.initials: S
authors.lastname: Weidt
keywords: classification; cognitive behavioral therapy; context awareness; depression; mHealth;  activities of daily living