Feasibility and Acceptability of Ecological Momentary Assessment with High-Risk Suicidal Adolescents Following Acute Psychiatric Care

Actigraphy Study Endpoints to Reduce Sample Size and Facilitate Drug Development for Pediatric Pulmonary Arterial Hypertension

OBJECTIVE

To investigate the feasibility of using actigraphy to measure physical activity (pA) and heart rate variability (HRV) as study endpoints in pediatric pulmonary arterial hypertension (PAH) and to compare their performance to 6-minute-walk distance (6MWD), a common primary endpoint used in PAH clinical trials in adults and children who can walk and understand the test process.

STUDY DESIGN

We conducted a prospective, multicenter, noninterventional study in pediatric PAH patients and healthy children. Actiheart and Fitbit Charge 2 recorded pA and heart rate data. HRV was defined as SD of daily heart rate. Actigraphy pA and HRV and 6MWD from the same subjects were analyzed to compare children with PAH with controls, and Panama functional classification (FC) III vs II. Power/sample size simulations were conducted to detect hypothetical treatment effect equivalent to differences seen between FC III and FC II.

RESULTS

We enrolled 116 children: 90 and 98 adhered with Actiheart and Fitbit, respectively. Actigraphy daily pA was ∼36% lower (P < .05) and daily HRV was ∼18% lower (P < .05) in children with PAH (n = 62) than healthy controls (n = 54). Daily pA and daily HRV trended ∼17% lower in FC III than FC II, whereas 6MWD showed little difference. Simulation at 80% power showed that pA required 175 subjects per group and HRV required 40 per group to detect the difference/effect, whereas 6MWD required over our maximum sample size of 200.

CONCLUSIONS

Actigraphy is a feasible measure in pediatric PAH. Compared with 6MWD, pA and HRV may be more sensitive in differentiating Panama FC III from II. HRV may improve actigraphy's utility in pediatric PAH.

Interpersonal risk factors for suicide in daily life among young people: A review of intensive longitudinal studies

Suicide is one of the leading causes of death among individuals aged 10-24. Research using intensive longitudinal methods to identify near-term predictors of suicidal thoughts and behaviors (STBs) has grown dramatically. Interpersonal factors may be particularly critical for suicide risk among young people, given the heightened salience of interpersonal experiences during adolescence and young adulthood. We conducted a narrative review on intensive longitudinal studies investigating how interpersonal factors contribute to STBs among adolescents and young adults. Thirty-two studies met the inclusion criteria and focused on theoretical and cross-theoretical interpersonal risk factors. Negative interpersonal states (e.g., perceived burdensomeness), hopelessness, and social support were consistently associated with proximal within-person changes in concurrent, but not prospective, suicidal thoughts. Further, work examining how these processes extend to suicidal behavior and among diverse samples remains scarce. Implications for contemporary interpersonal theories and intensive longitudinal studies of STBs among young people are discussed.

Anhedonia Links Sleep Problems and Suicidal Thoughts: An Intensive Longitudinal Study in High-Risk Adolescents

Growing research indicates that sleep problems are a robust independent risk factor for suicidal thoughts and behaviors among youth. However, relatively little is known about how this risk is conferred. This study used an intensive longitudinal design to investigate anhedonia as a mechanism linking sleep problems and next-day suicidal thoughts in a clinically high-risk sample of adolescents. Adolescents (N = 48; Mage=14.96; 77.1% white, 64.6% female) completed an ecological momentary assessment (EMA) study design for 28 days following discharge from acute psychiatric care for suicide risk. Daily sleep diaries were used to assess prior night total sleep time and sleep onset latency. Ecological momentary assessment was used to assess anhedonia and suicidal thoughts up to six times per day. A series of multi-level structural equation models were used to examine facets of anhedonia as parallel mediators of the association between sleep problems and next-day suicidal thoughts. Significant direct effects were found between sleep problems and consummatory anhedonia, consummatory anhedonia and suicidal thoughts, and anticipatory anhedonia and suicidal thoughts. There were significant indirect (mediated) effects between sleep problems and next-day suicidal thoughts through consummatory anhedonia, but not anticipatory anhedonia. Findings provide initial evidence as to how sleep problems may confer risk for next-day suicidal thoughts- by increasing consummatory anhedonia. Future research is needed to replicate these findings in larger samples and investigate how modifying anhedonia may mitigate suicide risk in youth.

A Gentle Introduction and Application of Feature-Based Clustering with Psychological Time Series

Psychological researchers and practitioners collect increasingly complex time series data aimed at identifying differences between the developments of participants or patients. Past research has proposed a number of dynamic measures that describe meaningful developmental patterns for psychological data (e.g., instability, inertia, linear trend). Yet, commonly used clustering approaches are often not able to include these meaningful measures (e.g., due to model assumptions). We propose feature-based time series clustering as a flexible, transparent, and well-grounded approach that clusters participants based on the dynamic measures directly using common clustering algorithms. We introduce the approach and illustrate the utility of the method with real-world empirical data that highlight common ESM challenges of multivariate conceptualizations, structural missingness, and non-stationary trends. We use the data to showcase the main steps of input selection, feature extraction, feature reduction, feature clustering, and cluster evaluation. We also provide practical algorithm overviews and readily available code for data preparation, analysis, and interpretation.

Ecological momentary assessment in prolonged grief research: Feasibility, acceptability, and measurement reactivity

Ecological momentary assessment (EMA) is a method of data collection that entails prompting individuals to report their experiences (e.g., thoughts, feelings, and behaviors) in real time over the course of their day-to-day lives. By providing rich information about how these experiences unfold over time within an individual, EMA has the potential to substantially advance our understanding of grief. However, there is uncertainty about how bereaved adults will respond to EMA, especially among those with high prolonged grief symptom severity. Accordingly, we evaluated the feasibility and acceptability of an EMA protocol in bereaved adults with low and high prolonged grief severity. Participants completed six 12-item EMA surveys per day on their smartphones for 17 days. Adherence was high (mean survey completion = 90%, median = 96%), and only 6% of participants withdrew. Adherence remained high in those with high prolonged grief symptom severity (mean = 86%; median = 96%). On average, participants reported agreement that survey frequency and length were acceptable. There was no evidence for systematic worsening of symptoms during EMA data collection. Together, these findings suggest that EMA is feasible, acceptable, and safe for bereaved adults, including those with high prolonged grief symptom severity.

Firearm Availability Reduces the Stability of Suicidal Ideation: Results from an Ecological Momentary Assessment Study

Firearm availability is correlated with increased risk of suicide but its link with suicidal ideation remains unclear. Previous studies are limited by retrospective reports and prospective designs with lengthy gaps between assessments that are ill-suited for measuring fluctuations in suicidal ideation. This study used ecological momentary assessment (EMA) to repeatedly assess suicidal ideation in a sample of 138 U.S. adults (81 handgun owners, 57 non-owners). Participants received six EMA prompts per day for 28 consecutive days. Results revealed no group differences in the frequency, maximum amplitude, or variability of suicidal ideation across male and female handgun owners and non-owners. Stability of suicidal ideation significantly differed across groups, however (F(1,132) = 4.5, p = 0.036); male handgun owners had the strongest stability and male non-owners had the weakest stability. Stability of suicidal ideation was significantly lower when participants reported a firearm was nearby as compared to when no firearm was nearby (F(4,17732) = 5.6, p < 0.001). Results suggest firearm availability increases reactivity to the environment, slows recovery from acutely elevated risk states, and may increase vulnerability to sudden shifts to higher risk states characterized by increased probability of suicidal behavior. Although these effects were observed in both handgun owners and non-owners, they disproportionately impact handgun owners because they report being near firearms more often.

Feasibility and Acceptability of Ecological Momentary Assessment to Assess Suicide Risk among Young People with Mood Disorder in China

Suicidal thoughts and behaviors (STBs) are increasing among young people (aged 12-24 years) in China. Although Ecological Momentary Assessment (EMA) has been increasingly used to study STBs worldwide, no study has been conducted on young people with mood disorders (MD) in China. This mixed-method study aimed to evaluate the feasibility and acceptability of suicide risk monitoring in 75 young people with MD. Participants completed five to eight daily EMA surveys and wore smart bands for the EMA study. Semi-structured interviews were used to collect feedback. High adherence to EMA surveys (73.0 %) and smart bands (87.4 %) indicated feasibility. Participants reported an overall positive experience with the EMA study (helpful, friendly, and acceptable). Additionally, the reasons they were willing to comply with the EMA study were: (1) seeing the possibility of returning to "normal," and (2) experiencing the process of returning. However, a small proportion of participants had negative experiences (e.g., annoyance and missing prompts). The results of this mixed-methods study provide preliminary support for the feasibility and acceptability of using EMA (combined smartphones and wearable sensor devices) to assess suicidality among young people with MD in the Chinese cultural and social context.

A systematic review on passive sensing for the prediction of suicidal thoughts and behaviors

Passive sensing data from smartphones and wearables may help improve the prediction of suicidal thoughts and behaviors (STB). In this systematic review, we explored the feasibility and predictive validity of passive sensing for STB. On June 24, 2024, we systematically searched Medline, Embase, Web of Science, PubMed, and PsycINFO. Studies were eligible if they investigated the association between STB and passive sensing, or the feasibility of passive sensing in this context. From 2107 unique records, we identified eleven prediction studies, ten feasibility studies, and seven protocols. Studies indicated generally lower model performance for passive compared to active data, with three out of four studies finding no incremental value. PROBAST ratings revealed major shortcomings in methodology and reporting. Studies suggested that passive sensing is feasible in high-risk populations. In conclusion, there is limited evidence on the predictive value of passive sensing for STB. We highlight important quality characteristics for future research.

Examination of Acceptability, Feasibility, and Iatrogenic Effects of Ecological Momentary Assessment (EMA) of Suicidal Ideation

Ecological momentary assessment (EMA) can be used to examine the dynamics of suicidal ideation in daily life. While the general acceptability and feasibility of EMA in suicide research has been established, further examination of potential iatrogenic effects (i.e., negative reactivity) and identifying those more likely to react negatively is needed. Participants (N = 82) with current suicidal ideation completed 21 days of EMA (4×/day) and filled in M = 78% (Med = 84%) of the EMA. No positive or negative affect reactivity was observed in EMA ratings over the study period. Retrospectively, most participants rated their experience as positive (69%); 22% indicated mood worsening, and 18% suicidal ideation reactivity. Those with more borderline personality traits, posttraumatic stress disorder (PTSD), and higher depressive, anxiety, and suicidal ideation symptoms, were more likely to report iatrogenic effects. In conclusion, while high compliance rates and lack of affect reactivity during EMA indicate that EMA is well tolerated in suicide research, a minority of participants may report subjective mood effects in retrospect.

Suicide Ideation Among Transgender and Gender Diverse Adolescents: The Role of Parental Invalidation of Adolescents' Gender Identity

Transgender and gender diverse (TGD) youth experience chronic and acute stress associated with their gender identity contributing to their increased risk of suicide and suicide ideation (SI) compared to non-TGD peers. This study examined how invalidating and accepting gender-related experiences with a parent impact SI severity among TGD adolescents cross-sectionally and longitudinally, within-person. Participants were 15 TGD adolescents with past month SI recruited across community and clinical settings. Adolescents completed a baseline assessment of validated interviews and self-report measures on parental invalidation and SI severity. Over a 14-day follow-up period, adolescents reported instances of parental gender invalidation and acceptance, relative stress of those experiences, and SI severity multiple times/day via ecological momentary assessment (EMA). Bivariate associations of parental invalidation and acceptance with SI were examined at baseline, while multilevel models examined the relationship within-person over follow-up. Cross-sectionally, greater perceived invalidation and non-affirmation by their parents was associated with more severe SI. Over the follow up, instances of perceived parental invalidation were associated with passive SI within-person. Findings partially support the minority stress theory and social safety perspective by showing that perceived gender-invalidation from parents affects SI in TGD adolescents, both cross-sectionally and longitudinally. Further research is needed to identify specific emotional and cognitive factors, such as perceived stress, that contribute to the risk of SI among TGD youth and inform the development of targeted interventions for this vulnerable population.

Can profiles of behaviors occurring within 48 h of a suicide attempt predict future severity of suicidal thoughts and reattempt?: An examination of hospitalized patients 12 Months post-discharge

Behavioral warning signs (WS) are near-term changes within individuals, which aid in determining imminent risk for suicide attempts. However, those who attempt suicide differ in their engagement of WS, and it is unclear if these differences relate to future risk of suicidal behavior. Using a sample of 132 adults presenting to a hospital following a suicide attempt, the current study sought to determine if differences in engagement in WS for the index attempt prospectively predicted suicide attempt, frequency of ideation, and intensity of suicide ideation 12 months post discharge. Latent class analyses (LCAs) conducted on 6 behaviors (i.e., alcohol use, nightmares, interpersonal negative life events, suicide communication, risky behavior, low sleep, and high sleep) found a 5-class solution optimally fit the data. One identified class, characterized by engagement in risky behaviors the hours before an attempt differed from other identified classes in terms of risk for future suicidal ideation and behaviors. More specifically, participants in "High Risky Behavior" class had higher rates of 12-month suicide reattempt, significantly more frequent suicide ideation, and significantly worse intensity of suicide ideation during the 12 months following their index attempt compared to participants endorsing typical patterns of WS. These results held when adjusting for various traditional baseline covariates (e.g., depressive symptoms). The current study demonstrates that patterns of behavioral WS may be utilized as their own prognostic indicator of future suicidal ideation and behaviors among high-risk individuals reporting a recent suicide attempt, which can inform post-discharge clinical intervention and prevention efforts.

Effects of frequent assessments on the severity of suicidal thoughts: an ecological momentary assessment study

Objective

In recent years, there has been a significant increase in research using ecological momentary assessment (EMA) to explore suicidal thoughts and behaviors (STBs). Meanwhile, concerns have been raised regarding the potential impacts of frequent and intense STBs assessments on the study participants.

Methods

From November 2021 to June 2023, a total of 83 adolescent and young adult outpatients (Mage = 21.0, SDage = 6.3, 71.1% female), who were diagnosed with mood disorders, were recruited from three psychiatric clinics in China. Smartphone-based EMA was used to measure suicidal thoughts three times per day at randomly selected times. We examined the change of suicidal thoughts in each measurement and within 1 day to evaluate potential adverse effects using Bayesian multilevel models.

Results

The 3,105 effective surveys were nested in 83 participants (median follow-up days: 14 days). The results of two-level models indicated that suicidal thoughts decreased during the monitoring period. However, this effect varied among different individuals in the two-level model.

Conclusion

Our findings did not support the notion that repeated assessment of suicidal thoughts is iatrogenic, but future research should continue to investigate the impact of frequent assessment on suicidal thoughts, taking into account individual differences and utilizing larger sample sizes.

Testing the interpersonal theory of suicide in adolescents: A multi-wave longitudinal study

BACKGROUND

Suicide is a major public health crisis among youth. Several prominent theories, including the Interpersonal Theory of Suicide (IPTS), aim to characterize the factors leading from suicide ideation to action. These theories are largely based on findings in adults and require testing and elaboration in adolescents.

METHODS

Data were examined from high-risk 13-18-year-old adolescents (N = 167) participating in a multi-wave, longitudinal study; 63% of the sample exhibited current suicidal thoughts or recent behaviors (n = 105). The study included a 6-month follow-up period with clinical interviews and self-report measures at each of the four assessments as well as weekly smartphone-based assessments of suicidal thoughts and behaviors. Regression and structural equation models were used to probe hypotheses related to the core tenets of the IPTS.

RESULTS

Feelings of perceived burdensomeness were associated with more severe self-reported suicidal ideation (b = 0.58, t(158) = 7.64, p < .001). Similarly, burdensomeness was associated with more frequent ideation based on weekly smartphone ratings (b = 0.11, t(1460) = 3.41, p < .001). Contrary to IPTS hypotheses, neither feelings of thwarted belongingness, nor interactions between burdensomeness and thwarted belongingness were significantly associated with ideation (ps > .05). Only elevated depression severity was associated with greater odds of suicide events (i.e., suicide attempts, psychiatric hospitalizations, and/or emergency department visits for suicide concerns) during the follow-up period (OR = 1.83, t(158) = 2.44, p = .01). No effect of acquired capability was found.

CONCLUSIONS

Perceptions of burdensomeness to others reflect a critical risk factor for suicidal ideation among high-risk adolescents. Null findings with other IPTS constructs may suggest a need to adopt more developmentally sensitive models or measures of interpersonal and acquired capability risk factors for youth. Refining methods and theoretical models of suicide risk may help improve the identification of high-risk cases and inform clinical intervention.

Predicting Lifetime Suicide Attempts in a Community Sample of Adolescents Using Machine Learning Algorithms

Suicide is a major global health concern and a prominent cause of death in adolescents. Previous research on suicide prediction has mainly focused on clinical or adult samples. To prevent suicides at an early stage, however, it is important to screen for risk factors in a community sample of adolescents. We compared the accuracy of logistic regressions, elastic net regressions, and gradient boosting machines in predicting suicide attempts by 17-year-olds in the Millennium Cohort Study (N = 7,347), combining a large set of self- and other-reported variables from different categories. Both machine learning algorithms outperformed logistic regressions and achieved similar balanced accuracies (.76 when using data 3 years before the self-reported lifetime suicide attempts and .85 when using data from the same measurement wave). We identified essential variables that should be considered when screening for suicidal behavior. Finally, we discuss the usefulness of complex machine learning models in suicide prediction.

Fluidity in capability: Longitudinal assessments of suicide capability using ecological momentary assessments

INTRODUCTION

Suicide capability is posited to facilitate the movement from ideation-to-action. Emerging evidence suggests capability comprises both trait- and state-like facets. This study examined fluctuations in and associations of acquired, dispositional, practical, and perceived capabilities, and suicidal mental imagery, and suicidal ideation.

METHOD

Seventy-five adults (48 females, Mage = 36.53 years) with lived experience of suicidal ideation and/or attempt responded to four prompts per day for 2 weeks that assessed suicide capability and suicidal ideation. Mean-squared successive differences and probability of acute change indices and multilevel models were used for analyses.

RESULTS

All facets of suicide capability fluctuated. Acquired and dispositional capabilities were trait-like, with practical and perceived capabilities being state-like. Suicidal mental imagery was the only facet of suicide capability that distinguished participants with a suicide attempt in the past 12 months from participants with a suicide attempt more than 1 year ago and suicide ideators. Suicidal mental imagery was associated with concurrent suicidal ideation and predictive of next assessment suicidal ideation.

CONCLUSION

Suicidal mental imagery may be uniquely associated with suicide capability. This study suggests there are trait- and state-like facets of capability that can combine to potentially ready an individual to engage in suicidal behaviors.

Acceptability and Feasibility of a Smartphone-Based Real-Time Assessment of Suicide Among Black Men: Mixed Methods Pilot Study

BACKGROUND

Suicide rates in the United States have increased recently among Black men. To address this public health crisis, smartphone-based ecological momentary assessment (EMA) platforms are a promising way to collect dynamic, real-time data that can help improve suicide prevention efforts. Despite the promise of this methodology, little is known about its suitability in detecting experiences related to suicidal thoughts and behavior (STB) among Black men.

OBJECTIVE

This study aims to clarify the acceptability and feasibility of using smartphone-based EMA through a pilot study that assesses the user experience among Black men.

METHODS

We recruited Black men aged 18 years and older using the MyChart patient portal messaging (the patient-facing side of the Epic electronic medical record system) or outpatient provider referrals. Eligible participants self-identified as Black men with a previous history of STB and ownership of an Android or iOS smartphone. Eligible participants completed a 7-day smartphone-based EMA study. They received a prompt 4 times per day to complete a brief survey detailing their STB, as well as proximal risk factors, such as depression, social isolation, and feeling like a burden to others. At the conclusion of each day, participants also received a daily diary survey detailing their sleep quality and their daily experiences of everyday discrimination. Participants completed a semistructured exit interview of 60-90 minutes at the study's conclusion.

RESULTS

In total, 10 participants completed 166 EMA surveys and 39 daily diary entries. A total of 4 of the 10 participants completed 75% (21/28) or more of the EMA surveys, while 9 (90%) out of 10 completed 25% (7/28) or more. The average completion rate of all surveys was 58% (20.3/35), with a minimum of 17% (6/35) and maximum of 100% (35/35). A total of 4 (40%) out of 10 participants completed daily diary entries for the full pilot study. No safety-related incidents were reported. On average, participants took 2.08 minutes to complete EMA prompts and 2.72 minutes for daily diary surveys. Our qualitative results generally affirm the acceptability and feasibility of the study procedures, but the participants noted difficulties with the technology and the redundancy of the survey questions. Emerging themes also addressed issues such as reduced EMA survey compliance and diminished mood related to deficit-framed questions related to suicide.

CONCLUSIONS

Findings from this study will be used to clarify the suitability of EMA for Black men. Overall, our EMA pilot study demonstrated mixed feasibility and acceptability when delivered through smartphone-based apps to Black men. Specific recommendations are provided for managing safety within these study designs and for refinements in future intervention and implementation science research.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

RR2-10.2196/31241.

Understanding suicidal transitions in Australian adults: protocol for the LifeTrack prospective longitudinal cohort study

BACKGROUND

The factors that influence transition from suicidal ideation to a suicide attempt or remission of suicidal thoughts are poorly understood. Despite an abundance of research on risk factors for suicidal ideation, no large-scale longitudinal population-based studies have specifically recruited people with suicidal ideation to examine the mechanisms underlying critical transitions to either suicide attempt or recovery from suicidal ideation. Without longitudinal data on the psychological, behavioural, and social determinants of suicide attempt and the remission of suicidal ideation, we are unlikely to see major gains in the prevention of suicide.

AIM

The LifeTrack Project is a population-based longitudinal cohort study that aims to identify key modifiable risk and protective factors that predict the transition from suicidal ideation to suicide attempt or remission of suicidal ideation. We will assess theory-informed risk and protective factors using validated and efficient measures to identify distinct trajectories reflecting changes in severity of suicidal ideation and transition to suicide attempt over three years.

METHODS

A three-year prospective population-based longitudinal cohort study will be conducted with adults from the general Australian population who initially report suicidal ideation (n = 842). Eligibility criteria include recent suicidal ideation (past 30 days), aged 18 years or older, living in Australia and fluent in English. Those with a suicide attempt in past 30 days or who are unable to participate in a long-term study will be excluded. Participants will be asked to complete online assessments related to psychopathology, cognition, psychological factors, social factors, mental health treatment use, and environmental exposures at baseline and every six months during this three-year period. One week of daily measurement bursts (ecological momentary assessments) at yearly intervals will also capture short-term fluctuations in suicidal ideation, perceived burdensomeness, thwarted belongingness, capability for suicide, and distress.

CONCLUSION

This study is intended to identify potential targets for novel and tailored therapies for people experiencing suicidal ideation and improve targeting of suicide prevention programs. Even modest improvements in current treatments may lead to important reductions in suicide attempts and deaths.

STUDY REGISTRATION

Australian New Zealand Clinical Trials Registry identifier: ACTRN12623000433606.

Intensive Longitudinal Assessment of Adolescents to Predict Suicidal Thoughts and Behaviors

OBJECTIVE

Suicide is a leading cause of death among adolescents. However, there are no clinical tools to detect proximal risk for suicide.

METHOD

Participants included 13- to 18-year-old adolescents (N = 103) reporting a current depressive, anxiety, and/or substance use disorder who owned a smartphone; 62% reported current suicidal ideation, with 25% indicating a past-year attempt. At baseline, participants were administered clinical interviews to assess lifetime disorders and suicidal thoughts and behaviors (STBs). Self-reports assessing symptoms and suicide risk factors also were obtained. In addition, the Effortless Assessment of Risk States (EARS) app was installed on adolescent smartphones to acquire daily mood and weekly suicidal ideation severity during the 6-month follow-up period. Adolescents completed STB and psychiatric service use interviews at the 1-, 3-, and 6-month follow-up assessments.

RESULTS

K-means clustering based on aggregates of weekly suicidal ideation scores resulted in a 3-group solution reflecting high-risk (n = 26), medium-risk (n = 47), and low-risk (n = 30) groups. Of the high-risk group, 58% reported suicidal events (ie, suicide attempts, psychiatric hospitalizations, emergency department visits, ideation severity requiring an intervention) during the 6-month follow-up period. For participants in the high-risk and medium-risk groups (n = 73), mood disturbances in the preceding 7 days predicted clinically significant ideation, with a 1-SD decrease in mood doubling participants' likelihood of reporting clinically significant ideation on a given week.

CONCLUSION

Intensive longitudinal assessment through use of personal smartphones offers a feasible method to assess variability in adolescents' emotional experiences and suicide risk. Translating these tools into clinical practice may help to reduce the needless loss of life among adolescents.

Lifetime and Current Self-Harm Thoughts and Behaviors and Their Relationship to Parent and Peer Attachment

Background: Previous research suggests attachment is a vulnerability factor for self-harm thoughts and behaviors in adults. Yet, few studies have investigated this relationship during adolescence, although adolescence is a critical period for changes in attachment relationships and self-harm onset. Whether and how attachment relates to self-harm thoughts and behaviors as measured in daily life is also unknown. Aims: To investigate whether and how paternal, maternal, and peer attachment are associated with lifetime and current adolescent self-harm thoughts and behaviors. Additionally, to examine how different attachment bonds interact in relation to lifetime and current adolescent self-harm thoughts and behaviors. Method: Pre-existing data from N = 1,913 adolescents of the SIGMA study were used. Attachment and lifetime history of self-harm thoughts and behaviors were measured via retrospective questionnaires. Current self-harm thoughts and behaviors were assessed 10 times per day for 6 days using the experience sampling method (ESM). Results: Paternal and maternal attachments were associated with lifetime self-harm thoughts and behaviors and current self-harm thoughts. No significant associations were found between peer attachment and self-harm outcomes. Limitations: Some analyses were underpowered. Conclusion: Our results highlight the importance of parent-child attachment relationships, which may be intervention targets for prevention and treatment of adolescent self-harm.

Using machine learning with intensive longitudinal data to predict depression and suicidal ideation among medical interns over time

BACKGROUND

Use of intensive longitudinal methods (e.g. ecological momentary assessment, passive sensing) and machine learning (ML) models to predict risk for depression and suicide has increased in recent years. However, these studies often vary considerably in length, ML methods used, and sources of data. The present study examined predictive accuracy for depression and suicidal ideation (SI) as a function of time, comparing different combinations of ML methods and data sources.

METHODS

Participants were 2459 first-year training physicians (55.1% female; 52.5% White) who were provided with Fitbit wearable devices and assessed daily for mood. Linear [elastic net regression (ENR)] and non-linear (random forest) ML algorithms were used to predict depression and SI at the first-quarter follow-up assessment, using two sets of variables (daily mood features only, daily mood features + passive-sensing features). To assess accuracy over time, models were estimated iteratively for each of the first 92 days of internship, using data available up to that point in time.

RESULTS

ENRs using only the daily mood features generally had the best accuracy for predicting mental health outcomes, and predictive accuracy within 1 standard error of the full 92 day models was attained by weeks 7-8. Depression at 92 days could be predicted accurately (area under the curve >0.70) after only 14 days of data collection.

CONCLUSIONS

Simpler ML methods may outperform more complex methods until passive-sensing features become better specified. For intensive longitudinal studies, there may be limited predictive value in collecting data for more than 2 months.

Ecological Momentary Assessments and Passive Sensing in the Prediction of Short-Term Suicidal Ideation in Young Adults

Importance

Advancements in technology, including mobile-based ecological momentary assessments (EMAs) and passive sensing, have immense potential to identify short-term suicide risk. However, the extent to which EMA and passive data, particularly in combination, have utility in detecting short-term risk in everyday life remains poorly understood.

Objective

To examine whether and what combinations of self-reported EMA and sensor-based assessments identify next-day suicidal ideation.

Design, Setting, and Participants

In this intensive longitudinal prognostic study, participants completed EMAs 4 times daily and wore a sensor wristband (Fitbit Charge 3) for 8 weeks. Multilevel machine learning methods, including penalized generalized estimating equations and classification and regression trees (CARTs) with repeated 5-fold cross-validation, were used to optimize prediction of next-day suicidal ideation based on time-varying features from EMAs (affective, cognitive, behavioral risk factors) and sensor data (sleep, activity, heart rate). Young adult patients who visited an emergency department with recent suicidal ideation and/or suicide attempt were recruited. Identified via electronic health record screening, eligible individuals were contacted remotely to complete enrollment procedures. Participants (aged 18 to 25 years) completed 14 708 EMA observations (64.4% adherence) and wore a sensor wristband approximately half the time (55.6% adherence). Data were collected between June 2020 and July 2021. Statistical analysis was performed from January to March 2023.

Main Outcomes and Measures

The outcome was presence of next-day suicidal ideation.

Results

Among 102 enrolled participants, 83 (81.4%) were female; 6 (5.9%) were Asian, 5 (4.9%) were Black or African American, 9 (8.8%) were more than 1 race, and 76 (74.5%) were White; mean (SD) age was 20.9 (2.1) years. The best-performing model incorporated features from EMAs and showed good predictive accuracy (mean [SE] cross-validated area under the receiver operating characteristic curve [AUC], 0.84 [0.02]), whereas the model that incorporated features from sensor data alone showed poor prediction (mean [SE] cross-validated AUC, 0.56 [0.02]). Sensor-based features did not improve prediction when combined with EMAs. Suicidal ideation-related features were the strongest predictors of next-day ideation. When suicidal ideation features were excluded, an alternative EMA model had acceptable predictive accuracy (mean [SE] cross-validated AUC, 0.76 [0.02]). Both EMA models included features at different timescales reflecting within-day, end-of-day, and time-varying cumulative effects.

Conclusions and Relevance

In this prognostic study, self-reported risk factors showed utility in identifying near-term suicidal thoughts. Best-performing models required self-reported information, derived from EMAs, whereas sensor-based data had negligible predictive accuracy. These results may have implications for developing decision algorithms identifying near-term suicidal thoughts to guide risk monitoring and intervention delivery in everyday life.

Acceptability and feasibility of ecological momentary assessment with augmentation of passive sensor data in young adults at high risk for suicide

Ecological Momentary Assessment (EMA) and wearable sensor data have the potential to enhance prediction of suicide risk in real-world conditions. However, the feasibility of this methodology with high-risk populations, including over extended periods, warrants closer attention. This study examined the feasibility and acceptability of concurrent EMA and wearable sensor monitoring in young adults after emergency department (ED) care for suicide risk-related concerns. For 2 months after ED discharge, 106 participants (ages 18-25; 81.1% female) took part in EMA surveys (4x per day) and passive sensor (Fitbit) monitoring and completed an end-of-study phone interview. Overall adherence to EMA (62.1%) and wearable sensor (53.6%) was moderate and comparable to briefer protocols. Relative to EMAs (81%), fewer participants completed the full 8 weeks of Fitbit (63%). While lower initial hopelessness was linked to reduced EMA adherence, previous-day suicidal ideation predicted lower Fitbit adherence on the next day. Self-endorsed barriers to EMA and wearable sensor adherence were also examined. Participants tended to report positive experience with the protocol, with majority indicating EMAs were minimally burdensome, reporting that the Fitbit was generally comfortable, and expressing interest in participating in a similar study again. Findings provide support for the feasibility and acceptability of concurrent intensive self-report and wearable sensor data during a high-risk period. Implications and future directions are discussed.

The use of advanced technology and statistical methods to predict and prevent suicide

In the past decade, two themes have emerged across suicide research. First, according to meta-analyses, the ability to predict and prevent suicidal thoughts and behaviours is weaker than would be expected for the size of the field. Second, review and commentary papers propose that technological and statistical methods (such as smartphones, wearables, digital phenotyping and machine learning) might become solutions to this problem. In this Review, we aim to strike a balance between the pessimistic picture presented by these meta-analyses and the optimistic picture presented by review and commentary papers about the promise of advanced technological and statistical methods to improve the ability to understand, predict and prevent suicide. We divide our discussion into two broad categories. First, we discuss the research aimed at assessment, with the goal of better understanding or more accurately predicting suicidal thoughts and behaviours. Second, we discuss the literature that focuses on prevention of suicidal thoughts and behaviours. Ecological momentary assessment, wearables and other technological and statistical advances hold great promise for predicting and preventing suicide, but there is much yet to do.

Using Experience Sampling Methods to support clinical management of psychosis: The perspective of people with lived experience

The Experience sampling method (ESM) has the potential to support person-centered care of psychotic disorders. However, clinical implementation is hampered by a lack of user involvement in the design of ESM tools. This qualitative study explored the perspective of nine people with lived experiences of psychosis. Participants reported a need to monitor a diverse range of daily-life experiences and indicated that ESM should allow for personalization to be clinically useful. While participants recognized the potential of ESM to increase awareness and control over their mental health, concerns were voiced about the validity and burden of monitoring one's own mental health.

Multidimensional variability in ecological assessments predicts two clusters of suicidal patients

The variability of suicidal thoughts and other clinical factors during follow-up has emerged as a promising phenotype to identify vulnerable patients through Ecological Momentary Assessment (EMA). In this study, we aimed to (1) identify clusters of clinical variability, and (2) examine the features associated with high variability. We studied a set of 275 adult patients treated for a suicidal crisis in the outpatient and emergency psychiatric departments of five clinical centers across Spain and France. Data included a total of 48,489 answers to 32 EMA questions, as well as baseline and follow-up validated data from clinical assessments. A Gaussian Mixture Model (GMM) was used to cluster the patients according to EMA variability during follow-up along six clinical domains. We then used a random forest algorithm to identify the clinical features that can be used to predict the level of variability. The GMM confirmed that suicidal patients are best clustered in two groups with EMA data: low- and high-variability. The high-variability group showed more instability in all dimensions, particularly in social withdrawal, sleep measures, wish to live, and social support. Both clusters were separated by ten clinical features (AUC = 0.74), including depressive symptoms, cognitive instability, the intensity and frequency of passive suicidal ideation, and the occurrence of clinical events, such as suicide attempts or emergency visits during follow-up. Initiatives to follow up suicidal patients with ecological measures should take into account the existence of a high variability cluster, which could be identified before the follow-up begins.

Preparing a Workforce of Care Coordinators to Address Patient Mental Health Needs in the Digital Age: Training and Needs Identification

Introduction

Care coordinators (CCs) are specialized healthcare providers and often the primary point of contact for patients with multiple medical and mental health comorbidities in integrated healthcare settings. Prior work shows CCs have lower comfort addressing mental health than physical health concerns. Digital mental health interventions can support CCs' management of patient mental health needs, but training gaps must be addressed prior to a digital mental health intervention's implementation.

Methods

As part of a quality improvement initiative, a 1-hour training focused on the assessment and management of depression and suicide-related thoughts and behaviors was delivered to CCs within a large midwestern healthcare system's Division of Ambulatory Care Coordination. CCs completed online surveys prior to and following the training.

Conclusion

Training resulted in increased comfort working with clinical populations, including patients who experience suicide-related thoughts and behaviors. Gains around screening for suicide risk were modest. Brief trainings for CCs can address training gaps, however, ongoing training and case consultation may also be indicated.

Sleep influences daily suicidal ideation through affective reactivity to interpersonal events among high-risk adolescents and young adults

BACKGROUND

Identifying proximal risk factors for suicidal ideation that are modifiable and relevant for adolescents and young adults is critical for suicide prevention. This study used an intensive monitoring approach to examine whether objectively- and subjectively- measured sleep characteristics predict next-day suicidal ideation occurrence and intensity through affective reactivity to interpersonal events in young people at high risk for suicide.

METHODS

Participants included 59 (13-23 years; 76% White; 75% female) adolescents and young adults undergoing intensive outpatient program treatment for depression and suicidality. Participants completed daily ratings of suicidal ideation, sleep quality, and affective reactivity to positive and negative interpersonal events for up to 3 months (M = 56 days, SD = 24.13). Actigraphy captured behavioral sleep duration and timing. Multilevel modeling was used to evaluate within-person fluctuations in sleep and affective reactivity as predictors of suicidal ideation, and multilevel mediation tested the indirect effects of sleep on suicidal ideation via affective reactivity to interpersonal events.

RESULTS

Results indicate significant indirect effects of objectively measured sleep duration and subjective sleep quality on next-day suicidal ideation via affective reactivity to negative and positive interpersonal events, respectively. Shorter-than-usual sleep predicted the presence and intensity of next-day suicidal ideation via heightened affective reactivity to negative interpersonal events. Worse sleep quality than usual predicted next-day suicidal ideation via reduced affective reactivity to positive interpersonal events.

CONCLUSIONS

Affectivity reactivity is a proximal mechanism through which sleep indices may influence risk for suicidal thinking on a daily basis. Findings highlight the utility of targeting sleep and emotion regulation in suicide prevention among adolescents and young adults at high-risk for suicide.

The Use of Intensive Longitudinal Methods in Research on Suicidal Thoughts and Behaviors: A Systematic Review

OBJECTIVE

Intensive longitudinal methods (ILM), such as ecological momentary assessment (EMA) and daily diary, involve repeatedly assessing individuals over short periods of time and have been increasingly used to study suicidal thoughts and behaviors (STBs). Suicidal thoughts have been shown to vary over short periods of time and reports of STBs are subject to negative biases. Therefore, ILM are important methodological tools for studying STBs, ones that capture enhanced precision and realism of data compared to traditional survey methods. The present systematic review aims to provide a comprehensive overview of ILM used to study STBs, including the various EMA and daily diary methodologies used, the feasibility of those methodologies, and the ethical considerations in this line of research. This review also summarizes the characteristics of descriptive STB outcomes specific to the ILM data collection period.

METHODS

A thorough search of PubMed and PsycINFO was conducted up to May 2020, resulting in twenty-eight papers reviewed.

RESULTS AND CONCLUSIONS

The review of the studies showed that ILM are largely feasible and do not have a negative impact on participants. In addition, the reviewed studies revealed unique aspects of STBs, such as the variability of suicidal thoughts, that suggest that ILM are important methodologies to use when studying STBs. Gaps in the research and recommendations for future research are discussed.HighlightsIt is feasible to use ILM to study suicidality.ILM do not have a negative impact on participants with suicidality.Few studies have used ILM to study suicidality in diverse samples.

Dynamic Regulatory Processes in the Transition From Suicidal Ideation to Action in Adults Leaving Inpatient Psychiatric Care: Protocol for an Intensive Longitudinal Study

BACKGROUND

US suicide rates have risen steadily in the past decade, and suicide risk is especially high in the months after discharge from inpatient psychiatric treatment. However, suicide research has lagged in examining dynamic within-person processes that contribute to risk over time among individuals known to be at high risk of suicide. Almost no research has examined how affective, cognitive, and physiological processes change over minutes, hours, or days to confer risk of suicidal behavior in daily life.

OBJECTIVE

This protocol describes a longitudinal study designed to examine real-world changes in risk of suicide across multiple assessment domains. Specifically, the study involves following adults known to be at high risk of suicide after discharge from inpatient psychiatric care using self-report, interview, actigraphy, and behavioral methods to identify proximal contributors to suicidal thoughts and behaviors. First, we hypothesize that negative affective experiences, which are featured in most major suicide theories, will comprise a latent factor indicative of psychache (emotional pain), which will predict increases in suicidal thinking over time. Second, we hypothesize that poor inhibitory control in the context of negative affective stimuli, as well as emotion-related impulsivity, will predict the transition from suicidal thinking to suicidal behavior over time. Third, we hypothesize that short sleep duration will precede within-person increases in suicidal ideation as well as increased odds of suicidal behavior among those reporting suicidal thoughts.

METHODS

The desired sample size is 130 adults with past-week suicidal thoughts or behaviors who are receiving inpatient psychiatric treatment. Participants will complete a battery of measures while on the inpatient unit to assess negative affective experiences, emotion-related impulsivity, inhibitory control, typical sleep patterns, and relevant covariates. After discharge from inpatient care, participants will complete 4 weeks of signal-contingent ecological momentary assessment surveys, as well as mobile behavioral measures of inhibitory control, while wearing an actigraphy device that will gather objective data on sleep. Participants will complete interviews regarding suicidal thoughts and behaviors at 4 and 8 weeks after discharge.

RESULTS

The study was funded by the National Institutes of Health in November 2020. Recruitment began in April 2021. Data analysis will begin after completion of data collection.

CONCLUSIONS

This study will elucidate how affective, cognitive, and physiological risk factors contribute (or do not contribute) to within-person fluctuations in suicide risk in daily life, with important implications for extant theories of suicide. Of import, the examined risk factors are all modifiable; thus, the results will inform identification of key targets for just-in-time, flexible, personalized, digital interventions that can be used to decrease emotional distress and prevent suicide among those at highest risk.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

DERR1-10.2196/38582.

Don't Miss the Moment: A Systematic Review of Ecological Momentary Assessment in Suicide Research

Suicide and suicide-related behaviors are prevalent yet notoriously difficult to predict. Specifically, short-term predictors and correlates of suicide risk remain largely unknown. Ecological momentary assessment (EMA) may be used to assess how suicidal thoughts and behaviors (STBs) unfold in real-world contexts. We conducted a systematic literature review of EMA studies in suicide research to assess (1) how EMA has been utilized in the study of STBs (i.e., methodology, findings), and (2) the feasibility, validity and safety of EMA in the study of STBs. We identified 45 articles, detailing 23 studies. Studies mainly focused on examining how known longitudinal predictors of suicidal ideation perform within shorter (hourly, daily) time frames. Recent studies have explored the prospects of digital phenotyping of individuals with suicidal ideation. The results indicate that suicidal ideation fluctuates substantially over time (hours, days), and that individuals with higher mean ideation also have more fluctuations. Higher suicidal ideation instability may represent a phenotypic indicator for increased suicide risk. Few studies succeeded in establishing prospective predictors of suicidal ideation beyond prior ideation itself. Some studies show negative affect, hopelessness and burdensomeness to predict increased ideation within-day, and sleep characteristics to impact next-day ideation. The feasibility of EMA is encouraging: agreement to participate in EMA research was moderate to high (median = 77%), and compliance rates similar to those in other clinical samples (median response rate = 70%). More individuals reported suicidal ideation through EMA than traditional (retrospective) self-report measures. Regarding safety, no evidence was found of systematic reactivity of mood or suicidal ideation to repeated assessments of STBs. In conclusion, suicidal ideation can fluctuate substantially over short periods of time, and EMA is a suitable method for capturing these fluctuations. Some specific predictors of subsequent ideation have been identified, but these findings warrant further replication. While repeated EMA assessments do not appear to result in systematic reactivity in STBs, participant burden and safety remains a consideration when studying high-risk populations. Considerations for designing and reporting on EMA studies in suicide research are discussed.

Trajectory Analysis of Suicidal Ideation in Spanish College Students Using Ecological Momentary Assessment

Introduction

Suicide is a preventable death in young people. It is well known that suicide behavior is a multicausal phenomenon. However, suicidal ideation (SI) commonly underlies suicide, and Ecological Momentary Assessment (EMA) can help us to better characterize it and its risk and protective factors in the short term. We aimed, first, to investigate the estimated prevalence and trajectories of SI in a community sample of Spanish college students using an EMA methodology and, second, explore the associations between risk and protective factors and SI categorized as moderate or low.

Materials and Methods

A total of 737 participants followed the EMA during a period of 6 months. We estimated the prevalence and trajectories of SI and the associations between depressive symptoms, positive and negative affect, thwarted belongingness, perceived burdensomeness, cognitive reappraisal, emotional suppression, and purpose in life with the MEmind smartphone App. SI was assessed 14 times during this period.

Results

Twenty-eight participants referred to SI at least once in longitudinal assessments. We found a lack of curvature and, thus, a relatively stable trajectory of SI. Two groups of latent dimensions were observed related to risk and protective factors of SI. One latent dimension of the risk factors (higher levels of thwarted belongingness, perceived burdensomeness, depressive symptoms, negative affect, and emotional suppression) best represented the group with moderate levels of SI, and a second latent dimension of protective variables (positive affect, cognitive reappraisal, and purpose in life) best represented the group with lower levels of SI.

Discussion

These findings may indicate that students with a sense of having a life worth living, in addition to having the ability to reevaluate their negative beliefs, are less likely to experience high levels of SI. Therefore, purpose in life would be a protective factor against the presence of SI.

Measuring Adolescents' Self-injurious Thoughts and Behaviors: Comparing Ecological Momentary Assessment to a Traditional Interview

The purpose of this study was to compare adolescents' reports of self-injurious thoughts and behaviors (SITBs) between ecological momentary assessment (EMA) and a traditional, retrospective interview. Adolescents were recruited following recent discharge from acute psychiatric care for a suicidal crisis (as part of a larger study). Participants completed: (1) EMA surveys assessing SITBs multiple times daily over a 28-day follow-up period, and (2) a follow-up phone interview to evaluate SITBs retrospectively at the end of the same 28-day follow-up period. Forty-one adolescents completed the final follow-up interview (M_age = 14.9 years; 78.0% White; 61.0% female). Adolescents' reports of SITB presence (vs. absence) and frequency, collected via EMA and retrospective interview over follow-up, were compared. Preliminary differences in SITB endorsement (presence/absence) were observed between reporting methods with more adolescents endorsing suicide ideation (SI; n = 30) and nonsuicidal self-injury (NSSI; n = 15) in EMA compared to retrospective interview (SI: n = 17; NSSI: n = 10). Reasons for withholding SITBs from EMA reports (gathered during a final qualitative interview) included not wanting to answer additional EMA questions and concerns about EMA-reporting consequences. There were no statistically significant differences in SITB frequency by report method. Further investigation is warranted in a larger sample to elucidate frequency patterns. Given the growing research using this method, these findings are important to help clarify the utility of EMA methods for studying SITBs in youth.

Proximal Risk for Suicide: A Daily Diary Study Protocol (Preprint)

Background

Suicide is a prevalent public health concern in the United States across all age groups. Research has emphasized the need to identify risk markers that prevent suicide along shorter timeframes, such as days to weeks. Furthermore, little has been done to explore the relative significance of factors that can predict short-term suicide risk or to evaluate how daily variability in these factors impacts suicidal ideation or behavior. This proposed project aims to identify risk factors that best predict near-time changes in suicidal ideation and examine potential interactions between these factors to predict transitions into suicidal thinking or behaviors.

Objective

The aim of this proposed study is threefold: (1) To identify which psychological risk factors are most strongly associated with proximal changes in suicide risk across days and weeks. (2) To evaluate theoretical assumptions of the Integrative-Motivational-Volitional Theory of Suicide. (3) To determine how disruptions in physiological arousal interact with theoretical mechanisms of risk to predict concurrent and short-term prospective increase in suicidal thoughts and behaviors.

Methods

A daily diary or ecological momentary assessment design will be utilized with 200 participants. Participants will complete 2 in-person visits separated by 3 weeks during which they will complete 3 brief daily assessments within their natural environments using the ilumivu research app on a smart device. Research will occur at the Mayo Clinic Health System (MCHS) Eau Claire site. Participants will be recruited through chart review and standard care delivery assessment.

Results

This manuscript outlines the protocol that will guide the conduct of the forthcoming study.

Conclusions

The proposed project aims to lead efforts using technological advances to capture microchanges in suicidal thinking/behavior over shorter timeframes and thereby guide future clinical assessment and management of suicidal patients. Results of this study will generate robust evidence to evaluate which risk factors predict proximal changes in suicidal ideation and behaviors. They will also provide the ability to examine potential interactions with multiple theoretically derived risk factors to predict proximal transitions into worsening suicidal thinking or behaviors. Such information will provide new targets for intervention that could ultimately reduce suicide-related morbidity and mortality.

International Registered Report Identifier (IRRID)

PRR1-10.2196/37583

Using intensive time sampling methods to capture daily suicidal ideation: A systematic review

INTRODUCTION

There has been an increased emphasis on understanding suicidal thoughts and behaviors as they occur in real-time, resulting in a proliferation of studies utilizing intensive time sampling methods. Given the continued growth in this area, there is a need to synthesize the feasibility of these methods in capturing suicidal ideation at the daily level, in addition to an examination of study factors that may impact suicidal ideation detection, to guide future research.

METHOD

Online databases (i.e., PsychINFO, ERIC, PubMed, MEDLINE) were systematically searched for articles published through December 2020 that assessed suicidal ideation at the daily level.

RESULTS

Twenty-six articles presenting data from sixteen independent datasets met inclusion criteria. Across included articles, suicidal ideation detection ranged from approximately 1-92% of participant-completed surveys, with 18-100% of unique study participants reporting suicidal ideation during the study period. Assessment-based factors (i.e., number of daily assessments, duration of daily assessment period) did not appear to be meaningfully associated with suicidal ideation detection rates. Rather, participant characteristics (i.e., baseline suicide risk history, inclusion criteria) were better indicators of a study's ability to capture suicidal ideation at the daily level.

CONCLUSIONS

Findings highlights the impact of targeting participants with elevated suicide risk at study enrollment.

Ecological momentary assessment of mental health in adults at suicide risk: An observational study protocol

AIMS

To describe the research protocol for an ecological momentary assessment (EMA) designed to examine patterns of suicidal ideation and relevant psychosocial stress indicators in adults at risk for suicide.

DESIGN

This observational and longitudinal study will collect data for 28 consecutive days.

METHODS

A total of 150 adults at risk for suicide will be recruited from a single suicide prevention centre and an outpatient clinic in Korea. Self-report questionnaires will be administrated during weeks 0, 1, 3 and 5. Participants will receive text messages three times a day for 4 weeks prompting them to access an online survey link for daily mood survey including depression, anxiety, stress and suicidal ideation. In addition, for the first 2 weeks, they will wear an actigraphy device designed to collect actigraphic data in terms of sleep patterns and physical activity. Data analyses such as descriptive statistics, independent t-tests, one-way ANOVA, chi-squared statistics and time-series and correlation analyses will be performed using IBM SPSS 26.0 and SAS version 9.3. The study received funding from National Research Foundation of Korea in February 2020. Institutional Review Board approval for our study was obtained in April 2021.

DISCUSSIONS

This study will yield fundamental information about daily patterns of suicide ideation and psychosocial stress indicators to develop preventive interventions for adults at risk for suicide.

IMPACT

Our study will contribute to the development of EMAs and interventions for adults at risk for suicide aimed at providing timely and individualized mental health services in a community setting.

TRIAL REGISTRATION

The trial is registered with the Clinical Research Information Service (CRIS). CRIS Registration Number: KCT0006165.

Feasibility and acceptability of experience sampling among LGBTQ+ young people with self-harmful thoughts and behaviours

This study was the first to determine whether it was feasible and acceptable to use experience sampling methods (ESM) among LGBTQ+ young people, who had current experiences of self-harm. Sixteen LGBTQ+ young people (16-25 years old) took part in the experience sampling study. This included a baseline assessment, a 7-day ESM assessment (participants were sampled six times a day using a phone app), and the option of an interview at the end of the 7-day ESM assessment. Feasibility data was descriptively analysed, with pilot ESM data presented. Qualitative data was thematically analysed to determine the acceptability (barriers and facilitators) of taking part in this study. Study feasibility was assessed by enrolment rate (55.2%), participant retention across assessment period (100%), ESM app feasibility (87.5%), and good adherence to total number of ESM surveys (67.6%). Individual study adherence ranged between 43 and 95.2%. Study acceptability was assessed by participant interviews. Thematic analysis indicated four superordinate themes; (i) Self-reflection and awareness; (ii) Practicalities of ESM surveys; (iii) Daily timeframes; and (iv) Suggestions for future studies. Pilot ESM data demonstrates that there was fluctuation of depressive and anxiety symptoms within- and between- participants over the course of the study, however, greater sample power is needed for full analysis. This study demonstrated that ESM designs are feasible and acceptable among LGBTQ+ young people with current experiences of self-harm. Pilot data indicated that specific experiences and moods are likely to be important to self-harm. These potentially have a temporal influence on self-harm behaviour or ideation, and therefore should be examined in a fully powered sample.

Using ecological momentary assessment to enhance irritability phenotyping in a transdiagnostic sample of youth

Irritability is a transdiagnostic symptom dimension in developmental psychopathology, closely related to the Research Domain Criteria (RDoC) construct of frustrative nonreward. Consistent with the RDoC framework and calls for transdiagnostic, developmentally-sensitive assessment methods, we report data from a smartphone-based, naturalistic ecological momentary assessment (EMA) study of irritability. We assessed 109 children and adolescents (Mage = 12.55 years; 75.20% male) encompassing several diagnostic groups – disruptive mood dysregulation disorder (DMDD), attention-deficit/hyperactivity disorder (ADHD), anxiety disorders (ANX), healthy volunteers (HV). The participants rated symptoms three times per day for 1 week. Compliance with the EMA protocol was high. As tested using multilevel modeling, EMA ratings of irritability were strongly and consistently associated with in-clinic, gold-standard measures of irritability. Further, EMA ratings of irritability were significantly related to subjective frustration during a laboratory task eliciting frustrative nonreward. Irritability levels exhibited an expected graduated pattern across diagnostic groups, and the different EMA items measuring irritability were significantly associated with one another within all groups, supporting the transdiagnostic phenomenology of irritability. Additional analyses utilized EMA ratings of anxiety as a comparison with respect to convergent validity and transdiagnostic phenomenology. The results support new measurement tools that can be used in future studies of irritability and frustrative nonreward.

Differential time varying associations among affective states and suicidal ideation among adolescents following hospital discharge

Suicide is a major public health problem among adolescents. Identifying factors that confer increased risk for suicidal ideation, particularly during the high-risk period following psychiatric hospitalization, is essential for preventing suicide in this population. Negative and positive affect are two such important modifiable risk factors. This study examined relationships between specific affective states and suicidal ideation, collected via daily diary, as continuous functions of time among discharged adolescents. Adolescents hospitalized for suicidal ideation and/or behavior responded to daily surveys for four weeks after discharge (N = 34; 952 observations). Time-varying effects models (TVEM) were used to predict same- and next-day suicidal ideation. Examining between-persons effects, adolescents reporting greater misery and less happiness compared to others had a significantly increased likelihood of same-day suicidal ideation; between-person anger was not significantly associated with suicidal ideation. Within-persons effects suggested that elevated same-day, but not previous-day, misery and anger were associated with suicidal ideation. Elevated within-person happiness was protective for same-day suicidal ideation, but was also associated with next-day suicidal ideation. These findings begin to clarify not only which, but when, specific affective processes influence suicidal ideation for discharged adolescents. These dynamic risk factors represent modifiable treatment targets relevant for real-time interventions.

Assessing the Real-time Influence of Racism-Related Stress and Suicidality Among Black Men: Protocol for an Ecological Momentary Assessment Study

BACKGROUND

Suicide is the third leading cause of death among Black adults aged 18-35 years. Although men represent a majority of suicide deaths among Black adults, less is known regarding the extent to which unique cultural stressors, such as racism-related stress (eg, racial discrimination), are salient in exacerbating suicide risk among Black men. Moreover, few studies examine the daily influence of racism-related stressors on suicide outcomes using real-time smartphone-based approaches. Smartphone-based mobile health approaches using ecological momentary assessments (EMA) provide an opportunity to assess and characterize racism-related stressors as a culturally sensitive suicide risk factor among Black young adult men.

OBJECTIVE

The goal of this study is to describe a protocol development process that aims to capture real-time racism-related stressors and suicide outcomes using a smartphone-based EMA platform (MetricWire).

METHODS

Guided by the Interpersonal Theory of Suicide (ITS), we developed a brief EMA protocol using a multiphased approach. First, we conducted a literature review to identify brief measures previously used in EMA studies, with special emphasis on studies including Black participants. The identified measures were then shortened to items with the highest construct validity (eg, factor loadings) and revised to reflect momentary or daily frequency. Feasibility and acceptability of the study protocol will be assessed using self-report survey and qualitative responses. To protect participants from harm, a three-tier safety protocol was developed to identify participants with moderate, elevated, and acute risk based on EMA survey response to trigger outreach by the study coordinator.

RESULTS

The final EMA protocol, which will be completed over a 7-day period, is comprised of 15 questions administered 4 times per day and a daily questionnaire of 22 items related to sleep-related impairment and disruption, as well as racism-related stress. Study recruitment is currently underway. We anticipate the study will be completed in February 2023. Dissemination will be conducted through peer-reviewed publications and conference presentations.

CONCLUSIONS

This protocol will address gaps in our understanding of Black men's suicide outcomes in the social contexts that they regularly navigate and will clarify the temporal role of racism-related stressors that influence suicidal outcomes.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

PRR1-10.2196/31241.

The growing field of digital psychiatry: current evidence and the future of apps, social media, chatbots, and virtual reality

As the COVID-19 pandemic has largely increased the utilization of telehealth, mobile mental health technologies - such as smartphone apps, vir-tual reality, chatbots, and social media - have also gained attention. These digital health technologies offer the potential of accessible and scalable interventions that can augment traditional care. In this paper, we provide a comprehensive update on the overall field of digital psychiatry, covering three areas. First, we outline the relevance of recent technological advances to mental health research and care, by detailing how smartphones, social media, artificial intelligence and virtual reality present new opportunities for "digital phenotyping" and remote intervention. Second, we review the current evidence for the use of these new technological approaches across different mental health contexts, covering their emerging efficacy in self-management of psychological well-being and early intervention, along with more nascent research supporting their use in clinical management of long-term psychiatric conditions - including major depression; anxiety, bipolar and psychotic disorders; and eating and substance use disorders - as well as in child and adolescent mental health care. Third, we discuss the most pressing challenges and opportunities towards real-world implementation, using the Integrated Promoting Action on Research Implementation in Health Services (i-PARIHS) framework to explain how the innovations themselves, the recipients of these innovations, and the context surrounding innovations all must be considered to facilitate their adoption and use in mental health care systems. We conclude that the new technological capabilities of smartphones, artificial intelligence, social media and virtual reality are already changing mental health care in unforeseen and exciting ways, each accompanied by an early but promising evidence base. We point out that further efforts towards strengthening implementation are needed, and detail the key issues at the patient, provider and policy levels which must now be addressed for digital health technologies to truly improve mental health research and treatment in the future.

SWAY: Associations between sleep disturbance and suicidality in psychiatric inpatients transitioning to the community: an ecological momentary assessment study protocol (Preprint)

Background

Patients are at high risk of suicidal behavior and death by suicide immediately following discharge from inpatient psychiatric hospitals. Furthermore, there is a high prevalence of sleep problems in inpatient settings, which is associated with worse outcomes following hospitalization. However, it is unknown whether poor sleep is associated with suicidality following initial hospital discharge.

Objective

Our study objective is to describe a protocol for an ecological momentary assessment (EMA) study that aims to examine the relationship between sleep and suicidality in discharged patients.

Methods

Our study will use an EMA design based on a wearable device to examine the sleep-suicide relationship during the transition from acute inpatient care to the community. Prospectively discharged inpatients 18 to 35 years old with mental disorders (N=50) will be assessed for eligibility and recruited across 2 sites. Data on suicidal ideation, behavior, and imagery; nonsuicidal self-harm and imagery; defeat, entrapment, and hopelessness; affect; and sleep will be collected on the Pro-Diary V wrist-worn electronic watch for up to 14 days. Objective sleep and daytime activity will be measured using the inbuilt MotionWare software. Questionnaires will be administered face-to-face at baseline and follow up, and data will also be collected on the acceptability and feasibility of using the Pro-Diary V watch to monitor the transition following discharge. The study has been, and will continue to be, coproduced with young people with experience of being in an inpatient setting and suicidality.

Results

South Birmingham Research Ethics Committee (21/WM/0128) approved the study on June 28, 2021. We expect to see a relationship between poor sleep and postdischarge suicidality. Results will be available in 2022.

Conclusions

This protocol describes the first coproduced EMA study to examine the relationship between sleep and suicidality and to apply the integrated motivational volitional model in young patients transitioning from a psychiatric hospital to the community. We expect our findings will inform coproduction in suicidology research and clarify the role of digital monitoring of suicidality and sleep before and after initial hospital discharge.

International Registered Report Identifier (IRRID)

PRR1-10.2196/33817

A cross-diagnostic study of Adherence to Ecological Momentary Assessment: Comparisons across study length and daily survey frequency find that early adherence is a potent predictor of study-long adherence

Background

Ecological momentary assessment (EMA) offers a highly valid strategy to assess everyday functioning in people with severe mental illness. Adherence is generally good, but several questions regarding the impact of study length, daily density of sampling, and symptom severity on adherence remain.

Methods

EMA adherence in two separate studies was examined. One sampled participants with schizophrenia (n=106) and healthy controls (n=76) 7 times per day for 7 days and the other sampled participants with schizophrenia (n=104) and participants with bipolar illness (n=76) 3 times per day for 30 days. Participants were asked where they were, who they were with, what they were doing and how they were feeling in both studies. The impact of rates of very early adherence on eventual adherence was investigated across the samples, and adherence rates were examined for associations with mood state and most common location when answering surveys.

Results

Median levels of adherence were over 80% across the samples, and the 10^th percentile for adherence was approximately 45% of surveys answered. Early adherence predicted study-long adherence quite substantially in every sample. Mood states did not correlate with adherence in the patient samples and being home correlated with adherence in only the bipolar sample.

Implications

Adherence was quite high and was not correlated with the length of the study or the density of sampling per study day. There was a tendency for bipolar participants who were more commonly away from home to answer fewer surveys but overall adherence for the bipolar patients was quite high. These data suggest that early nonadherence is a potential predictor of eventual nonadherence and study noncompletion.

Disturbed sleep as a clinical marker of wish to die: A smartphone monitoring study over three months of observation

BACKGROUND

Smartphone monitoring could contribute to the elucidation of the correlates of suicidal thoughts and behaviors (STB). In this study, we employ smartphone monitoring and machine learning techniques to explore the association of wish to die (passive suicidal ideation) with disturbed sleep, altered appetite and negative feelings.

METHODS

This is a prospective cohort study carried out among adult psychiatric outpatients with a history of STB. A daily questionnaire was administered through the MEmind smartphone application. Participants were followed-up for a median of 89.8 days, resulting in 9,878 person-days. Data analysis employed a machine learning technique called Indian Buffet Process.

RESULTS

165 patients were recruited, 139 had the MEmind mobile application installed on their smartphone, and 110 answered questions regularly enough to be included in the final analysis. We found that the combination of wish to die and sleep problems was one of the most relevant latent features found across the sample, showing that these variables tend to be present during the same time frame (96 hours).

CONCLUSIONS

Disturbed sleep emerges as a potential clinical marker for passive suicidal ideation. Our findings stress the importance of evaluating sleep as part of the screening for suicidal behavior. Compared to previous smartphone monitoring studies on suicidal behavior, this study includes a long follow-up period and a large sample.

Neural Correlates Associated With Suicide and Nonsuicidal Self-injury in Youth

There is no definitive neural marker of suicidal thoughts and behaviors (STBs) or nonsuicidal self-injury (NSSI), and relative to adults, research in youth is more limited. This comprehensive review focuses on magnetic resonance imaging studies reporting structural and functional neural correlates of STBs and NSSI in youth to 1) elucidate shared and independent neural alternations, 2) clarify how developmental processes may interact with neural alterations to confer risk, and 3) provide recommendations based on convergence across studies. Forty-seven articles were reviewed (STBs = 27; NSSI = 20), and notably, 63% of STB articles and 45% of NSSI articles were published in the previous 3 years. Structural magnetic resonance imaging research suggests reduced volume in the ventral prefrontal and orbitofrontal cortices among youth reporting STBs, and there is reduced anterior cingulate cortex volume related to STBs and NSSI. With regard to functional alterations, blunted striatal activation may characterize STB and NSSI youth, and there is reduced frontolimbic task-based connectivity in suicide ideators and attempters. Resting-state functional connectivity findings highlight reduced positive connectivity between the default mode network and salience network in attempters and show that self-injurers exhibit frontolimbic alterations. Together, suicidal and nonsuicidal behaviors are related to top-down and bottom-up neural alterations, which may compromise approach, avoidance, and regulatory systems. Future longitudinal research with larger and well-characterized samples, especially those integrating ambulatory stress assessments, will be well positioned to identify novel targets that may improve early identification and treatment for youth with STBs and NSSI.

Heart Rate Variability Duration: Expanding the Ability of Wearable Technology to Improve Outpatient Monitoring?

Heart rate variability (HRV) evaluates beat-to-beat interval (BBI) differences and is a suggested marker of the autonomic nervous system with diagnostic/monitoring capabilities in mental health; especially parasympathetic measures. The standard duration for short-term HRV analysis ranges from 24 h down to 5-min. However, wearable technology, mainly wrist devices, have large amounts of motion at times resulting in need for shorter duration of monitoring. The objective of this study was to evaluate the correlation between 1 and 5 min segments of continuous HRV data collected simultaneously on the same patient. Subjects wore a patch electrocardiograph (Cardea Solo, Inc.) over a 1-7 day period. For every consecutive hour the patch was worn, we selected a 5-min, artifact-free electrocardiogram segment. HRV metric calculation was performed to the entire 5-min segment and the first 1-min from this same 5-min segment. There were 492 h of electrocardiogram data collected allowing calculation of 492 5 min and 1 min segments. 1 min segments of data showed good correlation to 5 min segments in both time and frequency domains: root mean square of successive difference (RMSSD) (R = 0.92), high frequency component (HF) (R = 0.90), low frequency component (LF) (R = 0.71), and standard deviation of NN intervals (SDNN) (R = 0.63). Mental health research focused on parasympathetic HRV metrics, HF and RMSSD, may be accomplished through smaller time windows of recording, making wearable technology possible for monitoring.