Dispelling “pleasing myths” about the integration of ecological momentary assessment and intervention into clinical research and practice
Authors: Joshua M. Smyth, Ulrich Ebner‐Priemer
Journal: World Psychiatry (2025)

There is a long and rich scientific and clinical history regarding the utility of ambulatory assessments – including relatively intensive strategies such as ecological momentary assessment (EMA) – to capture feelings, thoughts, behaviors, and context of everyday life1, 2. EMA approaches can be beneficial in many ways, notably by providing a glimpse into everyday life that is missed in clinical appointments (i.e., ecological validity), characterizing processes that occur over time, providing information on the environments and contexts experienced by a patient, and reducing recall and reporting biases that can occur in clinic. More recently, coupled with tremendous developments in mobile technology, there has been increasing attention on how to implement intervention approaches using ambulatory technology, particularly delivering micro-intervention content at moments of identified need (ecological momentary intervention, EMI)3. Enthusiasm for these approaches continues to increase. Yet, the actual evidence of significant benefit is still somewhat lacking. Herein we discuss several assumptions often held about EMA/EMI ("pleasing myths"), explaining why and how they need to be dispelled. A first "pleasing myth" is that EMA will just "work" simply through its application – that is, EMA will provide novel insight into characterizing patients' everyday experiences, as the methods are fancy, innovative and mobile. Unfortunately, the benefits of EMA do not emerge simply from the technology; rather, care must be taken to connect the design and implementation to the research and/or clinical goals. For example, there is no agreed upon "generic" assessment battery for EMA. The content of what is assessed must be derived from the most relevant constructs and contexts in a patient's everyday life, and reflect the relevant dynamic processes and mechanisms to be characterized and/or intervened upon. A second "pleasing myth" is that EMI will produce benefit by providing the right help at the right moment. Actually, even presuming careful design of assessment content, there are many unanswered questions on the development and application of EMI (and subsequent approaches, such as just-in-time adaptive interventions3, 4). EMIs are not "full" interventions, but brief, low-burden, micro-intervention elements/components in everyday life, often delivered through smartphones or other devices, and increasingly reflecting mechanisms-focused approaches (i.e., targeting mechanistic processes). Although there are examples of identifying personalized moments of risk, such as intense craving in the context of substance use, we know relatively little about what parameters we can reliably capture and which are psychologically or behaviorally relevant. Moreover, even when successful at identifying a risk moment (e.g., acute depressive symptoms, high interpersonal anger), we often lack an empirical basis regarding the best time point to intervene (e.g., is intervening at the highest risk moment appropriate, or is it preferable to intervene in advance and/or facilitate recovery processes?), as well as what (micro-) intervention content is most efficacious at improving the targeted process(es). A third "pleasing myth" is that mobile applications ("apps") and mHealth are "cool" and engaging, so patients will love to use them. Unfortunately, the evidence suggests that just the opposite is true: most apps, including those targeting mental health and behavior change, are used infrequently and often abandoned within a few weeks or months. Given that most EMA/EMI approaches are reliant upon active reporting (e.g., responding to brief self-report items), efficiency in the design of assessment content is essential, as it relates strongly to patient burden and the capacity to obtain high-quality data and good compliance. That said, carefully designed EMA studies have demonstrated the capacity to retain patients with good reporting compliance over long periods of time (months for ongoing EMA studies, and even several years using episodic EMA sampling in measurement burst designs). A fourth "pleasing myth" is that it is easy to implement EMA/EMI, as one can just get a student or hire someone to quickly program an app. Actually, although the tools and expertise for app development continue to improve, there are many challenges to developing and implementing a novel EMA/EMI app system. Most notably, if intended as part of clinical care and/or research, it is vital that the app has excellent user features, which requires careful development and testing (ideally including the target population). Apps have to be robust to implementation details, operating systems, and device characteristics. Moreover, these features of apps have to be maintained over time and respond to any relevant changes. Finally, when being used in clinical contexts, it is essential that the apps follow medical device law regulation (which may vary depending on the context of implementation). Although these issues are tractable (particularly through collaboration with academic/industry partners), they are not trivial and should be carefully considered prior to implementing EMA/EMI. A fifth "pleasing myth" is that all we need is the EMA/EMI app to address all problems of an individual patient, and we can reduce or remove the need for clinical involvement. Here, too, the evidence does not support the premise: the use of an app by itself (e.g., for behavior change, or to address mental health needs) often does not result in significant and/or sustained improvements. Psychological and behavioral changes are difficult to achieve and sustain, and likely require comprehensive approaches that include integrated systems of care5. In such models, EMA/EMI approaches can be used as one element of care, with EMA helping to provide a real-life psycho-behavioral phenotype of each patient, and EMI helping to extend change/intervention processes into everyday life, facilitating the awareness and practice of applying such processes outside of the clinic. We believe that persistent and incorrect assumptions ("pleasing myths") about EMA/EMI have hindered them from realizing their full potential. We need to dispel these myths and facilitate continued and expanded efforts to efficiently leverage the capabilities of patient-centered ambulatory assessment and intervention. Considering the many benefits (real life, real time, help in the moment), we remain enthusiastic about integrating EMA/EMI into clinical research and practice6. Some particular areas in which EMA/EMI can help revolutionize treatment and research include the potential for treatment delivery plans to be dynamically adapted over time (e.g., in response to need, to identifying what works for a given person, to changes in clinical and/or experiential functioning); high scalability (although difficult to develop, once developed they can be widely disseminated at low cost as a supplemental/adjuvant treatment); inclusion of environmental sensors in care; and efficient provision of coherent summaries (e.g., visualizations) of real-world everyday life data to patients, providers and/or others, to facilitate care and promote well-being.