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Moyamoya disease (MMD) is a known progressive obstructive cerebrovascular disorder. Monitoring and managing mood and stress are critical for patients with MMD, as they affect clinical outcomes. The ecological momentary assessment (EMA) method is a longitudinal study design by which multiple variable assessments can be performed over time to detect momentary fluctuations and changes in psychological dimensions such as mood and stress over time.
This study aimed to identify predicting factors associated with momentary mood and stress at both the within-person and between-person levels and to examine individual fluctuation of mood over time in the short term using an EMA method combined with a mobile phone app.
Participants aged older than 18 years were recruited from a tertiary hospital in Seoul, Korea, between July 2018 and January 2019. The PsyMate scale for negative affect (NA) and positive affect (PA) and the Trier Inventory for Chronic Stress Scale were uploaded on patient mobile phones. Using a mobile app, data were collected four times a day for 7 days. Pearson correlations and mixed modeling were used to predict relationships between repeatedly measured variables at both the between-person and within-person levels.
The mean age of the 93 participants was 40.59 (SD 10.06) years, 66 (71%) were female, and 71 (76%) were married. Participants provided 1929 responses out of a possible 2604 responses (1929/2604, 74.08%). The mean momentary NA and PA values were 2.15 (SD 1.12) and 4.70 (SD 1.31) out of 7, respectively. The momentary stress value was 2.03 (SD 0.98) out of 5. Momentary NA, PA, and stress were correlated (
The EMA method using a mobile phone app demonstrated its ability to capture changes in mood and stress in various environmental contexts in patients with MMD. The results could provide baseline information for developing interventions to manage negative mood and stress of patients with MMD based on the identified predictors affecting mood and stress at two different levels.
Moyamoya disease (MMD) is a rare idiopathic vascular disorder that is characterized by progressive bilateral stenosis or occlusion of the distal branches of the carotid arteries with an abnormal vascular network [
The prevalence of MMD in Korea has gradually increased and reached 16.1 per 100,000 persons in 2011 [
The clinical features of MMD or MMS in adult patients generally involve cerebral hemorrhages and infarction, whereas children develop ischemic attacks [
Mood is a state of subjective feeling that can be changed by events and is typically described as having either positive or negative valences [
The ecological momentary assessment (EMA) method, also known as the experience sample method or ambulatory assessment, is a repeated observational study design by which time-varying variables can be assessed in natural and real-life environments [
This study aimed to identify predicting factors associated with momentary mood and stress at both the within-person and between-person levels and to examine individual fluctuation of mood over time in the short term using an EMA method combined with a mobile phone app.
Adult patients with MMD, who visited the outpatient clinic of a tertiary hospital or were admitted in the same hospital, were recruited from July 2018 to January 2019. Only participants who used Android operating systems were included, as the developed mobile app was only available for this operating system with the version 4.4 or higher as described in a previous study [
Measurements in this study included baseline variables, such as demographic characteristics, disease-specific information, trait mood (anxiety and depression), and trait stress. Momentary measures were mood and stress. The study variables at baseline and momentary measures are summarized in
Study variables at all time points.
Variables | Baseline | Ecological momentary assessment | ||||||
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Day 1 | Day 2 | Day 3 | Day 4 | Day 5 | Day 6 | Day 7 |
Demographic characteristics | x | N/Aa | N/A | N/A | N/A | N/A | N/A | N/A |
Disease-specific information | x | N/A | N/A | N/A | N/A | N/A | N/A | N/A |
Korean Hospital Anxiety and Depression Scale | x | N/A | N/A | N/A | N/A | N/A | N/A | N/A |
Korean Perceived Stress Scale | x | N/A | N/A | N/A | N/A | N/A | N/A | N/A |
Momentary mood (PsyMate) | N/A | x | x | x | x | x | x | x |
Momentary stress (Trier Inventory for Chronic Stress) | N/A | x | x | x | x | x | x | x |
ax: variables measured at the day point.
bN/A: not applicable.
Patients provided demographic information such as age, sex, income, level of education, symptoms experienced, and disease duration since the diagnosis. The perceived severity of the disease was also self-reported at baseline using a 5-point scale.
We used the Korean version of the Hospital Anxiety and Depression Scale (K-HADS) [
To measure trait stress, we used the Korean version of the Perceived Stress Scale, which consists of 10 items [
Momentary mood was measured using the Korean version of the PsyMate, translated from the English version with reference to the original Dutch version. We obtained permission to use PsyMate from the developers [
Stress was assessed by the Korean version of the Trier Inventory for Chronic Stress, adapted from the German version [
The questionnaires were uploaded on a mobile app for the Android operating system developed in the previous study [
After obtaining participant informed consent, we held an individual and face-to-face 30-min intake session with each patient. Patients filled the baseline measures and were allowed time to download the app and practice answering for the EMA study. Researchers helped the participants answer the baseline survey and install the app. Patients were provided a reward in coupons when they completed the baseline survey and enrollment. They were also informed that they would receive additional coupons on completion of the EMA study. Researchers preset the survey period for each patient in advance to push notifications and instructed participants to carry their mobile phone during the scheduled survey period and to answer the survey question when they received the notification requesting them to do so.
Measures of mood and stress were set on the mobile app, and notifications were set to appear four times a day for 7 consecutive days (4 times ×7 days=28 times/person) in semirandom, 90-min blocks. Notifications were sent in the morning between 8 AM and 9 PM, early afternoon between noon and 1 PM, evening between 5 PM and 6 PM, and at night between 9 PM and 10 PM. Participants were instructed that they would receive a reminder notification when they did not input the response within 45 min after they received the first notification for each scheduled measurement. Researchers monitored participant compliance to the protocol and managed participation by phoning patients who did not respond on the first day and attempted to solve any participation difficulties and problems in the EMA study.
Data analysis was performed with STATA 14.0 (StataCorp) using 1929 responses from 93 participants who provided more than three responses in the total course of the study to capture changes over time [
A total of 93 participants with MMD were recruited. Of 93 participants, 71 (76%) were recruited from the outpatient department and 22 participants (24%) were recruited from the admission wards of a university hospital. The mean age of the participants was 40.59 years (SD 10.06), 71% (66/93) participants were female, and 76% (71/93) participants were married. The mean number of years since diagnosis was 3.68 (SD 4.05), and the perceived severity level was 3.56 (SD 1.00) out of 5. The mean HADS anxiety and depression scores were 7.17 (SD 3.38) and 7.14 (SD 3.51) out of 21, respectively, and the mean perceived stress level was 1.64 (SD .98) out of 4. The participant baseline characteristics are summarized in
Participant characteristics at baseline (n=93).
Characteristics | n (%) | Mean (SD) | Possible range | ||||
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20–29 | 11 (12) | 40.59 (10.06) | N/Aa | |||
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30–39 | 37 (40) | N/A | N/A | |||
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40–49 | 26 (28) | N/A | N/A | |||
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50–59 | 15 (16) | N/A | N/A | |||
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≥60 | 4 (4) | N/A | N/A | |||
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Female | 66 (71) | N/A | N/A | |||
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Male | 27 (29) | N/A | N/A | |||
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Married | 71 (76) | N/A | N/A | |||
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Not married | 22 (24) | N/A | N/A | |||
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≤High school | 41 (44) | N/A | N/A | |||
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≥College | 52 (56) | N/A | N/A | |||
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<2000 | 23 (25) | N/A | N/A | |||
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2000–3000 | 16 (18) | N/A | N/A | |||
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3000–4000 | 22 (24) | N/A | N/A | |||
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>4000 | 31 (33) | N/A | N/A | |||
Years since the diagnosis | N/A | 3.68 (4.05) | N/A | ||||
Perceived severity | N/A | 3.56 (1.00) | 1–5 | ||||
HADSc anxiety | N/A | 7.17 (3.38) | 0–21 | ||||
HADS depression | N/A | 7.14 (3.51) | 0–21 | ||||
Perceived stress | N/A | 1.64 (.98) | 0–4 |
aN/A: not applicable.
bn=92.
cHADS: Hospital Anxiety and Depression Scale.
Participants provided 1929 responses out of a possible 2604 (1929/2604, 74.1%). Of 1883 responses, 799 (42.4%) were answered while participants were resting, 344 responses (18.3%) while working, 293 responses (15.6%) doing household work, and 188 responses (10.0%) while eating or drinking at the moment of answering. Of the 1929 responses, 1147 (59.5%) were obtained when participants were at home, 325 responses (16.9%) were obtained at the office, and 87 responses (4.5%) were obtained at a café or restaurant. Of all 1929 responses, 444 (23.1%) were obtained while the participants were alone, and 1348 (69.9%) were obtained on weekdays. Of 1929 responses, 489 (25.3%), 497 (25.8%), 509 (26.4%), and 434 (22.5%) were provided in the morning, afternoon, evening, and at night, respectively. The mean momentary NA and PA were 2.15 (SD 1.12) and 4.70 (SD 1.31) out of 7, respectively. The mean momentary stress level was 2.03 (SD .68) out of 5. Measures of momentary variables are summarized in
Measures of momentary variables (n=1929).
Momentary variables | n (%) | Mean (SD) | Possible range | ||||
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Household work | 293 (15.6) | N/Ab | N/A | |||
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Working | 344 (18.3) | N/A | N/A | |||
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Eating/drinking | 188 (10.0) | N/A | N/A | |||
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Resting | 799 (42.4) | N/A | N/A | |||
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Other | 259 (13.7) | N/A | N/A | |||
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Home | 1147 (59.5) | N/A | N/A | |||
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Office | 325 (16.9) | N/A | N/A | |||
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Café or restaurant | 87 (4.5) | N/A | N/A | |||
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Hospital | 66 (3.4) | N/A | N/A | |||
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Public place | 138 (7.2) | N/A | N/A | |||
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Other | 164 (8.5) | N/A | N/A | |||
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Yes | 444 (23.1) | N/A | N/A | |||
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No | 1485 (76.9) | N/A | N/A | |||
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Yes | 581 (30.1) | N/A | N/A | |||
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No | 1348 (69.9) | N/A | N/A | |||
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Morning (8 AM to 9 PM) | 489 (25.3) | N/A | N/A | |||
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Afternoon (12 noon to 1 PM) | 497 (25.8) | N/A | N/A | |||
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Evening (5 PM to 6 PM) | 509 (26.4) | N/A | N/A | |||
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Night (9 PM to 10 PM) | 434 (22.5) | N/A | N/A | |||
Momentary negative affect | N/A | 2.15 (1.12) | 1–7 | ||||
Momentary positive affect | N/A | 4.70 (1.31) | 1–7 | ||||
Momentary stress | N/A | 2.03 (0.68) | 1–5 |
an=1883.
bN/A: not applicable.
cn=1927.
Momentary NA, PA, and stress were significantly correlated (
Correlation coefficients between momentary variables (n=93).
Momentary variables | Momentary NAa (r value) | Momentary PAb (r value) |
Momentary NA | 1 | -0.607c |
Momentary PA | −0.607c | 1 |
Momentary stress | 0.538c | −0.272c |
aNA: negative affect.
bPA: positive affect.
c
Analysis by mixed modeling was performed based on 1929 completed assessments from the participants who provided more than three responses for analyzing changes of momentary mood and stress over time at both level 1 (within-person) and level 2 (between-person).
Momentary predicting factors were examined by three models at levels 1 and 2. Disease-specific variables such as perceived severity and years since the diagnosis, age, sex, and trait mood variables at the baseline were added into models 2 and 3 for adjustment. Momentary variables included
Designed levels, models, and variables.
Level and model | Variables | |
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1. Momentary variables | What, where, with whom, weekend, and time of day |
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2. Disease-specific variables | Variables of Model 1 + perceived severity and years since the diagnosis |
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3. Trait variables | Variables of Model 2 + age, sex, trait anxiety/depression, and stress |
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1. Momentary variables | What, where, with whom, weekend, and time of day |
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2. Disease-specific variables | Variables of Model 1 + perceived severity and years since the diagnosis |
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3. Trait variables | Variables of Model 2 + age, sex, trait anxiety/depression, and stress |
Common momentary variables associated with momentary mood and stress at both the within-person (level 1) and between-person (level 2) levels were identified. Momentary NA increased when being alone and being at the hospital at both levels, whereas momentary PA increased when eating or drinking, resting, being at a café or restaurant, or at the public place but decreased when being alone at both levels. Momentary stress increased when at the office, at the public place, or as the time of the day went by but decreased when resting or during the weekend.
Different factors affecting momentary mood and stress at different levels were also identified. Variables of being at a café or restaurant (coefficient=−0.19;
Fixed effect model parameter estimates at within-person and between-person levels in model 3.
Variablesa | Momentary negative affect, coefficient (SE) | Momentary positive affect, coefficient (SE) | Momentary stress, coefficient (SE) | |||||||
Within | Between | Within | Between | Within | Between | |||||
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Household work | Reference | Reference | Reference | Reference | Reference | Reference |
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Working | 0.05 (0.09) | 0.08 (0.12) | −0.20 (0.12) | −0.20 (0.15) | 0.26 (0.42) | 0.64 (0.61) |
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Eating or drinking | −0.09 (0.07) | −0.20 (0.10)b | 0.24 (0.09)b | 0.27 (0.12)b | 0.23 (0.33) | −0.56 (0.49) |
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Resting | −0.08 (0.05) | −0.21 (0.07)c | 0.15 (0.06)b | 0.30 (0.08)c | −1.03 (0.23)c | −1.56 (0.33)c |
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Other | −0.01 (0.06) | −0.02 (0.09) | 0.03 (0.09) | −0.05 (0.11) | −0.26 (0.31) | −1.20 (0.45) |
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Home | Reference | Reference | Reference | Reference | Reference | Reference |
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Office | 0.05 (0.08) | −0.19 (0.12) | −0.04 (0.11) | 0.21 (0.14) | 1.82 (0.41)c | 1.56 (0.58)c |
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Café or restaurant | −0.19 (0.09)b | −0.10 (0.12) | 0.37 (0.12)c | 0.33 (0.15)b | −0.75 (0.42) | −0.17 (0.61) |
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Hospital | 0.32 (0.12)b | 0.54 (0.12)c | −0.17 (0.16) | −0.07 (0.15) | 0.60 (0.58) | 5.67 (0.62)c |
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Public place | −0.06 (0.07) | 0.01 (0.09) | 0.21 (0.09)b | 0.28 (0.12)b | 0.91 (0.33)c | 2.13 (0.47)c |
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Other | −0.10 (0.06) | −0.10 (0.09) | 0.22 (0.08) | 0.35 (0.11) | 0.08 (0.30) | 0.83 (0.43) |
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Being alone | 0.10 (0.04)b | 0.24 (0.05)c | −0.16 (0.05)c | −0.49 (0.07)c | −0.37 (0.20) | −0.34 (0.27) |
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Weekend | −0.08 (0.03)b | −0.03 (0.05) | 0.02 (0.05) | 0.01 (0.06) | −1.20 (0.16)c | −0.76 (0.25)c |
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8-9 AM | Reference | Reference | Reference | Reference | Reference | Reference |
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12 noon-1 PM | −0.03 (0.04) | −0.01 (0.06) | 0.09 (0.06) | 0.08 (0.08) | 0.76 (0.20)c | 0.77 (0.31)c |
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5-6 PM | −0.04 (0.04) | −0.01 (0.06) | 0.03 (0.05) | −0.03 (0.08) | 1.07 (0.20)c | 1.03 (0.30)c |
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9-10 PM | −0.04 (0.04) | −0.05 (0.06) | 0.17 (0.06)c | 0.14 (0.08) | 1.48 (0.21)c | 1.40 (0.32)c |
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Perceived severity | 0.11 (0.08) | 0.13 (0.02)c | −0.03 (0.09) | −0.06 (0.03)b | 0.69 (0.41) | 0.73 (0.11)c |
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Years since the diagnosis | −0.03 (0.02) | −0.01 (0.01) | −0.03 (0.02) | −0.04 (0.01)b | −0.16 (0.10) | −0.10 (0.03)c |
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Trait anxiety and depression | 0.06 (0.02)c | 0.07 (0.01)c | −0.06 (0.02)c | −0.08 (0.01)c | 0.21 (0.08)b | 0.19 (0.02)c |
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Trait stress | 0.04 (0.02)b | 0.03 (0.01)c | 0.01 (0.02) | 0.02 (0.01)b | 0.22 (0.12) | 0.23 (0.03)c |
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aAge and sex adjusted.
b
c
Both the momentary NA and PA of participants fluctuated over time. We arbitrarily selected 10 participants from those who completed all 28 assessments to show the individual fluctuation of affect over time. Specific graphs of NA and PA fluctuation were constructed for each selected participant in accordance with momentary and trait variables (
Individual fluctuation of negative affect over time for the selected participants. NA: negative affect; A to I: selected participants.
Individual fluctuation of positive affect over time for the selected participants. PA: positive affect; A to I: selected participants.
This study used the EMA method to assess and predict momentary factors associated with momentary mood and stress in a real-life context in adult patients with MMD. The results showed that context variables of the participants’ natural environment affected momentary mood and stress at both the within-person and between-person levels after adjusting for participant demographics and disease-specific characteristics and trait anxiety and depression.
We also identified common variables affecting momentary mood and stress at both the within-person and between-person levels and distinguished different variables having different effects at the within-person and between-person levels. Participants commonly showed higher NA when being alone or at the hospital at both levels. Meanwhile, some factors such as activities of eating or drinking or resting affected momentary NA at the between-person level only. Participants commonly expressed decreased stress when resting or during the weekend and increased stress at the office and as the time of the day went by at both levels. Meanwhile, being at the hospital was associated with higher stress only at the between-person level. These results showed that different factors at different levels are associated with NA and stress, although there are numerous common factors. These factor differences between the two levels should be considered when designing individualized interventions to manage the mood and stress of patients with MMD.
This study also established that an EMA method using a mobile app could capture individual fluctuations of mood and stress over time while participants perform their usual daily tasks. This result is aligned with the result from a previous study that applied an EMA app using the same scale of the PsyMate to assess the mood of Dutch patients in an ambulatory mental health setting [
In an additional analysis, we found that patients who had been diagnosed less than a year ago appeared to be more depressed than those who were diagnosed more than a year ago. These results indicate that an emotional care plan with close, regular monitoring is needed for patients with MMD, especially for those with higher anxiety and depression, and within a year after diagnosis. The levels of anxiety and depression of the participants in this study at baseline were 7.17 (SD 3.38) and 7.14 (SD 3.51) out of 21, respectively. This implies that adults with MMD may also strive to overcome negative feelings, as do patients with other cerebrovascular diseases who are at continuous risk of cerebrovascular hemorrhage and infarction [
Perceived stress is a known predictor of depression and depressive symptoms in patients with stroke [
Perceived social support plays a critical role in buffering stress and promoting psychological well-being [
Our study had limitations. This study included patients who used Android OS, and those who used other systems were excluded. In addition, there might be challenges regarding technical issues and potential malfunctioning of the configuration, although a helpline was provided by our research team. These technical points need to be addressed to improve the EMA survey in the future. In addition, as the patients were recruited from a tertiary-level hospital in Seoul, patients in communities or in smaller facilities may differ from this study population in terms of clinical severity, years since the diagnosis, or trait mood and stress levels.
Studies on the impact of social support or stress-coping strategies on mood and stress in MMD warrants further investigation. EMA methods integrated into momentary interventions for improving mood and stress could be a promising future direction in MMD.
In this study, we evaluated the EMA method using a mobile phone app and demonstrated that the EMA method was able to capture mood and stress change over time and by assessing momentary contextual variables. With the identified predictors affecting mood and stress at two different levels, the results of this study could provide valuable information for developing individualized patient-centered interventions for managing the mood and stress of patients with MMD who are psychologically vulnerable and whose states cannot be easily assessed in a real-world environment.
ecological momentary assessment
Korean version of the Hospital Anxiety and Depression Scale
Moyamoya disease
Moyamoya syndrome
magnetic resonance
negative affect
positive affect
The authors thank the participants of this study for sharing a part of their life. This study was supported by the Basic Science Research Program through the National Research Foundation of Korea (NRF) funded by the Ministry of Education (2017R1D1A1B03030706).
None declared.