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mDIARY STUDY: A smartphone-based Dialectical Behavioural Therapy
Jennifer Highland

mDiary Study: Designing, implementing, and evaluating a smartphone-based Dialectical Behavioural Therapy

The MDiary Study is a part of the ENTER project (previously called E-Mental), which is being done in collaboration with The Mental Health Services in the Region of Southern Denmark (MHS), the South Denmark University, Aalborg University, and Context Consulting.

Borderline Personality Disorder (BPD)

Borderline is a serious and debilitating mental disorder characterised by difficulties with regulating emotions, which leads to unstable and self-destructive behaviours and relationships.

The prevalence of BPD is 1%-5%. Borderline increases the risk for suicide by 4-fold, while patients with comorbid Borderline and a tendency to self-harm have a further 2-fold attenuated risk. BDP is difficult to treat, and even more difficult when co-occurring with other disorders.

Dialectical Behaviour Therapy (DBT) is the best validated treatment for Borderline, showing medium to large effect sizes as compared to treatment as usual. Dialectical Behaviour Therapy uses self-monitoring as the mainstay of treatment, which helps patients regulate their emotions by means of emotional regulating skills, and reduce problem behaviour.

Self-monitoring has traditionally been done by means of daily paper diaries. The latest developments in smartphone applications have generated alternatives for ecological momentary assessments of problematic behaviour with the additional functionality of prompting patients to practice skills targeting emotion regulation.

Monsenso’s involvement in the the mDIARY Study for patients with Borderline Personality Disorder

Monsenso is responsible for improving and developing additional modules in the Monsenso mHealth solution. The objective of the study is to prove that the Monsenso DBT (Dialectical Behavioural Therapy) solution is a reliable and clinically valid way to collect patient data, helping individuals with Borderline learn these skills at home, speeding up their recovery.

1. Skills tracking
In the current configuration used for DBT treatment, skill used throughout the day can be selected in the daily self-assessment. This does not take into account if the patients have actually learned the skills, meaning a lot of skills will appear in the list that the patient might not already know. In order to personalise the skills list, and in order to help the clinicians and patients to track progress, the skills should be configurable in the sense that the patient is able to indicate whether they have not learned a skill, are in the process of learning a skill, or know it and can use it meaningfully. This implies, the the patients should be able to, on their phone in the configuration section of the self-assessment, to have a list of skills appear, where they can indicate whether a skill is ’Not known’, ’In the process of learning’, or ’I know it, and can use it meaningfully’.

2. Skills training / Psychoeducation
In DBT treatment, skills are an essential part, and patients often have a paper folder, with descriptions of each skill. In the current version, the “Action Plans”’ in the system have been used for this purpose, but it makes it not very easy to overview and need more ways of presenting content, like videos or sound files. The layout is like a dictionary, where patients can find information regarding their disorder, usual treatment regime, prevalence, but alto typical issues and preventive actions that could be taken.

3. Emotion rating (BEARS)
One parameter in the self-assessment should be named “Emotions” in which joy, anger, attachment, sadness, safety, anxiety, pride and shame can be be rated on a scale of 0-4:

0 – Not at all
1 – A Little
2 – Some
3 – A lot
4 – Extreme

It is important that they are all rated in the same screen, as the patient need to see these together.

4. Therapy progress / Detailed overview
The overview screen will be re-designed and focus around “Therapy progress,” highlighting the progress over time. The key factor for the use of the system should be the patients’ development and progress over an extended period. The scope of the solution is to include graphs of the clinical questionnaires in the overview screen, which includes summary scores of DERS, BSL, and HTQ questionnaires. Likewise the attendance percentage should be shown, together with the Hierarchy level rated by the clinician.

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