Table 2 Quotes related to theme 1 (effects of monitoring) and theme 2 (effects of weekly questionnaires and alerts)

Theme 1: effects of monitoring

 ID13: During the monitoring period I have mentioned this several times, but what really surprised me and helped me a lot was the compartmentalization in those five parts a day. That really was a revelation that I had never heard before in mental health care. Nobody had divided it in small pieces of three hours. Previously, I only had the Life Chart, once every 24 h. A big yes, or a big no, or a big wow or a big ‘bleh’. And now, something unpleasant could happen, and it would make sense that it makes me feel bad, or hyper, or sad. That will maybe last a part of three hours, but then my mood is… […] So this is what I learned from the monitoring, and I don’t know if this was the intended effect of the study. But what I learned is to look at myself much more objectively, and much more relaxed. (female patient in her forties)

 ID22: Yes, that they become much more aware of factors influencing their mood. And that really differs across persons. That’s one thing. Or the fact that they become much more aware of their vulnerability in developing mood swings. An important part of treatment is about accepting that you are chronically instable. Some people keep wanting a sort of stable phase or that everything will be okay again, will return to how it was before. And that of course doesn’t always work out like that. And this [ESM] holds up some sort of mirror for them, of course. (male psychiatrist in his thirties)

 ID2: In the period that I filled in the assessments, I experienced several times that I answered that I hadn’t been outside, for example, during a week I was at my mothers’ place sitting around and being depressed. And then I had to answer three times that I hadn’t yet been outside, and no, I didn’t feel that well. You know, like that, and then I thought, well, okay I’ll just go. That happened multiple times I think. (female patient in her twenties)

 ID25: Yes, this really helps, you get to the point much more easily, and can give better targeted lifestyle advice. If they haven’t already developed those insights themselves. That is what I believe to be the advantage of self-monitoring and assignments you can do at home, outside our conversations here in the clinic: that you can adapt your own behavior and make healthy choices, so that is a nice side effect of this study, I think. (male psychiatric nurse in his fifties)

 ID17: Especially when the assessments come at an inconvenient moment. I find that very stressful. That is mostly the problem. The questions were completed in no time, but just, when I was in the car for example, a text comes, and I keep thinking, “I should not forget, I should not forget”. That’s it. No, the amount of work itself was not that much. (female patient in her forties)

 ID24: On the Life Chart you can indicate that you score this or that, on average. A lot of people will then say that the actual situation is very different. So the micro-level is much more fine-grained. The danger is, though, that if people feel very bad, because their relationship has ended or I don’t know, that they will immediately think that they have a depression. That the micro-level overshadows the macro-level. (male psychiatrist in his sixties)

 ID8: By continually confronting you with it, you keep getting reminded of the fact you’re doing badly. Or badly… Sad, that you’re feeling sad. So then I found it hard to look at it another way. Because normally, I do that, I try to do things differently and find distraction and everything. But when I looked for distractions, I got a new assessment, making me think, “damn, I am indeed doing very badly”. And that’s what I found really annoying, or really annoying… I didn’t like that. (female patient in her thirties)

 ID23: Well, if there are people who keep getting hung up on it and keep feeling sad as a result, then I find that a negative consequence. But still, if that is the case, it suggests to me that we [patient and clinician] have to work on that. So in that sense, it can be helpful. (male psychiatrist in his forties)

 ID15: Now I’m doing well, and I complete the Life Chart every morning. And then, for the rest of the day, I don’t have to think about my having bipolar disorder. Because then I know that I’m okay, I don’t have to pay attention to anything. But if you have to complete a questionnaire five times a day, then you really get confronted five times a day that you have that disorder. Throughout the day, you keep being confronted with ‘you have a disorder’. (female patient in her fifties)

 Interviewer: Was the burden too much? Weighing it against what patients gained from it?

 ID23: Maybe. Maybe it was too much, but you don’t know that beforehand. That’s why I think: you have to try. And self-management is a major step. So to invest a good amount of energy into that, because you have a severe disorder, you can invest a lot of energy into that, and then it is actually helpful to have something like this available to see if it gives you more insight. So in hindsight, yes it might have been burdensome, but I find that a bit too easy. Although, if you start using it now as a tool in clinical practice, then it might have to be toned down just a little. (male psychiatrist in his forties)

Theme 2: effects of weekly questionnaires and alerts

 ID14: I had expected that, when feeling more manic, or hypomanic, I would really find the questionnaire stupid. That’s what I expected, but that happened actually right near the end of the ESM monitoring period, that I noticed “something is happening and I don’t really trust it”. And you also notified me of elevated things. And at that moment, that was actually really nice. Like, I really have to take step back. I feel fantastic, that’s not it, but I hadn’t realized yet that the scores were high until I saw it in the questionnaires. And then I could admit it more easily to myself, that maybe I had to take a step back. I will e-mail [clinician]. That was a really good experience that really helped me. Like: if I see it coming beforehand one way or another, because usually I notice it too late, then I experience everything less intense. (female patient in her twenties)

 ID22: Well, I was really busy then, and then I also got those alerts and I thought: “do I have to do something with this as well?” That felt a bit as a responsibility, in a way. Whereas I always believe, you know, people really have to reach out themselves. That’s what you teach them, that we don’t take it all over and take care of them. So you really need to make clear agreements beforehand, like “what are we going to do when I see this?” And now, it just happened. I think it is something you can use in your treatment, but then you really have to discuss with patients, “what will we do, do you want me to reach out, or not? You get the alerts, do you appreciate that or not?” I think that is a good opportunity, but you have to think about this really well.” (male psychiatrist in his thirties)

 ID7: That I was not alone or let go in this. Because on the one hand, I am really inclined to go my own way and withdraw myself, really disregard everything and everyone. But back then I would consistently complete the questionnaires. And well, that by doing so I was not and could not be invisible. And actually, I like that. Because the withdrawing that I do, I actually don’t want to do that. And then it helps if somewhere a graph shows: “this woman is not doing well. And I will e-mail her.” (female patient in her fifties)