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Background: College is an exciting but also challenging time with an increased risk for mental health issues. Only a minority of the college students concerned get professional help, a problem that might be improvable by internetand mobile-based interventions (IMIs). However, adherence of IMIs is a concern. While guidance might be a solution, it is resource-intensive, derailing potential implementation on population level. The first aim of this trial is to evaluate the efficacy of the IMI StudiCare Mindfulness (StudiCare-M) for college students with “on demand” and no guidance. The second aim is to examine potential moderators and mediators, contributing to the questions of “how” and “for whom” such interventions work. Methods: In this three-armed randomized controlled trial, both an unguided and “guidance on demand” (GoD) condition of StudiCare-M are compared to a waitlist control group. StudiCare-M is based on principles of acceptance and commitment therapy and stress management and consists of 7 modules plus two booster sessions. Participants in the GoD condition may ask their e-coach for support whenever needed. A total of 387 college students with moderate to low mindfulness are recruited at 15+ cooperating universities in Germany, Austria, and Switzerland via circular emails. Assessments take place before as well as 1, 2, and 6 months after randomization. The primary outcome is mindfulness. Secondary outcomes include stress, depression, anxiety, interoception, presenteeism, wellbeing, intervention satisfaction, adherence, and potential side effects. Among examined moderators and mediators are sociodemographic variables, pre-treatment symptomatology, treatment expectancy, self-efficacy, cognitive fusion, emotion regulation, and alexithymia. All data will be analyzed according to intention-to-treat (ITT) principles. Discussion: Providing effective interventions to help college students become more resilient can make a valuable contribution to the health and functionality of future society. If effective under the condition of minimal or no guidance, StudiCare-M offers a low-threshold potentially resource-efficient possibility to enhance college student mental health on a population level. Moderation- and mediation analyses will deliver further insights for optimization of target groups and intervention content., publishedVersion

Objectives: Physical activity (PA) positively influences several aspects of mental well-being including affect improvements. Yet, the fact that subjective and objective measures of PA often diverge challenges research on the relationship of PA and affect.Methods: Subjective (ecological momentary assessment, EMA) and objective (combined heart rate and accelerometric activity tracker) measures of PA alongside repeated ratings of positive and negative affects were obtained from 37 participants over 7 consecutive days.Results: Subjective and objective PA were significantly positively correlated. Affect improvements, that is, negative affect decrease as well as positive affect increase, were predicted by both subjective (EMA) and objective (activity tracker) data.Conclusions: Measurement concordance supports the validity of both assessment strategies. Affect improvements result from both subjective representations of one’s own activity as well as from physiological mechanisms of PA that one is not aware of, suggesting two independent routes to affect improvements.

Background: Interoceptive accuracy and sensibility are decreased in depressive samples. However, different studies showed that cognitive-behavioural therapy (CBT) and mindfulness interventions are promising approaches to improve interoceptive abilities. Based on these findings, the study aims to investigate the pre–post effect of CBT in a depressive sample. Additionally, we examined the effect of mindfulness-based stress reduction (MBSR) training in the context of CBT. Methods: Sixty depressive patients were investigated over four weeks, with two conditions—CBT vs. CBT + MBSR. Further, the changes in interoceptive abilities (interoceptive accuracy and sensibility) of the depressive patients were compared to baseline data of healthy controls. Results: The depressive patients showed significantly higher levels of depression and lower mindfulness and interoceptive abilities than healthy controls. The depressive sample showed a significant decrease in depressive symptoms and increased mindfulness and interoceptive abilities after CBT. Lastly, depressive patients of the CBT + MBSR condition did not differ from those who only received CBT in the levels of depression, mindfulness or interoceptive abilities over the time course. Discussion: This study demonstrates a positive effect of CBT on interoceptive abilities in a depressive sample. It is shown that the depressive sample did not profit from additional mindfulness training. It can be concluded that CBT is an efficient treatment, resulting in increased interoceptive abilities. Unexpectedly, the combination of CBT and MBSR has no additional effect on these changes. Future studies should investigate the effect of MBSR as a stand-alone therapy., publishedVersion

Background: Physical inactivity is a major contributor to the development and persistence of chronic diseases. Mobile health apps that foster physical activity have the potential to assist in behavior change. However, the quality of the mobile health apps available in app stores is hard to assess for making informed decisions by end users and health care providers. Objective: This study aimed at systematically reviewing and analyzing the content and quality of physical activity apps available in the 2 major app stores (Google Play and App Store) by using the German version of the Mobile App Rating Scale (MARS-G). Moreover, the privacy and security measures were assessed. Methods: A web crawler was used to systematically search for apps promoting physical activity in the Google Play store and App Store. Two independent raters used the MARS-G to assess app quality. Further, app characteristics, content and functions, and privacy and security measures were assessed. The correlation between user star ratings and MARS was calculated. Exploratory regression analysis was conducted to determine relevant predictors for the overall quality of physical activity apps. Results: Of the 2231 identified apps, 312 met the inclusion criteria. The results indicated that the overall quality was moderate (mean 3.60 [SD 0.59], range 1-4.75). The scores of the subscales, that is, information (mean 3.24 [SD 0.56], range 1.17-4.4), engagement (mean 3.19 [SD 0.82], range 1.2-5), aesthetics (mean 3.65 [SD 0.79], range 1-5), and functionality (mean 4.35 [SD 0.58], range 1.88-5) were obtained. An efficacy study could not be identified for any of the included apps. The features of data security and privacy were mainly not applied. Average user ratings showed significant small correlations with the MARS ratings (r=0.22, 95% CI 0.08-0.35; P, publishedVersion

Objective: Previous research has shown reduced interoceptive accuracy (IAcc) in depression. Attention deficit represents a key symptom of depression. Moreover, IAcc is positively correlated with attention. There is no study that investigates the effect of depression on IAcc and attention. The aim of this study is to examine the mediating effect of IAcc on depression and attention. Methods: Thirty-six depressed patients from the Psychosomatic Clinic inWindach were matched with 36 healthy controls according to age and sex and were assessed at Ulm University. All participants completed the Beck Depression Inventory-II, the heartbeat perception task to examine IAcc, and the d2 test assessing selective attention. Results: Depressed patients showed attention deficits—both for general visual attention and IAcc—compared to healthy controls. The mediation analyses revealed that the relationship between depression and attention is not mediated via IAcc. Furthermore, depression predicts IAcc and attention, but these effects are direct and largely unaffected by the respective other variable. Discussion: The results of the present study highlight both interoceptive as well as attention deficits in depressed patients. No clear mediation between these variables could be shown in this study. More elaborative research is needed to clarify whether different approaches to improve IAcc are effective for these deficits in depressed patients and could therefore be of importance as an additional aspect of therapy in depression., publishedVersion

Background: Through the increasingly aging population, the health care system is confronted with various challenges such as expanding health care costs. To manage these challenges, mobile apps may represent a cost-effective and low-threshold approach to support older adults. Objective: This systematic review aimed to evaluate the quality, characteristics, as well as privacy and security measures of mobile apps for older adults in the European commercial app stores. Methods: In the European Google Play and App Store, a web crawler systematically searched for mobile apps for older adults. The identified mobile apps were evaluated by two independent reviewers using the German version of the Mobile Application Rating Scale. A correlation between the user star rating and overall rating was calculated. An exploratory regression analysis was conducted to determine whether the obligation to pay fees predicted overall quality. Results: In total, 83 of 1217 identified mobile apps were included in the analysis. Generally, the mobile apps for older adults were of moderate quality (mean 3.22 [SD 0.68]). Four mobile apps (5%) were evidence-based; 49% (41/83) had no security measures. The user star rating correlated significantly positively with the overall rating (r=.30, P=.01). Obligation to pay fees could not predict overall quality. Conclusions: There is an extensive quality range within mobile apps for older adults, indicating deficits in terms of information quality, data protection, and security precautions, as well as a lack of evidence-based approaches. Central databases are needed to identify high-quality mobile apps., publishedVersion

Background Mobile health apps (MHA) have the potential to improve health care. The commercial MHA market is rapidly growing, but the content and quality of available MHA are unknown. Instruments for the assessment of the quality and content of MHA are highly needed. The Mobile Application Rating Scale (MARS) is one of the most widely used tools to evaluate the quality of MHA. Only few validation studies investigated its metric quality. No study has evaluated the construct validity and concurrent validity. Objective This study evaluates the construct validity, concurrent validity, reliability, and objectivity, of the MARS. Methods Data was pooled from 15 international app quality reviews to evaluate the metric properties of the MARS. The MARS measures app quality across four dimensions: engagement, functionality, aesthetics and information quality. Construct validity was evaluated by assessing related competing confirmatory models by confirmatory factor analysis (CFA). Non-centrality (RMSEA), incremental (CFI, TLI) and residual (SRMR) fit indices were used to evaluate the goodness of fit. As a measure of concurrent validity, the correlations to another quality assessment tool (ENLIGHT) were investigated. Reliability was determined using Omega. Objectivity was assessed by intra-class correlation. Results In total, MARS ratings from 1,299 MHA covering 15 different health domains were included. Confirmatory factor analysis confirmed a bifactor model with a general factor and a factor for each dimension (RMSEA = 0.074, TLI = 0.922, CFI = 0.940, SRMR = 0.059). Reliability was good to excellent (Omega 0.79 to 0.93). Objectivity was high (ICC = 0.82). MARS correlated with ENLIGHT (ps, publishedVersion

Interozeption beschreibt die Wahrnehmung körperinterner Signale und deren Verarbeitung. Der Körper muss adäquat auf Bedürfnisse und Defizite reagieren, um eine körperliche Homöostase herzustellen, welche entscheidend für einen gesunden körperlichen und mentalen Zustand ist. Darüber hinaus konnte in verschiedenen Studien der Zusammenhang von Interozeption mit unterschiedlichen gesundheitsrelevanten Variablen (u. a. Stress, körperliche Aktivität, Emotionswahrnehmung und -regulation) sowie deren Einfluss auf die verschiedenen Erhebungsmethoden belegt werden. Weiterhin konnte auch eine gestörte Interozeptionsfähigkeit in diversen klinischen Populationen (u. a. Depressionen, Essstörungen) nachgewiesen werden. Basierend auf diesen Beobachtungen ist es somit entscheidend, Maßnahmen zu entwickeln, welche interozeptive Prozesse fördern. In den letzten Jahren haben sich hierbei insbesondere selbst- und körperfokussierte Ansätze als vielversprechende Maßnahmen herauskristallisiert. Insgesamt lässt sich daraus ableiten, dass Interozeption eine entscheidende Rolle für die individuelle Gesundheit spielt. Die vorliegende Dissertation hat das Ziel, die Interaktion von gesundheitsrelevanten Variablen (u. a. chronischem Stress) und interozeptiven Prozessen zu beleuchten und den bisherigen Forschungsstand substantiell um den Aspekt der Interventionen zu erweitern. Dies bedeutet, dass beeinträchtigte interozeptive Prozesse in entsprechenden klinischen Störungsbildern (Anorexia nervosa und Zwangsstörungen) genauer elaboriert werden und dass Veränderungen dieser Prozesse während einer Therapie bei zwei klinischen Stichproben sowie durch ein Body Scan-Training in einer gesunden Stichprobe untersucht werden sollen. In Studie I wurde der Zusammenhang von interozeptiver Akkuranz (erfasst via Herzwahrnehmungstest) und chronischem Stress anhand von Selbstberichts- und psychophysiologischen Maßen (Fragebögen zum chronischen Stress, Haarcortisol und Dehydroepiandrosteron (DHEA) sowie deren Verhältnis) untersucht. Dabei zeigte sich, dass eine höhere interozeptive Akkuranz mit einem verminderten chronischen Stresserleben und psychophysiologischen Stresslevel zusammenhängt und dieser Zusammenhang durch eine hohe Selbstregulation mediiert wird. Anhand von Studie II und III konnte herausgefunden werden, dass die interozeptive Akkuranz in einer Stichprobe mit Anorexia nervosa und Zwangsstörungen verglichen mit einer zugeordneten gesunden Kontrollgruppe vermindert ist. Für die subjektive Komponente der Interozeption, die sogenannte interozeptive Sensibilität, konnte zudem eine Reduktion der Werte der Subskala „Interozeptive Wahrnehmung“ bei dem Eating Disorder Inventory-2 bei Patientinnen mit Anorexia nervosa nachgewiesen werden. Darüber hinaus zeigte sich in Studie II, dass Patientinnen mit Anorexia nervosa sich deskriptiv hinsichtlich der interozeptiven Akkuranz und Sensibilität durch eine kognitiv-behaviorale Therapie verbessern. Für Zwangspatienten (Studie III) konnte dies nicht nachgewiesen werden. Im Rahmen von Studie IV wurden zwei weitere Studien durchgeführt, welche sich lediglich hinsichtlich der Kontrollgruppen (Studie 1: aktive Kontrollgruppe, die ein Hörbuch hörte; Studie 2: inaktive Kontrollgruppe) unterschieden. In dieser Studie wurde der Einfluss eines achtwöchigen Body Scan-Trainings auf interozeptive Prozesse in einer gesunden Stichprobe untersucht. Hier erfolgte erneut die Erhebung der interozeptiven Akkuranz via Herzwahrnehmungstest. Zusätzlich wurde die interozeptive Sensibilität über ein Sicherheitsrating nach dem Herzwahrnehmungstest und mittels Subskala des Eating Disorder Inventory-2 erfasst. Die Ergebnisse der ersten Studie zeigen eine deskriptive Verbesserung der interozeptiven Akkuranz und Sensibilität (Sicherheitsrating) im Vergleich zur aktiven Kontrollgruppe. Die zweite Studie konnte darüber hinaus nachweisen, dass die Probanden, die an dem Body Scan-Training teilnahmen, eine signifikante Verbesserung der interozeptiven Akkuranz und Sensibilität (Sicherheitsrating) im Vergleich zur inaktiven Kontrollgruppe aufzeigten. Keine Effekte konnten für die interozeptive Sensibilität, erfasst über die Subskala des Eating Disorder Inventory-2, gefunden werden. Insgesamt lässt sich anhand der verschiedenen Studien die bedeutende Rolle und der gesundheitsrelevante Charakter interozeptiver Prozesse im präventiven und therapeutischen Kontext hervorheben. Ebenso lässt sich ableiten, dass der Wahl und der Dauer der Interventionsmaßnahme zur Förderung interozeptiver Prozesse eine entscheidende Rolle zukommt und hierbei selbst- und körperfokussierte Verfahren von Bedeutung sind. Zukünftige Studien sollten weitere Einflussfaktoren der Interozeption identifizieren, verschiedene Ansätze zur Verbesserung interozeptiver Prozesse zusammenführen sowie auch digitale Möglichkeiten (Online-/App-basiert) nutzen., Interoception describes the ability to perceive and process internal bodily signals. It is important to react to needs and deficits to ensure bodily homeostasis, which is necessary for a healthy body and mind. Former studies demonstrated a relationship between interoception and different health-related variables (e.g., stress, physical activity, emotion perception and regulation) as well as its influence on the assessment of interoception. Additionally, previous studies found impaired interoceptive processes in various mental disorders (e.g., depression, eating disorders). Consequently, there is a need to improve interoceptive processes. Previous research investigating different self- and body-related methods indicated positive effects on interoceptive processes. Thus, it can be inferred that interoception is essential for individual health. This thesis aimed at further exploring the interaction between health-related factors (such as stress) and interoceptive processes and at substantially extending former knowledge focussing on the aspect of interventions. This implemented the investigation of impaired interoceptive abilities in different mental disorders (anorexia nervosa and obsessive-compulsive disorder) in more detail. Furthermore, the change of interoceptive processes in such clinical samples during a cognitive-behavioral therapy as well as the effect of a body scan training in a healthy sample were considered in more detail. Study I investigated the relationship between interoceptive accuracy (measured via the heartbeat perception task) and chronic stress. For the measurement of chronic stress, different questionnaires and psychophysiological indicators (cortisol, dehydroepiandrosterone (DHEA), and the ratio of both) were used. Results showed that a higher interoceptive accuracy was related to decreased chronic stress experience and psychophysiological stress levels. Furthermore, this negative association was mediated by the participants’ enhanced self-regulation. Study II and III found a decreased interoceptive accuracy (heartbeat perception task) in anorexia nervosa and obsessive-compulsive disorder patients compared to healthy-matched controls. Regarding self-evaluated interoception, so-called interoceptive sensibility, a reduced score in the subscale “Interoceptive Awareness” of the Eating Disorder Inventory-2 for patients with anorexia nervosa was found. Additionally, based on the descriptive results of study II, patients showed a trend towards recovery during a cognitive-behavioral therapy. For the patients with obsessive-compulsive disorder (study III), no change was found. Study IV included two further studies, differentiating between control groups (Study 1: active control group listening to an audio book; Study 2: inactive control group). The investigation aimed to explore the effects of an 8-week body scan training in a healthy sample. Therefore, interoceptive accuracy was assessed via the heartbeat perception task. Additionally, self-reported interoceptive sensibility was measured via confidence ratings and the subscale of the Eating Disorder Inventory-2. Results indicated a descriptive trend for interoceptive accuracy and sensibility (confidence rating) in comparison to the active control group. Furthermore, the second study showed a significant improvement of interoceptive accuracy and sensibility (confidence rating) compared to the inactive control group. No such effects were found for interoceptive sensibility assessed via the subscale of the Eating Disorder Inventory-2. To conclude, these findings emphasize the health relevance of interoceptive processes in the context of prevention and treatment. Moreover, the choice and the duration of the intervention seem to be crucial for the success of improved interoceptive processes. Self- and bodily-related methods seem to be effective. Future studies should investigate other influencing factors on interoception and combine different approaches to improve interoceptive processes. Especially in terms of enhancing interoceptive processes, mobile- and online-based methods could be a promising approach.

Objectives Physical activity and healthy eating seem to be protective against experiencing stress and negative affect as well as increase positive affect. At the same time, previous studies showed that people reduce salutogenic behaviours such as physical activity and healthy eating in the face of stress and negative affect while increasing such behaviours in the context of positive affect. Due to daily fluctuations of these behaviours, the present study examined these relationships in daily life using ecological momentary assessment (EMA). Design and methods Fifty‐one university students responded to six daily prompts during 7 days via smartphone‐based EMA. Items examined stress, emotional experience, physical activity duration, and healthy eating. Results Higher stress and negative affect, as well as lower positive affect, were related to a reduction in subsequent physical activity. Higher physical activity levels, in turn, were associated with less subsequent stress and negative affect, as well as more positive affect. No such effects for stress and affect on healthy eating or vice versa were found. Conclusions Engaging in physical activity is related to better mood and less stress/negative affect over the next several hours in daily life. Prevention efforts therefore may benefit by focusing on promoting physical activity, particularly when stress/negative affect is high to ‘break the cycle’ of inactivity, stress, and negative affect. Potential effects of healthy eating might be more subtle and characterized by interindividual differences or state effects. Statement of contribution What is already known on this subject? Physical activity can reduce stress as well as negative emotions and can enhance positive emotions.People tend to eat less healthy food during stressful times, and healthy eating can increase general health.Physical activity and healthy eating have been mostly assessed separately and through retrospective methods. What does this study add? This is an EMA study investigating bidirectional effects of stress, emotions, and salutogenic behaviour.After physical activity, people felt less stressed/negative and more positive; feeling better and less stressed resulted in more physical activity.Healthy eating was not associated with stress or emotion level and vice versa.

Objectives Physical activity and healthy eating seem to be protective against experiencing stress and negative affect as well as increase positive affect. At the same time, previous studies showed that people reduce salutogenic behaviours such as physical activity and healthy eating in the face of stress and negative affect while increasing such behaviours in the context of positive affect. Due to daily fluctuations of these behaviours, the present study examined these relationships in daily life using ecological momentary assessment (EMA). Design and methods Fiftyone university students responded to six daily prompts during 7 days via smartphonebased EMA. Items examined stress, emotional experience, physical activity duration, and healthy eating. Results Higher stress and negative affect, as well as lower positive affect, were related to a reduction in subsequent physical activity. Higher physical activity levels, in turn, were associated with less subsequent stress and negative affect, as well as more positive affect. No such effects for stress and affect on healthy eating or vice versa were found. Conclusions Engaging in physical activity is related to better mood and less stress/negative affect over the next several hours in daily life. Prevention efforts therefore may benefit by focusing on promoting physical activity, particularly when stress/negative affect is high to ‘break the cycle of inactivity, stress, and negative affect. Potential effects of healthy eating might be more subtle and characterized by interindividual differences or state effects. I 02130B27 (VLID)4605588