The prediction of study-emergent suicidal ideation in bipolar disorder: a pilot study using ecological momentary assessment data

Temporal prediction of suicidal ideation in an ecological momentary assessment study with recurrent neural networks

INTRODUCTION

Ecological Momentary Assessment (EMA) holds promise for providing insights into daily life experiences when studying mental health phenomena. However, commonly used mixed-effects linear statistical models do not fully utilize the richness of the ultidimensional time-varying data that EMA yields. Recurrent Neural Networks (RNNs) provide an alternative data analytic method to leverage more information and potentially improve prediction, particularly for non-normally distributed outcomes.

METHODS

As part of a broader research study of suicidal thoughts and behavior in people with borderline personality disorder (BPD), eighty-four participants engaged in EMA data collection over one week, answering questions multiple times each day about suicidal ideation (SI), stressful events, coping strategy use, and affect. RNNs and mixed-effects linear regression models (MEMs) were trained and used to predict SI. Root mean squared error (RMSE), mean absolute percent error (MAPE), and a pseudo-R2 accuracy metric were used to compare SI prediction accuracy between the two modeling methods.

RESULTS

RNNs had superior accuracy metrics (full model: RMSE = 3.41, MAPE = 42 %, pseudo-R2 = 26 %) compared with MEMs (full model: RMSE = 3.84, MAPE = 56 %, pseudo-R2 = 16 %). Importantly, RNNs showed significantly more accurate prediction at higher values of SI. Additionally, RNNs predicted, with significantly higher accuracy, the SI scores of participants with depression diagnoses and of participants with higher depression scores at baseline.

CONCLUSION

In this EMA study with a moderately sized sample, RNNs were better able to learn and predict daily SI compared with mixed-effects models. RNNs should be considered as an option for EMA analysis.

Predicting the presence of tinnitus using ecological momentary assessments

Mobile applications have gained popularity in healthcare in recent years. These applications are an increasingly important pillar of public health care, as they open up new possibilities for data collection and can lead to new insights into various diseases and disorders thanks to modern data analysis approaches. In this context, Ecological Momentary Assessment (EMA) is a commonly used research method that aims to assess phenomena with a focus on ecological validity and to help both the user and the researcher observe these phenomena over time. One phenomenon that benefits from this capability is the chronic condition tinnitus. TrackYourTinnitus (TYT) is an EMA-based mobile crowdsensing platform designed to provide more insight into tinnitus by repeatedly assessing various dimensions of tinnitus, including perception (i.e., perceived presence). Because the presence of tinnitus is the dimension that is of great importance to chronic tinnitus patients and changes over time in many tinnitus patients, we seek to predict the presence of tinnitus based on the not directly related dimensions of mood, stress level, arousal, and concentration level that are captured in TYT. In this work, we analyzed a dataset of 45,935 responses to a harmonized EMA questionnaire using different machine learning techniques. In addition, we considered five different subgroups after consultation with clinicians to further validate our results. Finally, we were able to predict the presence of tinnitus with an accuracy of up to 78% and an AUC of up to 85.7%.

Feasibility and Acceptability of a Preoperative Multimodal Mobile Health Assessment in Spine Surgery Candidates

BACKGROUND

Rapid growth in smartphone use has expanded opportunities to use mobile health (mHealth) technology to collect real-time patient-reported and objective biometric data. These data may have important implication for personalized treatments of degenerative spine disease. However, no large-scale study has examined the feasibility and acceptability of these methods in spine surgery patients.

OBJECTIVE

To evaluate the feasibility and acceptability of a multimodal preoperative mHealth assessment in patients with degenerative spine disease.

METHODS

Adults undergoing elective spine surgery were provided with Fitbit trackers and sent preoperative ecological momentary assessments (EMAs) assessing pain, disability, mood, and catastrophizing 5 times daily for 3 weeks. Objective adherence rates and a subjective acceptability survey were used to evaluate feasibility of these methods.

RESULTS

The 77 included participants completed an average of 82 EMAs each, with an average completion rate of 86%. Younger age and chronic pulmonary disease were significantly associated with lower EMA adherence. Seventy-two (93%) participants completed Fitbit monitoring and wore the Fitbits for an average of 247 hours each. On average, participants wore the Fitbits for at least 12 hours per day for 15 days. Only worse mood scores were independently associated with lower Fitbit adherence. Most participants endorsed positive experiences with the study protocol, including 91% who said they would be willing to complete EMAs to improve their preoperative surgical guidance.

CONCLUSION

Spine fusion candidates successfully completed a preoperative multimodal mHealth assessment with high acceptability. The intensive longitudinal data collected may provide new insights that improve patient selection and treatment guidance.

The role of digital tools in providing youth mental health: results from an international multi-center study

Since the traditional mental health system showed significant limitations in the early identification, diagnosis and treatment of the current new youth psychopathological trajectories, by substantially failing in targeting the needs of the current young generation, there is the demand to redesign and digitally adapt youth mental health care and systems. Indeed, the level of digital literacy and the level of digital competency and knowledge in the field of digital psychiatry is still under-investigated among mental health professionals, particularly in youth mental health. Therefore, we aimed at: (a) carrying out a post-hoc analysis of an international multi-centre study, to investigate the opinions of mental health professionals regarding the feasibility, efficacy and clinical experience in delivering digital mental health interventions (DMHIs) in youths; (b) providing a comprehensive overview on the integrated digitally-based youth mental health care models and innovations. Mental health professionals declared the lack of a formal training in digital psychiatry, particularly in youth mental health. Subjects who received a formal theoretical/practical training on DMHIs displayed a statistical trend towards a positive feasibility of digital psychiatry in youth mental health (p = 0.053) and a perceived increased efficacy of digital psychiatry in youths (p = 0.051). Respondents with higher Digital Psychiatry Opinion (DPO) scores reported a positive perceived feasibility of DMHIs in youths (p < 0.041) and are more prone to deliver DMHIs to young people (p < 0.001). Respondents with higher knowledge scores (KS) declared that DMHIs are more effective in youth mental health (p < 0.001). Overall, the digitalisation indeed allowed young people to keep in touch with a mental health professional, facilitating a more dynamic and fluid mental health care access and monitoring, generally preferred and considered more feasible by post-Millennial youngsters. Accordingly, our findings demonstrated that mental health professionals are more prone to offer DMHIs in youth mental health, particularly whether previously trained and knowledgeable on the topic.

Association of real-time assessed mood, affect and suicidal ideation in psychiatric inpatients with unipolar depression

Previous research provided preliminary support of a potential reinforcing effect of suicidal ideation demonstrating reduced negative affect and increased positive affect after thinking about suicide. The present study therefore sought to investigate the role of mood and affect as a proximal risk factor of suicidal ideation in a high-risk sample. Seventy-four psychiatric inpatients (72% female) with unipolar depression and current and/or lifetime suicidal ideation aged 18 to 85 years (M = 37.6, SD = 14.3) took part in an ecological momentary assessment (EMA) over 6 days. Multilevel analyses were calculated. Analyses revealed negative valence of mood and low positive affect to be predictors of subsequent intensity of suicidal ideation (active, passive) as well as predictors of change in suicidal ideation (active, passive) since the last measurement. High negative affect only predicted intensity of passive suicidal ideation. Suicidal ideation (active, passive) was prospectively associated with subsequent negative valence of mood and lower positive affect as well as with higher intensity of negative affect. Suicidal ideation (active, passive) also predicted the change in valence of mood, positive affect and negative affect since the last measurement. Mood and affect should be taken into account as important proximal risk factors of active and passive suicidal ideation. The results do not support the idea of a reinforcing effect of suicidal ideation. In fact, they show a pattern of reduced subsequent positive affect, negative valence of mood and increased negative affect. Replication studies with larger samples and longer EMA follow-ups are needed.

Apps and gaps in bipolar disorder: A systematic review on electronic monitoring for episode prediction

BACKGROUND

Long-term clinical monitoring in bipolar disorder (BD) is an important therapeutic tool. The availability of smartphones and wearables has sparked the development of automated applications to remotely monitor patients. This systematic review focus on the current state of electronic (e-) monitoring for episode prediction in BD.

METHODS

We systematically reviewed the literature on e-monitoring for episode prediction in adult BD patients. The systematic review was done according to the guidelines for reporting of systematic reviews and meta-analyses (PRISMA) and was registered in PROSPERO on April 29, 2020 (CRD42020155795). We conducted a search of Web of Science, MEDLINE, EMBASE, and PsycINFO (all 2000-2020) databases. We identified and extracted data from 17 published reports on 15 relevant studies.

RESULTS

Studies were heterogeneous and most had substantial methodological and technical limitations. Models varied widely in their performance. Published metrics were too heterogeneous to lend themselves to a meta-analysis. Four studies reported sensitivity (range: 0.21 - 0.95); and two reported specificity for prediction of mood episodes (range: 0.36 - 0.99). Two studies reported accuracy (range: 0.64 - 0.88) and four reported area under the curve (AUC; range: 0.52-0.95). Overall, models were better in predicting manic or hypomanic episodes, but their performance depended on feature type.

LIMITATIONS

Our conclusions are tempered by the lack of appropriate information impeding our ability to synthesize the available evidence.

CONCLUSIONS

Given the clinical variability in BD, predicting mood episodes remains a challenging task. Emerging e-monitoring technology for episode prediction in BD requires more development before it can be adopted clinically.

[Digital Options for Treating Mental Disorders during the COVID-19 Pandemic]

The COVID-19 pandemic and its consequences, such as contact restrictions, pose new challenges to psychiatric-psychotherapeutic care in many parts of the world. This article provides an overview of digital methods for treating mental disorders under pandemic conditions and for reducing pandemic-related psychological distress (e.g., due to social isolation). Current challenges and limitations in the use of digital treatment options and their long-term perspectives in psychiatric-psychotherapeutic care are discussed.

Contributions of health technologies in risk assessment for suicide behavior: an integrative review

OBJECTIVE

to identify how health technologies contribute to risk assessment for suicidal behavior.

METHODS

an integrative review carried out on the MEDLINE, CINAHL, Web of Science, SCOPUS, LILACS and BDENF databases. The sample consisted of 12 primary studies, with no temporal or language delimitation. Analysis of results occurred descriptively.

RESULTS

the technologies included assistance and teaching aspects favorable to data screening, monitoring and navigation, capable of predicting individual, biological, clinical, psychological, environmental and social markers for suicidal behavior. Thus, measurement scale, software and computational algorithms constituted valid and sensitive instruments for improving performance, expanding skills and knowledge, good care practices, effective communication and assistance planning.

CONCLUSION

the identified technologies proved to be effective in identifying risk states for suicidal behavior, representing effective resources for directing care and necessary interventions.

Capturing Clinical Symptoms with Ecological Momentary Assessment: Convergence of Momentary Reports of Psychotic and Mood Symptoms with Diagnoses and Standard Clinical Assessments

Objective: The development and deployment of technology-based assessments of clinical symptoms are increasing. This study used ecological momentary assessment (EMA) to examine clinical symptoms and relates these sampling results to structured clinical ratings. Methods: Three times a day for 30 days, participants with bipolar disorder (n=71; BPI) or schizophrenia (n=102; SCZ) completed surveys assessing five psychosis-related and five mood symptoms, in addition to reporting their location and who they were with at the time of survey completion. Participants also completed Positive and Negative Syndrome Scale (PANSS) interviews with trained raters. Mixed-model repeated-measures (MMRM) analyses examined diagnostic effects and the convergence between clinical ratings and EMA sampling. Results: In total, 12,406 EMA samples were collected, with 80-percent adherence to prompts. EMA-reported psychotic symptoms manifested substantial convergence with equivalent endpoint PANSS items. Patients with SCZ had more severe PANSS and EMA psychotic symptoms. There were no changes in symptom severity scores as a function of the number of previous assessments. Conclusions: EMA surveyed clinical symptoms converged substantially with commonly used clinical rating scales in a large sample, with high adherence. This suggested that remote assessment of clinical symptoms is valid and practical and was not associated with alterations in symptoms as a function of reassessment, with additional benefits of "in the moment" sampling, such as eliminating recall bias and the need for informant reports.

Suicidal ideation and affect lability in single and multiple suicidal attempters with Major Depressive Disorder: An exploratory network analysis

INTRODUCTION

A better understanding of the specific contribution of risk factors to suicidal behavior could arise from analyzing suicidal ideation (SI) in clinical samples, and comparing single versus multiple suicide attempters through contemporary methods allowing complex and dynamical analyses of multiple and simultaneously interacting suicide risk factors.

METHOD

We explored associations among suicidal ideation (SI), affect lability and other suicide risk factors in 323 suicidal attempters diagnosed with major depressive disorder (MDD). We analyzed the network structure and centrality of the total sample, and compared single versus multiple attempters and subjects with low and high suicidal ideation.

RESULTS

SI was connected with anxiety (trait) and hopelessness. Central nodes for global and specific groups were affect lability (from anxiety to depression), anxiety as a trait, and harm avoidance. We observed some specific differences between clinical profiles of repeaters and non-repeaters and significant network density between high and low SI.

LIMITATIONS

Because our cross-sectional design, we cannot establish casual relationships among variables. We only examined associations at group level but not at single subject level.

CONCLUSIONS

Affect lability (mainly the shifts from anxiety to depression) and trait anxiety were central in each estimated network. These symptoms might be suitable targets for early detecting and treating suicidal patients.

A Literature Review Comparing Clinicians' Approaches and Skills to In-Person, Synchronous, and Asynchronous Care: Moving Toward Competencies to Ensure Quality Care

Introduction: Research is increasing on asynchronous technologies used by specialist clinicians and primary care, including e-mail, text, e-consultation, and store-and-forward (asynchronous) options. Studies typically describe interventions and care outcomes rather than development of clinical skills for using technology. Methods: This article attempts to compare clinicians' approaches to, and skills for, asynchronous technologies versus in-person and synchronous (i.e., video) care. Literature from technology, health care, pedagogy, and business were searched from 2000 to 2019 for title words, including synchronous (e.g., video, telemental or behavioral health, telepsychiatry), asynchronous (e.g., app, e-consultation, e-mail, text, sensor in a wearable device), education, clinical, and consultation. Results: From a total of 4,812 potential references, two authors (D.M.H., J.T.) found 4,622 eligible for full text review and found 381 articles directly relevant to the concept areas in combination for full text review. However, exclusion criteria subtracted 305, leaving a total of 76 articles. While in-person and synchronous care are similar in many ways, the clinical approach to asynchronous care has many differences. As asynchronous technologies and models of care are feasible and effective, often for consultation, an outline of patient, primary care provider, and specialist clinician goals and skills are presented. Few studies specifically discuss skills or competencies for asynchronous care, but components from published clinical informatics, video, social media, and mobile health competencies were organized into Accreditation Council of Graduate Medical Education domains. Conclusions: Further implementation of science research is needed for asynchronous technology interventions, as well as clinician competencies using asynchronous technologies, to ensure optimal outcomes for patients in health care.

A Framework for Competencies for the Use of Mobile Technologies in Psychiatry and Medicine: Scoping Review

BACKGROUND

To ensure quality care, clinicians need skills, knowledge, and attitudes related to technology that can be measured.

OBJECTIVE

This paper sought out competencies for mobile technologies and/or an approach to define them.

METHODS

A scoping review was conducted to answer the following research question, "What skills are needed for clinicians and trainees to provide quality care via mHealth, have they been published, and how can they be made measurable and reproducible to teach and assess them?" The review was conducted in accordance with the 6-stage scoping review process starting with a keyword search in PubMed/Medical Literature Analysis and Retrieval System Online, APA PsycNET, Cochrane, EMBASE, PsycINFO, Web of Science, and Scopus. The literature search focused on keywords in 4 concept areas: (1) competencies, (2) mobile technologies, (3) telemedicine mode, and (4) health. Moreover, 2 authors independently, in parallel, screened the search results for potentially relevant studies based on titles and abstracts. The authors reviewed the full-text articles for final inclusion based on inclusion/exclusion criteria. Inclusion criteria were keywords used from concept area 1 (competencies) and 2 (mobile technologies) and either 3 (telemedicine mode) or 4 (health). Exclusion criteria included, but were not limited to, keywords used from a concept area in isolation, discussion of skills abstractly, outline or listing of what clinicians need without detail, and listing immeasurable behaviors.

RESULTS

From a total of 1232 results, the authors found 78 papers eligible for a full-text review and found 14 papers directly relevant to the 4 key concepts. Although few studies specifically discussed skills, the majority were clinical studies, and the literature included no lists of measurable behaviors or competency sets for mobile technology. Therefore, a framework for mobile technology competencies was built according to the review, expert consensus, and recommendations of the Institute of Medicine's Health Professions Education Summit and Accreditation Council of Graduate Medical Education framework. This framework borrows from existing competency framework domains in telepsychiatry and social media (patient care, medical knowledge, practice-based learning and improvement, systems-based practice, professionalism, and interpersonal skills and communication) and added domains of mHealth clinical decision support, device/technology assessment/selection, and information flow management across an electronic health record platform. mHealth Asynchronous components require additional traditional learning, teaching, supervisory and evaluation practices. Interactive curricula with case-, problem-, and system-based teaching may help faculty focus on decision making and shape skills and attitudes to complement clinical exposure.

CONCLUSIONS

Research is needed on how to customize implementation and evaluation of mHealth competencies and to ensure skill development is linked to the quality of care. This will require the management of organizational change with technology and the creation of a positive electronic culture in a complex policy and regulatory environment.

Mobile Health Technology Interventions for Suicide Prevention: Systematic Review

BACKGROUND

Digital interventions are proposed as one way by which effective treatments for self-harm and suicidal ideation may be improved and their scalability enhanced. Mobile devices offer a potentially powerful medium to deliver evidence-based interventions with greater specificity to the individual when the intervention is needed. The recent proliferation of publicly available mobile apps designed for suicide prevention underlines the need for robust evidence to promote safe practice.

OBJECTIVE

This review aimed to examine the effectiveness of currently available mobile health (mHealth) technology tools in reducing suicide-specific outcomes.

METHODS

The following databases were searched: Cochrane Central Register of Controlled Trials (The Cochrane Library), MEDLINE, EMBASE, PsycINFO, and relevant sources of gray literature. All published and unpublished randomized controlled trials (RCTs), pseudo-RCTs, and pre-post observational studies that evaluated the effectiveness of mHealth technology in suicide prevention delivered via mobile computing and communication technology were included. Studies were included if they measured at least one suicide outcome variable (ie, suicidal ideation, suicidal intent, nonsuicidal self-injurious behavior, and suicidal behavior). A total of 2 review authors independently extracted data and assessed study suitability, in accordance with the Cochrane Collaboration Risk of Bias Tool, on July 31, 2018. Owing to the heterogeneity of outcomes found across studies, results were not amenable for pooled synthesis, and a meta-analysis was not performed. A narrative synthesis of the available research is presented here.

RESULTS

A total of 7 studies met criteria for inclusion . Four published articles that reported on the effectiveness of the following mobile phone apps were included: iBobbly, Virtual Hope Box, BlueIce, and Therapeutic Evaluative Conditioning. Results demonstrated some positive impacts for individuals at elevated risk of suicide or self-harm, including reductions in depression, psychological distress, and self-harm and increases in coping self-efficacy. None of the apps evaluated demonstrated the ability to significantly decrease suicidal ideation compared with a control condition. In addition, 3 unpublished and recently completed trials also met criteria for inclusion in the review.

CONCLUSIONS

Further research is needed to evaluate the efficacy of stand-alone mHealth technology-based interventions in suicide prevention. The small number of studies reported in this review tentatively indicate that such tools may have a positive impact on suicide-specific outcomes. Future mHealth intervention evaluations would benefit from addressing the following 3 main methodological limitations : (1) heterogeneity of outcomes: a lack of standardized measurement of suicide outcomes across studies; (2) ecological validity: the tendency to exclude potential participants because of the elevated suicide risk may reduce generalizability within clinical settings; and (3) app regulation and definition: the lack of a standardized classification system for mHealth intervention type points to the need for better definition of the scope of such technologies to promote safe practice.

TRIAL REGISTRATION

PROSPERO CRD42017072899; https://www.crd.york.ac.uk/prospero/display_record.php?RecordID=72899.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

RR2-10.2196/resprot.8635.

Use of ecological momentary assessment to detect variability in mood, sleep and stress in bipolar disorder

Objective

Our aim was to study within-person variability in mood, cognition, energy, and impulsivity measured in an Ecological Momentary Assessment paradigm in bipolar disorder by using modern statistical techniques. Exploratory analyses tested the relationship between bipolar disorder symptoms and hours of sleep, and levels of pain, social and task-based stress. We report an analysis of data from a two-arm, parallel group study (bipolar disorder group N = 10 and healthy control group N = 10, with 70% completion rate of 14-day surveys). Surveys of bipolar disorder symptoms, social stressors and sleep hours were completed on a smartphone at unexpected times in an Ecological Momentary Assessment paradigm twice a day. Multi-level models adjusted for potential subject heterogeneity were adopted to test the difference between the bipolar disorder and health control groups.

Results

Within-person variability of mood, energy, speed of thoughts, impulsivity, pain and perception of skill of tasks was significantly higher in the bipolar disorder group compared to health controls. Elevated bipolar disorder symptom domains in the evening were associated with reduced sleep time that night. Stressors were associated with worsening of bipolar disorder symptoms. Detection of symptoms when an individual is experiencing difficulty allows personalized, focused interventions.

Electronic Ecological Momentary Assessment (EMA) in youth with bipolar disorder: Demographic and clinical predictors of electronic EMA adherence

BACKGROUND

Ecological momentary assessment (EMA) is increasingly used to characterize patients' daily lives, monitor mood, and test efficacy of treatment interventions. However, few studies have examined patient characteristics impacting adherence with EMA protocols, and to our knowledge, no such study has been conducted in youth with bipolar disorder (BD).

METHODS

As part of a larger observational study, 14- to 21-year-olds diagnosed with BD, and who were between episodes of illness (n = 39, 19.0 ± 2.05 Mean ± Standard Deviation years old, 74.4% female) and psychiatrically healthy controls (n = 47, 18.3 ± 2.40 years old, 66.0% female) completed baseline diagnostic and symptom severity interviews, and were instructed to complete diary assessments of mood, sleep, and behavior electronically three times per day for 21 consecutive days (i.e., in total 5418 (or 63 per person) diary entries). Multiple regression was used to examine effects of BD participants' demographic and clinical characteristics on diary completion rates.

RESULTS

53.8 ± 9.3 diary entries per person were actually completed. Adherence rates were high (87.5% of healthy controls and 80.4% of adolescents with BD), but were still significantly poorer in youth with BD. Adequate adherence (≥80%) rates were also significantly poorer in youth with BD relative to healthy controls (56.4% versus 83.0%). Among youth with BD, more lifetime suicide attempts and higher current mood elevation symptom severity predicted significantly poorer adherence.

LIMITATIONS

Limited sample size/generalizability.

CONCLUSIONS

Findings highlight the importance of considering the impact of patient characteristics on adherence with EMA protocols among youth with severe mental illness.

Directionality of change in obsessive compulsive disorder (OCD) and suicidal ideation over six years in a naturalistic clinical sample✰

BACKGROUND

Obsessive compulsive disorder (OCD) is associated with elevated suicide risk, but the directionality of the association between OCD severity and suicidal ideation has not been established, which was the goal of this study.

METHODS

Participants (n = 325) were adults with either a current or past diagnosis of Diagnostic and Statistical Manual of Mental Disorders, 4th Edition (DSM-IV) OCD who were assessed annually for suicidal ideation and OCD symptom severity for six years. Cross-lagged panel analyses statistically compared unidirectional and bidirectional models over time. Serious suicide-related adverse events were reported.

RESULTS

The best-fitting and most parsimonious model included paths predicting suicidal ideation from OCD symptom severity, but not vice versa. These results were confirmed by comparing a model with cross-lagged paths constrained equal to a freely estimated model. Higher OCD symptom severity in a given year was associated with a higher suicidal ideation severity in the subsequent year. Five suicide-related adverse events were reported throughout the duration of the study, including two suicide deaths and three suicide attempts.

LIMITATIONS

The study relied on a single-item, annual measure of suicidal ideation in adults, with substantial variability in severity of suicide risk, and missing data increased with later observations in the study.

DISCUSSION

OCD symptom severity predicted next year suicidal ideation severity. In contrast, suicidal ideation severity in a given year did not predict next-year OCD symptom severity in this OCD sample. Thus, rather than waiting for suicidal ideation to resolve, clinicians should consider providing empirically supported treatments for OCD.

Ecological assessment of daily suicidal thoughts and attempts among suicidal teens after psychiatric hospitalization: Lessons about feasibility and acceptability

Despite its potential to yield information about the dynamic course of suicidal ideation/behavior in individuals' natural environment, Ecological Momentary Assessment (EMA) has been strikingly underutilized among suicidal teens. This study reports on feasibility and acceptability of ecological assessment of daily suicide risk-related outcomes ("daily diaries," a special case of EMA) among adolescent inpatients in the critical post-discharge period. Thirty-four adolescents (76% female; ages 13-17) responded to daily electronic surveys for four weeks after discharge. Survey adherence was 69% (n = 650 days) and decreased each week. Adherence was half as likely among adolescents without attempt history (OR = 0.50, CI = 0.27-0.95). Mid- and end-point study responses indicated high acceptability of daily diaries. Most adolescents reported no change or more positive change in their thoughts/mood after daily surveys. Suicidal ideation was reported on 24.4% (n = 159) of the days. In the month post discharge, more teens reported suicidal thoughts using daily surveys (70.6%) compared to end-of-study assessment (45.2%) (Chi-square = 4.24, p = .039). Two participants (5.9%) reported an attempt. Ideation frequency and duration varied across time, suggesting utility of frequent assessments in this context. EMA data collection with high-risk adolescents offers a feasible approach to examining real-time suicidal ideation/behavior, yielding nuanced information that is critical to advancing suicide prevention efforts.

Smartphones, Sensors, and Machine Learning to Advance Real-Time Prediction and Interventions for Suicide Prevention: a Review of Current Progress and Next Steps

PURPOSE OF REVIEW

As rates of suicide continue to rise, there is urgent need for innovative approaches to better understand, predict, and care for those at high risk of suicide. Numerous mobile and sensor technology solutions have already been proposed, are in development, or are already available today. This review seeks to assess their clinical evidence and help the reader understand the current state of the field.

RECENT FINDINGS

Advances in smartphone sensing, machine learning methods, and mobile apps directed towards reducing suicide offer promising evidence; however, most of these innovative approaches are still nascent. Further replication and validation of preliminary results is needed. Whereas numerous promising mobile and sensor technology based solutions for real time understanding, predicting, and caring for those at highest risk of suicide are being studied today, their clinical utility remains largely unproven. However, given both the rapid pace and vast scale of current research efforts, we expect clinicians will soon see useful and impactful digital tools for this space within the next 2 to 5 years.

A longitudinal investigation of the Concise Health Risk Tracking Self-Report (CHRT-SR) in suicidal patients during and after hospitalization

The Concise Health Risk Tracking Self-Report (CHRT-SR) scale is a brief self-report instrument to assess suicide risk. Initial investigations have indicated good psychometric properties in psychiatric outpatients. The aims of this paper were to examine the construct validity and factor structure of the twelve- (CHRT-SR12) and seven-item (CHRT-SR7) versions and to test if clinically expected within-person changes in suicide risk over time were measurable using the CHRT-SR in two study cohorts hospitalized for suicidal ideation or behavior: (1) patients with major depressive disorder (MDD) who participated in a psychological intervention trial, n = 65, and (2) participants with bipolar disorder or MDD in an observational study, n = 44. The CHRT-SR12 and self-report measures of hopelessness, depression, and positive psychological states were administered during admission and several times post-discharge. Both versions showed good internal consistency in inpatients and confirmed the three-factor structure (i.e., hopelessness, perceived lack of social support and active suicidal ideation and plans) found in outpatients. CHRT-SR scores had strong correlations with negative and positive affective constructs in the expected directions, and indicated decreases in suicide risk following discharge, in line with clinical expectations. The CHRT-SR12 and CHRT-SR7 are promising self-report measures for assessing suicide risk in very high-risk patient populations.

Mobile Health Technology Interventions for Suicide Prevention: Protocol for a Systematic Review and Meta-Analysis

BACKGROUND

Previous research has reported that two of the major barriers to help-seeking for individuals at risk of suicide are stigma and geographical isolation. Mobile technology offers a potential means of delivering evidence-based interventions with greater specificity to the individual, and at the time that it is needed. Despite documented motivation by at-risk individuals to use mobile technology to track mental health and to support psychological interventions, there is a shortfall of outcomes data on the efficacy of mobile health (mHealth) technology on suicide-specific outcomes.

OBJECTIVE

The objective of this study is to develop a protocol for a systematic review and meta-analysis that aims to evaluate the effectiveness of mobile technology-based interventions for suicide prevention.

METHODS

The search includes the Cochrane Central Register of Controlled Trials (CENTRAL: The Cochrane Library), MEDLINE, Embase, PsycINFO, CRESP and relevant sources of gray literature. Studies that have evaluated psychological or nonpsychological interventions delivered via mobile computing and communication technology, and have suicidality as an outcome measure will be included. Two authors will independently extract data and assess the study suitability in accordance with the Cochrane Collaboration Risk of Bias Tool. Studies will be included if they measure at least one suicide outcome variable (ie, suicidal ideation, suicidal intent, nonsuicidal self-injurious behavior, suicidal behavior). Secondary outcomes will be measures of symptoms of depression. Where studies are sufficiently homogenous and reported outcomes are amenable for pooled synthesis, meta-analysis will be performed. A narrative synthesis will be conducted if the data is unsuitable for a meta-analysis.

RESULTS

The review is in progress, with findings expected by summer 2018.

CONCLUSIONS

To date, evaluations of mobile technology-based interventions in suicide prevention have focused on evaluating content as opposed to efficacy. Indeed, previous research has identified mobile applications that appear to present harmful content. The current review will address a gap in the literature by evaluating the efficacy of stand-alone mobile technology tools in suicide prevention. It is imperative that research identifies the evidence base for such tools in suicide prevention in order to inform policy, guide clinical practice, inform users and focus future research.

TRIAL REGISTRATION

PROSPERO International Prospective Register of Systematic Reviews CRD42017072899; https:// www.crd.york.ac.uk/prospero/display_record.asp?ID=CRD42017072899  (Archived by WebCite at http://www.webcitation.org/ 6tZAj0yqJ).

Trajectories of suicidal ideation over 6 months among 482 outpatients with bipolar disorder

INTRODUCTION

Suicidal ideation occurs frequently among individuals with bipolar disorder; however, its course and persistence over time remains unclear. We aimed to investigate 6-months trajectories of suicidal ideation among adults with bipolar disorder.

METHODS

The Bipolar CHOICE study randomized 482 outpatients with bipolar disorder to 6 months of lithium- or quetiapine-based treatment including other psychotropic medications as clinically indicated. Participants were asked at 9 visits about suicidal ideation using the Concise Health Risk Tracking scale. We performed latent Growth Mixture Modelling analysis to empirically identify trajectories of suicidal ideation. Multinomial logistic regression analyses were applied to estimate associations between trajectories and potential predictors.

RESULTS

We identified four distinct trajectories. The Moderate-Stable group represented 11.1% and was characterized by constant suicidal ideation. The Moderate-Unstable group included 2.9% with persistent thoughts about suicide with a more fluctuating course. The third (Persistent-low, 20.8%) and fourth group (Persistent-very-low, 65.1%) were characterized by low levels of suicidal ideation. Higher depression scores and previous suicide attempts (non-significant trend) predicted membership of the Moderate-Stable group, whereas randomized treatment did not.

LIMITATIONS

No specific treatments against suicidal ideation were included and suicidal thoughts may persist for several years.

CONCLUSION

More than one in ten adult outpatients with bipolar disorder had moderately increased suicidal ideation throughout 6 months of pharmacotherapy. The identified predictors may help clinicians to identify those with additional need for treatment against suicidal thoughts and future studies need to investigate whether targeted treatment (pharmacological and non-pharmacological) may improve the course of persistent suicidal ideation.

Technology to assess and support self-management in serious mental illness

The functional impairment associated with serious mental illness (SMI) places an immense burden on individuals and society, and disability often persists even after efficacious treatment of psychopathologic symptoms. Traditional methods of measuring functioning have limitations, and numerous obstacles reduce the reach and impact of evidence-based interventions developed to improve functioning in SMI. This review describes the potential of technological innovations for overcoming the challenges involved in both functional assessment and intervention in people with SMI. Ecological momentary assessment (EMA), which involves the repeated sampling of naturalistic behaviors and experiences while individuals carry out their daily lives, has provided a new window through which the determinants of day-to-day function in SMI can be observed. EMA has several advantages over traditional assessment methods and has in recent years evolved to use mobile-based platforms, such as text messaging and smartphone applications, for both assessment and promotion of self-management in people with SMI. We will review promising data regarding the acceptability, adherence, and efficacy of EMA-based mobile technologies; explore ways in which these technologies can extend the reach and impact of evidence-based psychosocial rehabilitative interventions in SMI; and outline future directions for research in this important area.

Predictors of daily life suicidal ideation in adults recently discharged after a serious suicide attempt: A pilot study

The aims of the study are to examine the predictive role of fluctuations in daily life mood, social contexts, and behavior on subsequent suicidal ideation (SI); and to identify clinical and psychological factors associated with the general frequency of SI in a high-risk sample. The sample comprised 42 adults (73.8% female) hospitalized for a suicide attempt. Immediately following hospital discharge, they used Ecological Momentary Assessment for seven consecutive days, providing repeated measures of SI, environmental, contextual, and behavioral factors. Controlling for prior SI, a number of contextual variables were associated with subsequent SI. Being at home or at work were both associated with an increased probability of SI, while being in the home of close others, or in a festive or leisure environment decreased SI probability. Working, passive leisure and inactivity all increased the likelihood of SI. Being alone increased SI while being with close others significantly reduced this risk. Finally, no overall effect for stressful events was found but negative family events specifically were associated with increased likelihood of SI (γ = 0.448, t = 2.255, df = 29, p < 0.05). The findings provide preliminary results regarding proximal environmental and behavioral factors associated with the occurrence of suicidal ideation in a high-risk sample.

Advances in mobile mental health: opportunities and implications for the spectrum of e-mental health services

Mobile health (mHealth), telemedicine and other technology-based services facilitate mental health service delivery and may be considered part of an e-mental health (eMH) spectrum of care. Web- and Internet-based resources provide a great opportunity for the public, patients, healthcare providers and others to improve wellness, practice prevention and reduce suffering from illnesses. Mobile apps offer portability for access anytime/anywhere, are inexpensive versus traditional desktop computers, and have additional features (e.g., context-aware interventions and sensors with real-time feedback. This paper discusses mobile mental health (mMH) options, as part of a broader framework of eMH options. The evidence-based literature shows that many people have an openness to technology as a way to help themselves, change behaviors and engage additional clinical services. Studies show that traditional video-based synchronous telepsychiatry (TP) is as good as in-person service, but mHealth outcomes have been rarely, directly compared to in-person and other eMH care options. Similarly, technology options added to in-person care or combined with others have not been evaluated nor linked with specific goals and desired outcomes. Skills and competencies for clinicians are needed for mHealth, social media and other new technologies in the eMH spectrum, in addition to research by randomized trials and study of health service delivery models with an emphasis on effectiveness.

Objectively Assessed Sleep Variability as an Acute Warning Sign of Suicidal Ideation in a Longitudinal Evaluation of Young Adults at High Suicide Risk

OBJECTIVE

Young adults attempt suicide at disproportionately high rates relative to other groups and demonstrate high rates of sleep disturbance. No study has yet prospectively evaluated disturbed sleep as an acute indicator of risk using an objective index of sleep. We investigated objective and subjective parameters of disturbed sleep as a warning sign of suicidal ideation among young adults over an acute period.

METHODS

A longitudinal study across a 21-day observation period and 3 time points. Fifty of 4,847 participants (aged 18-23 years) were prescreened from a university undergraduate research pool (February 2007-June 2008) on the basis of suicide attempt history and recent suicidal ideation. Actigraphic and subjective sleep parameters were evaluated as acute predictors of suicidal ideation (Beck Scale for Suicide Ideation), with adjustment for baseline symptoms. Hierarchical regression analyses were employed to predict residual change scores.

RESULTS

Ninety-six percent of participants (n = 48) endorsed a suicide attempt history. Mean actigraphy values revealed objectively disturbed sleep parameters; 78% (n = 39) and 36% (n = 18) endorsed clinically significant insomnia and nightmares, respectively. When results were controlled for baseline suicidal and depressive symptoms, actigraphic and subjective sleep parameters predicted suicidal ideation residual change scores at 7- and 21-day follow-ups (P < .001). Specifically, actigraphy-defined variability in sleep timing, insomnia, and nightmares predicted increases in suicidal ideation (P < .05). In a test of competing risk factors, sleep variability outperformed depressive symptoms in the longitudinal prediction of suicidal ideation across time points (P < .05).

CONCLUSIONS

Objectively and subjectively measured sleep disturbances predicted acute suicidal ideation increases in this population, independent of depressed mood. Self-reported insomnia and nightmares and actigraphically assessed sleep variability emerged as acute warning signs of suicidal ideation. These findings highlight the potential utility of sleep as a proposed biomarker of suicide risk and a therapeutic target.

Negative Emotions and Suicidal Ideation during Psychosocial Treatments in Older Adults with Major Depression and Cognitive Impairment

OBJECTIVE

To examine the relationship of negative emotions with suicidal ideation during 12 weeks of Problem Adaptation Therapy (PATH) versus Supportive Therapy of Cognitively Impaired Older Adults (ST-CI), hypothesizing that improved negative emotions are associated with reduced suicidal ideation, PATH improves negative emotions more than ST-CI, and improved negative emotions, rather than other depression symptoms, predict reduction in suicidal ideation.

METHODS

In a randomized controlled trial of two home-delivered psychosocial interventions, 74 older participants (65-95 years old) with major depressive disorder and cognitive impairment were recruited in collaboration with community agencies. The sample reported less intense feelings than suicidal intention. Interventions and assessments were conducted in participants' homes. PATH focuses on improving emotion regulation, whereas ST-CI focuses on nonspecific therapeutic factors, such as understanding and empathy. Improved negative emotions were measured as improvement in Montgomery Asberg's Depression Rating Scales' (MADRS) observer ratings of sadness, anxiety, guilt, hopelessness, and anhedonia. Suicidal ideation was assessed with the MADRS Suicide Item.

RESULTS

MADRS Negative Emotions scores were significantly associated with suicidal ideation during the course of treatment (F_[1,165] = 12.73, p = 0.0005). PATH participants had significantly greater improvement in MADRS emotions than ST-CI participants (treatment group by time: F_[1,63.2] = 7.02, p = 0.0102). Finally, improved negative emotions, between lagged and follow-up interview, significantly predicted reduction in suicidal ideation at follow-up interview (F_{[1, 96]} = 9.95, p = 0.0022).

CONCLUSION

Findings thatimprovement in negative emotions mediates reduction in suicidal ideation may guide the development of psychosocial interventions for reduction of suicidal ideation (clinicaltrials.gov; NCT00368940).

Tracking post-trauma psychopathology using mobile applications: A usability study

Trauma exposure markedly increases risk for psychopathology including posttraumatic stress disorder (PTSD). Understanding the course by which PTSD develops after a traumatic event is critical to enhancing early intervention. Although prior work has explored the course of PTSD symptoms in the subsequent months, relatively few studies have explored the course of symptoms in the acute post-trauma period, defined as the 30 days after a traumatic event. A key challenge to conducting such studies is the lack of efficient means to collect data that does not impose significant burden on the participant during this time. The present study evaluated the use of a mobile phone application to collect symptom data during the acute post trauma period. Data was obtained from 23 individuals who experienced a Criterion A traumatic event and were recruited from the Emergency Department of a Level 1 Trauma Center. Participants completed 44.93% of daily assessments across a 30-day period. Responses rates were uncorrelated with PTSD symptoms or depression symptoms at 1-month and 3-month posttrauma. Participants reported that the surveys were moderately helpful and posed minimal burden. These findings suggest that mobile applications can be used to learn about the course of post-trauma recovery.

Prediction of near-term increases in suicidal ideation in recently depressed patients with bipolar II disorder using intensive longitudinal data

BACKGROUND

There are substantial gaps in understanding near-term precursors of suicidal ideation in bipolar II disorder. We evaluated whether repeated patient-reported mood and energy ratings predicted subsequent near-term increases in suicide ideation.

METHODS

Secondary data were used from 86 depressed adults with bipolar II disorder enrolled in one of 3 clinical trials evaluating Interpersonal and Social Rhythm Therapy and/or pharmacotherapy as treatments for depression. Twenty weeks of daily mood and energy ratings and weekly Hamilton Depression Rating Scale (HDRS) were obtained. Penalized regression was used to model trajectories of daily mood and energy ratings in the 3 week window prior to HDRS Suicide Item ratings.

RESULTS

Participants completed an average of 68.6 (sd=52) days of mood and energy ratings. Aggregated across the sample, 22% of the 1675 HDRS Suicide Item ratings were non-zero, indicating presence of at least some suicidal thoughts. A cross-validated model with longitudinal ratings of energy and depressed mood within the three weeks prior to HDRS ratings resulted in an AUC of 0.91 for HDRS Suicide item >2, accounting for twice the variation when compared to baseline HDRS ratings. Energy, both at low and high levels, was an earlier predictor than mood.

LIMITATIONS

Data derived from a heterogeneous treated sample may not generalize to naturalistic samples. Identified suicidal behavior was absent from the sample so it could not be predicted.

CONCLUSIONS

Prediction models coupled with intensively gathered longitudinal data may shed light on the dynamic course of near-term risk factors for suicidal ideation in bipolar II disorder.

Rationale and protocol for using a smartphone application to study autism spectrum disorders: SMARTAUTISM

INTRODUCTION

Longitudinal studies on the evolution of autism spectrum disorder (ASD) symptoms are limited and have primarily used repeated measurements performed several months apart. However, measurements of changes in everyday life should more closely reflect the 'real life' of the patient and his or her family. We propose to study the child's ASD symptoms and their effect on the quality of life, psychological status and anxiety of the child's parents over a 6-month period using SMARTAUTISM, a smartphone application.

METHOD AND ANALYSIS

This is a prospective, longitudinal, exploratory, open study with a 6-month follow-up period. Data will be recorded longitudinally over multiple weeks under natural conditions. The factors affecting the quality of life and anxiety of parents of children with ASD and the children's functional symptoms will be examined, and the feasibility of using a smartphone application designed for parents of ASD patients will be assessed.

PRIMARY OBJECTIVE

Explore the evolution of a child's behaviour over 6 months and the (psychological and social) effects of these changes on the family.

SECONDARY OBJECTIVE

Assess the feasibility of our application by examining the filling rate and application usage by parents for 6 months. 100 families containing 1 child diagnosed with ASD will be included. At baseline, sociodemographic, psychiatric and medical data will be recorded. The correlations of the general epidemiological variables (primary outcome measure) will be evaluated via multivariate analysis. The application filling rate (relative to the ideal filling rate) will be used to assess the feasibility of the application (secondary outcome measure).

ETHICS AND DISSEMINATION

The SMARTAUTISM study has the approval of the local ethics committee, and data security will be ensured via the use of encryption and a secure medical server. The use of this application will be proposed at autism resource centres across France.

Technology-Based Early Warning Systems for Bipolar Disorder: A Conceptual Framework

Recognition and timely action around "warning signs" of illness exacerbation is central to the self-management of bipolar disorder. Due to its heterogeneity and fluctuating course, passive and active mobile technologies have been increasingly evaluated as adjunctive or standalone tools to predict and prevent risk of worsening of course in bipolar disorder. As predictive analytics approaches to big data from mobile health (mHealth) applications and ancillary sensors advance, it is likely that early warning systems will increasingly become available to patients. Such systems could reduce the amount of time spent experiencing symptoms and diminish the immense disability experienced by people with bipolar disorder. However, in addition to the challenges in validating such systems, we argue that early warning systems may not be without harms. Probabilistic warnings may be delivered to individuals who may not be able to interpret the warning, have limited information about what behaviors to change, or are unprepared to or cannot feasibly act due to time or logistic constraints. We propose five essential elements for early warning systems and provide a conceptual framework for designing, incorporating stakeholder input, and validating early warning systems for bipolar disorder with a focus on pragmatic considerations.

Considerations in the Use of Interactive Voice Recording for the Temporal Assessment of Suicidal Ideation and Alcohol Use

Abstract. Background: A greater understanding of the temporal variation of suicidal ideation and suicidal behavior is needed to inform more effective prevention efforts. Interactive voice recording (IVR) allows for the study of temporal relationships that cannot be captured with most traditional methodologies. Aims: To examine the feasibility of implementing IVR for the assessment of suicidal ideation. Method: Participants (n = 4) receiving a brief intervention based on dialectical behavior therapy were asked to respond to three phone-based surveys each day over 6 weeks that assessed suicidal ideation and alcohol consumption. Results: Participants completed 77.7% of daily assessments, reported that calls were not burdensome, and indicated that calls were sometimes helpful in interrupting suicidal ideation. Conclusion: The preliminary data reported here provide optimism for the use of IVR and other forms of ecological momentary assessment in the exploration of the antecedents of suicidal behavior.

Psychoeducation in bipolar disorder with a SIMPLe smartphone application: Feasibility, acceptability and satisfaction

BACKGROUND

During the last fifteen years, the possibility of delivering psychoeducation programs through Internet-based platforms have been explored. Studies evaluating those programs have shown good to acceptable retention rates. In this context, we developed a smartphone application (SIMPLe) collecting information about mood symptoms and offering personalized psychoeducation messages. The main aims of this study were to evaluate the feasibility, acceptability and satisfaction of the smartphone application.

METHODS

The study was conducted from March to August 2015. Participation in the study was proposed to a consecutive sample of adult patients attending an outpatient mental health clinic. Sociodemographic data, clinical and functional assessments alongside smartphone ownership and uses were collected at baseline and at 3 months' follow-up. A 5 item Likert-scale satisfaction questionnaire was also employed.

RESULTS

51 participants were initially enrolled in the study, 36 (74%) remained actively using the application after 3 months. The whole sample interacted with the application a mean of 77 days (SD=26.2). During these days they completed 88% of the daily tests. Over 86% of the participants agreed that the experience using the application was satisfactory.

LIMITATIONS

The diversity of smartphones operating systems led to a moderate, although representative, sample number. Additionally, the subjective data reporting, narrow time frame of use and stability of the patients could have affected the results.

CONCLUSIONS

The results confirm that this particular intervention is feasible and represent a satisfactory and acceptable instrument for the self-management of bipolar disorder as an add-on to the usual treatment but future clinical trials must still probe its efficacy.

Real-Time Monitoring of Non-linear Suicidal Dynamics: Methodology and a Demonstrative Case Report

In recent years, a number of different authors have stressed the usefulness of non-linear dynamic systems approach in suicide research and suicide prevention. This approach applies specific methods of time series analysis and, consequently, it requires a continuous and fine-meshed assessment of the processes under consideration. The technical means for this kind of process assessment and process analysis are now available. This paper outlines how suicidal dynamics can be monitored in high-risk patients by an Internet-based application for continuous self-assessment with integrated tools of non-linear time series analysis: the Synergetic Navigation System. This procedure is illustrated by data from a patient who attempted suicide at the end of a 90-day monitoring period. Additionally, future research topics and clinical applications of a non-linear dynamic systems approach in suicidology are discussed.

Daily mood monitoring of symptoms using smartphones in bipolar disorder: A pilot study assessing the feasibility of ecological momentary assessment

BACKGROUND

Personal device technology has facilitated gathering data in real-time using Ecological momentary assessment (EMA). We hypothesized that using smartphones to measure symptoms in auto-generated surveys twice a day would be feasible in a group with bipolar disorder (BD). A second exploratory objective of this study was to compare potential differences in core symptoms between BD and healthy control (HC) groups.

METHODS

A two-arm, parallel group, observational study was designed to measure completion rates of surveys of symptoms of mood, energy, speed of thought, impulsivity, and social stress in BD (N=10) and HC (N=10) participants. The surveys were auto-generated twice a day for fourteen days, and subjects could also perform self-generated surveys. Completion rates were compared between BD and HC groups. Scores were averaged for each participant over the 14 day period, and group medians were compared.

RESULTS

Median completion rates did not differ between groups: 95% in BD, 88% in HC (p=0.68); the median completion rate of auto-generated surveys in the BD group was 79% and in the HC group was 71% (p=0.22). The BD group had significantly lower median mood score (p=0.043) and energy score (p=0.007) than the HC group. Median scores of speed of thoughts (p=0.739), impulsivity (p=0.123) and social stress (p=0.056) did not significantly differ between BD and HC. The BD group had significantly higher range of variability of group median mood (p=0.043), speed of thoughts (p=0.002) and impulsivity (p=0.005) scores over the course of 14 days than HC, while range of variability of energy (p=0.218) and social stress (p=0.123) scores did not differ. Results were not significantly different between auto-generated and self-generated surveys for BD or HC.

LIMITATIONS

This pilot study was conducted for a short time and with a small sample.

CONCLUSIONS

This study demonstrates feasibility of using EMA with a smartphone to gather data on BD symptoms.

A clinical measure of suicidal ideation, suicidal behavior, and associated symptoms in bipolar disorder: Psychometric properties of the Concise Health Risk Tracking Self-Report (CHRT-SR)

OBJECTIVE

People with bipolar disorder are at high risk of suicide, but no clinically useful scale has been validated in this population. The aim of this study was to evaluate the psychometric properties in bipolar disorder of the 7- and 12-item versions of the Concise Health Risk Tracking Self-Report (CHRT-SR), a scale measuring suicidal ideation, suicidal behavior, and associated symptoms.

METHODS

The CHRT was administered to 283 symptomatic outpatients with bipolar I or II disorder who were randomized to receive lithium plus optimized personalized treatment (OPT), or OPT without lithium in a six month longitudinal comparative effectiveness trial. Participants were assessed using structured diagnostic interviews, clinician-rated assessments, and self-report questionnaires.

RESULTS

The internal consistency (Cronbach α) was 0.80 for the 7-item CHRT-SR and 0.90 for the 12-item CHRT-SR with a consistent factor structure, and three independent factors (current suicidal thoughts and plans, hopelessness, and perceived lack of social support) for the 7-item version. CHRT-SR scores are correlated with measures of depression, functioning, and quality of life, but not with mania scores.

CONCLUSIONS

The 7- and 12-item CHRT-SR both had excellent psychometric properties in a sample of symptomatic subjects with bipolar disorder. The scale is highly correlated with depression, functioning, and quality of life, but not with mania. Future research is needed to determine whether the CHRT-SR will be able to predict suicide attempts in clinical practice.

Ecological momentary assessment (EMA) of depression-related phenomena

Ecological momentary assessment (EMA) is one research method increasingly employed to better understand the processes that underpin depression and related phenomena. In particular, EMA is well suited to the study of affect (e.g., positive and negative affect), affective responses to stress (e.g., emotion reactivity), and behaviors (e.g., activity level, sleep) that are associated with depression. Additionally, EMA can provide insights into self-harm behavior (i.e. suicide and non-suicidal self-injury), and other mood disorders (e.g. bipolar disorder) commonly associated with depressive episodes. Given the increasing availability and affordability of handheld computing devices such as smartphones, EMA is likely to play an increasingly important role in the study of depression and related phenomena in the future.

Augmenting psychoeducation with a mobile intervention for bipolar disorder: a randomized controlled trial

BACKGROUND

Psychosocial interventions for bipolar disorder are frequently unavailable and resource intensive. Mobile technology may improve access to evidence-based interventions and may increase their efficacy. We evaluated the feasibility, acceptability and efficacy of an augmentative mobile ecological momentary intervention targeting self-management of mood symptoms.

METHODS

This was a randomized single-blind controlled trial with 82 consumers diagnosed with bipolar disorder who completed a four-session psychoeducational intervention and were assigned to 10 weeks of either: 1) mobile device delivered interactive intervention linking patient-reported mood states with personalized self-management strategies, or 2) paper-and-pencil mood monitoring. Participants were assessed at baseline, 6 weeks (mid-point), 12 weeks (post-treatment), and 24 weeks (follow up) with clinician-rated depression and mania scales and self-reported functioning.

RESULTS

Retention at 12 weeks was 93% and both conditions were associated with high satisfaction. Compared to the paper-and-pencil condition, participants in the augmented mobile intervention condition showed significantly greater reductions in depressive symptoms at 6 and 12 weeks (Cohen׳s d for both were d=0.48). However, these effects were not maintained at 24-weeks follow up. Conditions did not differ significantly in the impact on manic symptoms or functional impairment.

LIMITATIONS

This was not a definitive trial and was not powered to detect moderators and mediators.

CONCLUSIONS

Automated mobile-phone intervention is feasible, acceptable, and may enhance the impact of brief psychoeducation on depressive symptoms in bipolar disorder. However, sustainment of gains from symptom self-management mobile interventions, once stopped, may be limited.