Real-time digital monitoring of a suicide attempt by a hospital patient

Suicide is among the most devastating problems facing clinicians, who currently have limited tools to predict and prevent suicidal behavior. Here we report on real-time, continuous smartphone and sensor data collected before, during, and after a suicide attempt made by a patient during a psychiatric inpatient hospitalization. We observed elevated and persistent sympathetic nervous system arousal and suicidal thinking leading up to the suicide attempt. This case provides the highest resolution data to date on the psychological, psychophysiological, and behavioral markers of imminent suicidal behavior and highlights new directions for prediction and prevention efforts.

Daily-level assessment of the contexts under which seeking social support relates to risk of suicidal thinking

INTRODUCTION

Perceived social support is a well-established protective factor against suicidal ideation, yet few studies have examined how actually seeking social support relates to suicidal ideation. We investigated the contexts under which social support seeking may be related to greater, or lesser, suicidal ideation.

METHODS

Undergraduates completed ecological momentary assessments up to 6 times daily. Multi-level moderated logistic regressions examined interactions between presence of daily-level support seeking with burdensomeness and loneliness as indicators of same-day and next-day suicidal ideation.

RESULTS

Seeking social support was positively associated with same-day, but not next-day reports of suicidal thinking. On days when participants felt burdensome and sought support, they had greater odds of reporting suicidal ideation (OR = 1.659, 95% CI = [1.420, 1.938]), compared with days they felt burdensome but did not seek support. There was no effect of burdensomeness on next-day ideation. There was no significant interaction effect between support seeking and loneliness on same-day or next-day ideation.

CONCLUSIONS

Seeking support and feeling like a burden are associated with a greater likelihood of experiencing suicidal ideation. The current results underscore the importance of equipping at-risk individuals with a toolbelt of a variety of coping skills.

Investigating predictors of treatment response in Dialectical Behavior Therapy for borderline personality disorder using LASSO regression

OBJECTIVE

Prior studies of Dialectical Behavior Therapy (DBT) for borderline personality disorder (BPD) have yielded heterogeneous findings on what factors differentiate individuals with or without sufficient treatment response, highlighting the need for further research.

METHOD

We investigated a sample of 105 individuals with BPD receiving a 6-month course of DBT. Participants were categorized as sufficient or insufficient responders using clinical and statistical change indices (based on emotion dysregulation, BPD symptom severity, utilization of DBT skills, and functional impairment). Sociodemographic, clinical severity, and treatment process factors were tested as potential predictors of treatment response using a machine learning approach (LASSO regression).

RESULTS

Two cross-validated LASSO regression models predicted treatment response (AUCs > .75). They suggested that higher homework completion rate, retention in treatment, and greater baseline severity were the most important predictors of DBT treatment response indicated by BPD symptom severity and utilization of DBT skills. Favorable effects of some aspects of therapeutic alliance during initial sessions were also found.

CONCLUSIONS

Future research may benefit from consolidating the criteria of treatment response, identifying clinically relevant variables, and testing the generalizability of findings to enhance knowledge of insufficient treatment response in DBT for BPD.

Social Support and Nonsuicidal Self-injury among adolescent Psychiatric Inpatients

Cross-sectional studies and prospective studies with long follow-up periods (e.g., years) have shown that lower levels of social support are associated with nonsuicidal self-injury (NSSI) among adolescents. This study examined how short-term changes in social support may contribute to NSSI behavior and whether different sources of support (e.g., friends, family members) provide differential protective effects against NSSI. We examined fluctuations in NSSI and social support perceived from multiple sources among a sample of 118 high-risk adolescents hospitalized for serious self-harm risk. Participants provided daily reports of social support and any self-injurious behavior for the duration of their inpatient treatment (721 total observations, average observations per participant = 6.11). Multi-level models were used to assess variability in social support and how these fluctuations relate to whether or not an individual engages in NSSI. Over one-third of participants reported engaging in NSSI at least once during inpatient hospitalization and self-reported social support varied within person across sources of support (ICC range = 0.68-0.81). Support perceived from family members and inpatient unit staff was inversely associated with NSSI, but no relationship was found between NSSI and support from other patients on the unit or friends outside of the unit. These findings suggest that the protective effects of social support for NSSI vary over short periods of time and that support perceived from adults is particularly relevant among this high-risk clinical sample. This study represents an important step in identifying risk factors to improve the detection and prevention of NSSI among adolescent inpatients.

A Pilot Implementation-Effectiveness Trial of a Single-Session Telehealth Workshop and Smartphone-Based Cognitive Behavioral Intervention for Managing Emotions Among College Students

The number of college students who need mental health treatment outpaces the resources available to counseling centers to provide these needed services, presenting a need for low-cost, scalable interventions for college populations. We conducted a pilot implementation-effectiveness trial of a scalable treatment package that consisted of a single (telehealth) workshop plus a companion app that provided ecological momentary intervention. Participants (n = 177) received a workshop provided by counseling center staff and trainees. We were interested in (1) engagement with the app, (2) acceptability of the treatment package, and (3) initial effectiveness of the treatment package. Regarding engagement with the app, we found that participants preferred two reminder prompts per day and identified two key breakpoints when engagement declined significantly: at day 15, when just over half of the sample practiced a skill on the app at least once during the day and at day 41, when just over one third of people practiced a skill on the app each day. Regarding acceptability of the treatment package, students generally reported positive attitudes about the single-session workshop and app, but also noted that the content and assessments in the app needed to be more dynamic to improve how engaging it is. Regarding effectiveness, we found that about 75% of the sample experienced a significant reduction in negative affect from pre- to post-ecological momentary intervention. Moreover, there were significant pre- to post-study decreases in experiential avoidance and symptoms of anxiety and depression and increases in self-efficacy for managing negative emotions. The results of this study are promising in terms of providing initial support for this novel treatment package and provide useful information for researchers planning to develop and test similar interventions.

The Effectiveness of a Brief Telehealth and Smartphone Intervention for College Students Receiving Traditional Therapy: Longitudinal Study Using Ecological Momentary Assessment Data

BACKGROUND

Brief interventions such as mental health apps and single-session interventions are increasingly popular, efficacious, and accessible delivery formats that may be beneficial for college students whose mental health needs may not be adequately met by college counseling centers. However, no studies so far have examined the effectiveness of these modes of treatment for college students who are already receiving traditional therapy, despite it being common among this population.

OBJECTIVE

The aim of this study was to compare the differences in self-reported momentary negative affect between college students in therapy and not in therapy who received a brief single-session intervention delivered by counseling center staff and a supplemental mobile app.

METHODS

Data for this study were drawn from E-Manage, a brief mobile health intervention geared toward college students. Participants in the study were 173 college students who indicated whether they had received therapy. We conducted a multilevel model to determine whether there were differences between those in therapy versus not in therapy in negative affect reported throughout the study. Following this, we conducted multilevel models with therapy status as the predictor and negative affect as the outcome.

RESULTS

Results of the multilevel model testing showed that the cross-level interaction between the time point (ie, pre- vs postexercise) and therapy status was significant (P=.008), with the reduction in negative affect from pre- to postexercise greater for those in therapy (b=-0.65, 95% CI -0.91 to -0.40; P<.001) than it was for those not in therapy (b=-0.31, 95% CI -0.43 to -0.19; P<.001). Therapy status was unassociated with both the pre-exercise (b=-1.69, 95% CI -3.51 to 0.13; P=.07) and postexercise (b=-1.37, 95% CI -3.17 to 0.43; P=.14) ratings of negative affect.

CONCLUSIONS

These findings suggest that app-based and single-session interventions are also appropriate to use among college students who are receiving traditional therapy. A randomized controlled trial comparing students receiving therapy to students receiving therapy and E-Manage will be necessary to determine to what extent E-Manage contributed to the reductions in negative affect that therapy-attending college students experienced.

Examining implicit positive affect toward suicide among suicidal and nonsuicidal adults and adolescents

OBJECTIVE

The purpose of this study was to examine implicit affect toward suicide (i.e., how good/bad suicide is perceived). Some people might be more likely to think about/choose suicide because they perceive it as a good option (to gain relief) relative to available alternatives.

METHOD

Implicit affect toward suicide among adults (N = 72) and adolescents (N = 174) with and without suicidal thoughts was examined using first-person (FP) perspective suicide pictures in the affect misattribution procedure (AMP).

RESULTS

Suicidal adults' implicit positive affect toward suicide was associated with STB variables, such as explicit valence (r = 0.34) and arousal (r = 0.44) ratings of suicide pictures, and implicit affect differentiated groups above and beyond explicit valence ratings. Contrary to our hypothesis, suicidal participants did not display higher implicit positive affect toward suicide than nonsuicidal participants. However, suicidal participants displayed consistent implicit affect toward different suicide pictures, whereas nonsuicidal participants evaluated some pictures as more pleasant than others (ORs = 1.92-2.27).

CONCLUSIONS

Implicit affect toward suicide may relate to STB, but stimuli characteristics (e.g., color) likely influence the accuracy of assessment with the AMP and should be a focus of future research involving this and other implicit measures.

The Mental Health Impact of Daily News Exposure During the COVID-19 Pandemic: Ecological Momentary Assessment Study

BACKGROUND

Consumption of distressing news media, which substantially increased during the COVID-19 pandemic, has demonstrable negative effects on mental health.

OBJECTIVE

This study examines the proximal impact of daily exposure to news about COVID-19 on mental health in the first year of the pandemic.

METHODS

A sample of 546 college students completed daily ecological momentary assessments (EMAs) for 8 weeks, measuring exposure to news about COVID-19, worry and optimism specifically related to COVID-19, hopelessness, and general worry.

RESULTS

Participants completed >80,000 surveys. Multilevel mediation models indicated that greater daily exposure to news about COVID-19 is associated with higher same-day and next-day worry about the pandemic. Elevations in worry specifically about COVID-19 were in turn associated with greater next-day hopelessness and general worry. Optimism about COVID-19 mediated the relationship between daily exposure to COVID-19 news and next-day general worry but was not related to hopelessness.

CONCLUSIONS

This study demonstrates the mental health impact of daily exposure to COVID-19 news and highlights how worry about the pandemic contributes over time to hopelessness and general worry.

An Ecological Momentary Intervention Study of Emotional Responses to Smartphone-Prompted CBT Skills Practice and the Relationship to Clinical Outcomes

The practice of therapeutic skills outside of sessions in which they are learned is one presumed key component of cognitive behavioral therapy (CBT). Yet, our understanding of how skills practice relates to clinical outcomes remains limited. Here, we explored patients' emotional responses to CBT skills practice in a pilot study pairing smartphone-app-delivered skills reminders and guided practice (ecological momentary intervention [EMI]) using ecological momentary assessment (EMA). Participants (n = 25) were adults recently hospitalized for a suicide attempt or severe suicidal thinking. They received brief inpatient CBT (1 to 3 sessions covering core CBT skills from the Unified Protocol), followed by 1 month of EMI and EMA after discharge. On average, participants reported modest reductions in negative affect after skills use (i.e., immediate responses; median time elapsed = 4.30 minutes). Additionally, participants tended to report less negative affect when the timepoint preceding the current assessment included EMI skills practice, rather than EMA alone (i.e., delayed responses; median time elapsed between prompts = 2.17 hours). Immediate effects were unrelated to longer-term clinical outcomes, whereas greater delayed effects were associated with lower symptom severity at follow-up. Future studies should further examine how CBT skills use in daily life may alleviate symptoms.

Effect of frequent assessment of suicidal thinking on its incidence and severity: high-resolution real-time monitoring study

Researchers, clinicians and patients are increasingly using real-time monitoring methods to understand and predict suicidal thoughts and behaviours. These methods involve frequently assessing suicidal thoughts, but it is not known whether asking about suicide repeatedly is iatrogenic. We tested two questions about this approach: (a) does repeatedly assessing suicidal thinking over short periods of time increase suicidal thinking, and (b) is more frequent assessment of suicidal thinking associated with more severe suicidal thinking? In a real-time monitoring study (n = 101 participants, n = 12 793 surveys), we found no evidence to support the notion that repeated assessment of suicidal thoughts is iatrogenic.

A Proof-of-Concept Ecological Momentary Assessment Study of Day-Level Dynamics in Value-Based Decision-Making in Opioid Addiction

BACKGROUND

Drug addiction is thought to be characterized by risky and impulsive behavior despite harmful consequences. Whether these aspects of value-based decision-making in people with addiction are stable and trait-like, and the degree to which they vary within-person and are sensitive to changes in psychological state, remains unknown. In this pilot study, we examined the feasibility of distinguishing these state- vs. trait-like components by probing day-level dynamics of risk and time preferences in patients with opioid use disorder (OUD) as they engaged with their natural environment.

METHODS

Twenty-three individuals with OUD receiving outpatient treatment (40% female; M = 45.67 [SD = 13.16] years of age) and twenty-one matched healthy community controls (47% female; M = 49.67 [SD = 14.38] years of age) participated in a 28-day smartphone-based ecological momentary assessment study (1085 person days; M = 24.66, SD = 5.84). Random prompts administered daily assessed subjects' psychological state (e.g., mood) and economic preferences for real delayed and risky monetary rewards.

RESULTS

Subjects demonstrated dynamic decision-making preferences, with 40-53% of the variation in known risk and ambiguity tolerance, and 67% in discounting, attributable to between-person vs. within-person (day-to-day) differences. We found that changes in psychological state were related to changes in risk preferences, with patients preferring riskier offers on days they reported being in a better mood but no differences between groups in aggregate level behavior. By contrast, temporal discounting was increased overall in patients compared to controls and was unrelated to global mood. The study was well-tolerated, but compliance rates were moderate and lower in patients.

CONCLUSION

Our data support the idea that decision-making preferences in drug addiction exhibit substantial within-person variability and that this variability can be well-captured using remote data collection methods. Preliminary findings suggested that aspects of decision-making related to consideration of risk may be more sensitive to within-person change in global psychological state while those related to consideration of delay to reward, despite also being somewhat variable, stably differ from healthy levels. Identifying the cognitive factors that contribute to opioid use risk in a "real-world" setting may be important for identifying unique, time-sensitive targets for intervention.

Just-in-Time Adaptive Interventions for Suicide Prevention: Promise, Challenges, and Future Directions

The suicide rate (currently 14 per 100,000) has barely changed in the United States over the past 100 years. There is a need for new ways of preventing suicide. Further, research has revealed that suicidal thoughts and behaviors and the factors that drive them are dynamic, heterogeneous, and interactive. Most existing interventions for suicidal thoughts and behaviors are infrequent, not accessible when most needed, and not systematically tailored to the person using their own data (e.g., from their own smartphone). Advances in technology offer an opportunity to develop new interventions that may better match the dynamic, heterogeneous, and interactive nature of suicidal thoughts and behaviors. Just-In-Time Adaptive Interventions (JITAIs), which use smartphones and wearables, are designed to provide the right type of support at the right time by adapting to changes in internal states and external contexts, offering a promising pathway toward more effective suicide prevention. In this review, we highlight the potential of JITAIs for suicide prevention, challenges ahead (e.g., measurement, ethics), and possible solutions to these challenges.

The role of temperament in the onset of suicidal ideation and behaviors across adolescence: Findings from a 10-year longitudinal study of Mexican-origin youth

Suicide among young people is an increasingly prevalent and devastating public health crisis around the world. To reduce the rate of suicide, it is important to identify factors that can help us better predict suicidal ideation and behaviors. Adolescent temperament (effortful control, negative emotionality, positive emotionality) may be a source of risk and resilience for the onset of suicidal ideation, plans, and attempts. The present study uses longitudinal data from a large, community sample of Mexican-origin youth (N = 674), assessed annually from age 12 to 21, to examine how temperament is associated with the onset of suicidal ideation and behaviors during adolescence and young adulthood. Results indicate that higher levels of effortful control (activation control, inhibitory control, attention) are associated with decreased probability of experiencing the onset of suicidal ideation, plans, and attempts, whereas higher levels of negative emotionality (particularly aggression, frustration, and depressed mood) are associated with increased probability of experiencing the onset of suicidal ideation and behaviors. Positive emotionality (surgency, affiliation) was not associated with the onset of suicidal ideation and behaviors. Supplemental analyses showed conceptually similar findings for the Big Five, with Conscientiousness associated with decreased risk, Neuroticism associated with increased risk, and the other three dimensions showing largely null results. The findings did not vary significantly for boys and girls or for youth born in the U.S. versus Mexico. Overall, these findings suggest that adolescent temperament serves as both a protective factor (via effortful control/Conscientiousness) and a risk factor (via negative emotionality/Neuroticism) for suicidal ideation and behaviors in Mexican-origin youth. (PsycInfo Database Record (c) 2022 APA, all rights reserved).

Can passive measurement of physiological distress help better predict suicidal thinking?

There has been growing interest in using wearable physiological monitors to passively detect the signals of distress (i.e., increases in autonomic arousal measured through increased electrodermal activity [EDA]) that may be imminently associated with suicidal thoughts. Before using these monitors in advanced applications such as creating suicide risk detection algorithms or just-in-time interventions, several preliminary questions must be answered. Specifically, we lack information about whether: (1) EDA concurrently and prospectively predicts suicidal thinking and (2) data on EDA adds to the ability to predict the presence and severity of suicidal thinking over and above self-reports of emotional distress. Participants were suicidal psychiatric inpatients (n = 25, 56% female, M age = 33.48 years) who completed six daily assessments of negative affect and suicidal thinking duration of their psychiatric inpatient stay and 28 days post-discharge, and wore on their wrist a physiological monitor (Empatica Embrace) that passively detects autonomic activity. We found that physiological data alone both concurrently and prospectively predicted periods of suicidal thinking, but models with physiological data alone had the poorest fit. Adding physiological data to self-report models improved fit when the outcome variable was severity of suicidal thinking, but worsened model fit when the outcome was presence of suicidal thinking. When predicting severity of suicidal thinking, physiological data improved model fit more for models with non-overlapping self-report data (i.e., low arousal negative affect) than for overlapping self-report data (i.e., high arousal negative affect). These findings suggest that physiological data, under certain contexts (e.g., when combined with self-report data), may be useful in better predicting-and ultimately, preventing-acute increases in suicide risk. However, some cautious optimism is warranted since physiological data do not always improve our ability to predict suicidal thinking.

Do Patterns and Types of Negative Affect During Hospitalization Predict Short-Term Post-Discharge Suicidal Thoughts and Behaviors?

We still have little understanding of short-term predictors of suicidal thoughts and behaviors (STBs). Prior research links increased negative affect to STBs, but the vast majority of earlier work is limited by measuring negative affect at one time point and aiming to predict STBs months or years in the future. Recently, intensive longitudinal studies have shown that negative affect is associated with suicidal thoughts over relatively short, clinically useful time periods; however, the specific patterns and types of negative affect that predict STBs remain unclear. Using ecological momentary assessment (EMA) data from psychiatric inpatients hospitalized for suicide risk (N = 83), this study sought to test whether the patterns (means and variability) of two types of negative affect (anxiety/agitation and shame/self-hatred, which were derived from a larger EMA battery) during hospitalization predict STBs in the four weeks after discharge: an extremely high-risk time for suicidal behavior. The mean - but not the variability - of both anxiety/agitation and shame/self-hatred during hospitalization predicted the number of days with suicidal thoughts after discharge. The mean and the variability of shame/self-hatred - but not anxiety/agitation - predicted post-discharge suicide attempt. We discuss implications for assessment and treatment of suicidal individuals and propose key directions for future research.

Practices for monitoring and responding to incoming data on self-injurious thoughts and behaviors in intensive longitudinal studies: A systematic review

Advancements in the understanding and prevention of self-injurious thoughts and behaviors (SITBs) are urgently needed. Intensive longitudinal data collection methods-such as ecological momentary assessment-capture fine-grained, "real-world" information about SITBs as they occur and thus have the potential to narrow this gap. However, collecting real-time data on SITBs presents complex ethical and practical considerations, including about whether and how to monitor and respond to incoming information about SITBs from suicidal or self-injuring individuals during the study. We conducted a systematic review of protocols for monitoring and responding to incoming data in previous and ongoing intensive longitudinal studies of SITBs. Across the 61 included unique studies/samples, there was no clear most common approach to managing these ethical and safety considerations. For example, studies were fairly evenly split between either using automated notifications triggered by specific survey responses (e.g., indicating current suicide risk) or monitoring and intervening upon (generally with a phone-based risk assessment) incoming responses (36%), using both automated notifications and monitoring/intervening (35%), or neither using automated notifications nor monitoring/intervening (29%). Certain study characteristics appeared to influence the safety practices used. Future research that systematically evaluates optimal, feasible strategies for managing risk in real-time monitoring research on SITBs is needed.

Day-to-day changes in negative attributions of stress: A daily diary study of cognitive vulnerability and negative affect in adults with elevated risk of suicidal thoughts and behaviors

BACKGROUND

The hopelessness theory is one of the most studied cognitive vulnerability theories of depression. It proposes that risk for depression is conferred by attributing the causes of negative events to global, internal, stable causes and inferring future negative consequences and negative characteristics about oneself from these events. Nearly all research has operationalized cognitive style using individuals' responses to hypothetical events at single timepoints. Far less research has explored attributions of specific events as they occur, none of which has involved clinical samples.

METHODS

This study aimed to examine if measuring event-specific attributions clarifies the relationship between negative cognitive style and clinical symptoms. Adults (n = 51), who had attempted suicide at least once in the year prior, were recruited from the community via online forums related to suicide risk. Participants provided nightly ratings of hopelessness and attributions of the most stressful event that day for four weeks.

RESULTS

The daily diary composite measure of cognitive style was more strongly associated with hopelessness and depressive symptoms than the trait measure. Daily attributions fully mediated the relationship between trait cognitive style and hopelessness.

LIMITATIONS

The measurement period could not capture the occurrence of a next depressive episode for all participants. Relatedly, we could not account for the precise nature of individual stressors.

CONCLUSIONS

At a population level, trait measures alone may be a useful risk factor. But, with the goal to move towards more personalized prediction and intervention, more dynamic, ecologically valid, and real time measures may help gain more traction.

Variability in the Functions of Nonsuicidal Self-Injury: Evidence From Three Real-Time Monitoring Studies

Despite functional models of nonsuicidal self-injury (NSSI) helping to explain why people engage in this perplexing behavior, we still lack an understanding of some of the key properties of NSSI functions. Here, we address three unanswered questions about NSSI functions: how much do distinct NSSI functions (1) vary between people over time, (2) vary within people over time, and (3) simultaneously co-occur over time? Data were drawn from three ecological momentary assessment (EMA) studies of self-injurious adult psychiatric outpatients (n = 7), community-based adolescents (n = 15), and community-based adults (n = 9). Across the three studies, there was a total of 271 NSSI episodes (all with corresponding functions captured by EMA). The vast majority (27 of 31; 87%) of participants exhibited unique patterns of NSSI functions during the monitoring periods, indicating high variability between people. The vast majority (26 of 31; 84%) of participants also showed changes in NSSI functions over time, indicating high variability within people. Although it was most common for only one function to be reported for a given NSSI episode, participants endorsed more than one function for 22% to 43% of NSSI episodes, indicating that different functions did simultaneously co-occur. These results underscore that reinforcement processes for NSSI differ from person-to-person, and are both time-varying and multifaceted, which has implications for personalized assessment and treatment of this clinical phenomenon.

Thwarted Belongingness Mediates Interpersonal Stress and Suicidal Thoughts: An Intensive Longitudinal Study with High-risk Adolescents

OBJECTIVE

Interpersonal negative life events (NLEs) have been linked to risk for suicidal thoughts and behaviors. However, little is known about how this risk is conferred over the short term and the mechanisms linking interpersonal NLEs to suicide risk, particularly in adolescents. This study used an intensive longitudinal design to examine thwarted belongingness with family and friends as potential mechanisms linking interpersonal NLEs to suicidal thoughts.

METHOD

Forty-eight adolescents (M_age = 14.96 years; 64.6% female, 77.1% White), who recently received acute psychiatric care for suicide risk, were followed intensely for 28 days after discharge. Smartphone-based ecological momentary assessment was used to measure presence of interpersonal NLEs at the day level, fluctuations in thwarted belongingness with family and friends (separately) within day, and fluctuations in suicidal thoughts within day. A multi-level structural equation model was utilized to examine family thwarted belongingness and friend thwarted belongingness as parallel mediators in the relationship between interpersonal NLEs and next-day suicidal thoughts.

RESULTS

Significant direct effects were observed between interpersonal NLEs and family thwarted belongingness, family thwarted belongingness and suicidal thoughts, and friend thwarted belongingness and suicidal thoughts. In addition, family, but not friend, thwarted belongingness significantly mediated the association between interpersonal NLEs and next-day suicidal thoughts.

CONCLUSIONS

Interpersonal NLEs predicted greater suicidal thoughts over the short term (next day) in high-risk adolescents. Findings suggest how interpersonal NLEs may confer risk for suicidal thoughts - by reducing feelings of family belongingness. Future research is needed to examine how modifying belongingness may reduce suicide risk in adolescents.

Consensus Statement on Ethical & Safety Practices for Conducting Digital Monitoring Studies with People at Risk of Suicide and Related Behaviors

Objective

Digital monitoring technologies (e.g., smart-phones and wearable devices) provide unprecedented opportunities to study potentially harmful behaviors such as suicide, violence, and alcohol/substance use in real-time. The use of these new technologies has the potential to significantly advance the understanding, prediction, and prevention of these behaviors. However, such technologies also introduce myriad ethical and safety concerns, such as deciding when and how to intervene if a participant's responses indicate elevated risk during the study?

Methods

We used a modified Delphi process to develop a consensus among a diverse panel of experts on the ethical and safety practices for conducting digital monitoring studies with those at risk for suicide and related behaviors. Twenty-four experts including scientists, clinicians, ethicists, legal experts, and those with lived experience provided input into an iterative, multi-stage survey, and discussion process.

Results

Consensus was reached on multiple aspects of such studies, including: inclusion criteria, informed consent elements, technical and safety procedures, data review practices during the study, responding to various levels of participant risk in real-time, and data and safety monitoring.

Conclusions

This consensus statement provides guidance for researchers, funding agencies, and institutional review boards regarding expert views on current best practices for conducting digital monitoring studies with those at risk for suicide-with relevance to the study of a range of other potentially harmful behaviors (e.g., alcohol/substance use and violence). This statement also highlights areas in which more data are needed before consensus can be reached regarding best ethical and safety practices for digital monitoring studies.

Increase in Suicidal Thinking During COVID-19

There is concern that the COVID-19 pandemic may cause increased risk of suicide. In the current study, we tested whether suicidal thinking has increased during the COVID-19 pandemic and whether such thinking was predicted by increased feelings of social isolation. In a sample of 55 individuals recently hospitalized for suicidal thinking or behaviors and participating in a 6-month intensive longitudinal smartphone monitoring study, we examined suicidal thinking and isolation before and after the COVID-19 pandemic was declared a national emergency in the United States. We found that suicidal thinking increased significantly among adults (odds ratio [OR] = 4.01, 95% confidence interval [CI] = [3.28, 4.90], p < .001) but not adolescents (OR = 0.84, 95% CI = [0.69, 1.01], p = .07) during the onset of the COVID-19 pandemic. Increased feelings of isolation predicted suicidal thinking during the pandemic phase. Given the importance of social distancing policies, these findings support the need for digital outreach and treatment.

A Pilot Study Using Frequent Inpatient Assessments of Suicidal Thinking to Predict Short-Term Postdischarge Suicidal Behavior

IMPORTANCE

The weeks following discharge from psychiatric hospitalization are the highest-risk period for suicide attempts. Real-time monitoring of suicidal thoughts via smartphone prompts may be more indicative of short-term risk than a single, cross-sectional assessment.

OBJECTIVE

To test whether modeling dynamic changes in real-time suicidal thoughts during psychiatric hospitalization can improve predictions of postdischarge suicide attempts vs using only baseline (ie, admission) data or using the mean level of real-time suicidal thoughts during hospitalization.

DESIGN, SETTING, AND PARTICIPANTS

In this prognostic study, 83 adults recruited from the inpatient psychiatric unit at Massachusetts General Hospital completed ecological momentary assessment surveys of suicidal thinking 4 to 6 times per day during hospitalization as well as brief follow-up surveys assessing suicide attempts at 2 and 4 weeks after discharge. Participants completed at least 3 real-time monitoring surveys. Inclusion criteria included hospitalization for suicidal thoughts and/or behaviors and English fluency. Data were collected from January 2016 to December 2018 and analyzed from January to December 2020.

MAIN OUTCOMES AND MEASURES

The primary outcome was suicide attempt in the month after discharge.

RESULTS

Of 83 participants (mean [SD] age, 38.4 [13.6] years; 43 [51.8%] male participants; 69 [83.1%] White individuals), 9 (10.8%) made a suicide attempt in the month after discharge. Mean cross-validated AUC for elastic net models revealed predictive accuracy was fair for the model using baseline data (area under the curve [AUC], 0.71; first to third quartile, 0.55-0.88), good for the model using the mean level of real-time suicidal thoughts during hospitalization (AUC, 0.81; first to third quartile, 0.67-0.91), and best for the model using dynamic changes in real-time suicidal thoughts during hospitalization (AUC, 0.89; first to third quartile, 0.81-0.97); this pattern of results held for other classification metrics (eg, accuracy, positive predictive value, Brier score) and when using different cross-validation procedures. Features assessing rapid fluctuations in suicidal thinking emerged as the strongest predictors of posthospital suicide attempts. A final set of models incorporating percentage missingness further improved both the mean (mean AUC, 0.93; first to third quartile, 0.90-1.00) and dynamic feature (mean AUC, 0.93; first to third quartile, 0.88-1.00) models.

CONCLUSIONS AND RELEVANCE

In this study, collecting real-time data about suicidal thinking during the course of hospitalization significantly improved short-term prediction of posthospitalization suicide attempts. Models including dynamic changes in suicidal thinking over time yielded the best prediction; features that captured rapid changes in suicidal thoughts were particularly strong predictors. Survey noncompletion also emerged as an important predictor of posthospitalization suicide attempts.

Positive and negative uses of social media among adolescents hospitalized for suicidal behavior

INTRODUCTION

There is public concern about potential associations between adolescent social media/smartphone use and risk for suicide. However, no prior studies leverage qualitative methods to explore the experiences of adolescents currently at-risk for suicide.

METHODS

This study examined social technology use from the perspectives of adolescents (n = 30; Mage = 16.1 years) currently hospitalized for a recent suicide attempt or severe ideation. We conducted in-depth interviews and coded transcripts using thematic analysis. We had three research questions: What (1) negative and (2) positive experiences do suicidal adolescents report related to their use of social media/smartphones? (3) How do adolescents describe their disconnection from these technologies use during inpatient hospitalization and views on a subsequent return to digital connectivity after discharge?

RESULTS AND CONCLUSIONS

Results reveal both positive and negative social technology uses, with most participants reporting mixed (positive and negative) experiences. Negatives/risks included trouble regulating use, stress related to social media metrics, encounters with "triggering" content, hostility and meanness, self-denigrating comparisons, and burdensome friendship expectations. Positives/benefits included social connection, social support, affect-enhancing content, shared interests, and resources for mental health and coping. Overall, the documented risks and benefits of social technology use correspond with established (offline) risk and protective factors for suicidal thoughts and behaviors. Participants generally valued the break from social technologies during hospitalization, and also viewed them as integral to social re-entry and identified related concerns. Future studies should test well-being focused 'digital hygiene' interventions for maximizing potential benefits and minimizing potential harms of social technologies for at-risk adolescents.