Ecological Assessment of Proximal Risk Factors for Suicide During Care Transitions

Project Summary/Abstract
Suicidal ideation and behavior are growing public health problems in the United States. This is particularly
concerning during the high-risk period following discharge from psychiatric hospitalization when risk for suicide
is among the highest rates observed. Unfortunately, our current ability to predict suicide is only slightly above
chance. This poor predictive ability may be due to an overreliance on distal/cross-sectional suicide risk factors
alone, rather than an emphasis on proximal risk factors (the dynamic cognitive, affective, and behavioral
experiences occurring in the days, hours, and minutes prior to suicide). The proposed study builds upon our
team's existing infrastructure and expertise in digital phenotyping and ecologically valid models of suicide risk.
We will examine how affective (e.g., negative affect) and contextual (e.g., social interactions, cognitions, & sleep
disruption) proximal risk factors interact to influence suicidal ideation and confer risk for suicidal behavior,
particularly during the high-risk period following hospitalization. We will recruit and follow-up with 240 psychiatric
inpatients hospitalized for suicidal ideation or behavior over a five-year study period. Participants will complete
baseline assessments including clinical interviews, laboratory-based behavioral assessments, and self-reports
of distal risk factors associated with suicide. During hospitalization, participants will begin completing ecological
momentary assessments (EMAs) of affect, cognition, behavior, and social/environmental context. Following
discharge, participants will continue EMA monitoring for 4-weeks at baseline and again for two 3-week EMA
“bursts” at 3- and 6-month follow-up assessments. During each EMA monitoring period, we will collect digital
phenotyping data (e.g., sleep, location, activity level/movement) using wearables and smartphone sensors. We
will conduct 3- and 6-month follow-up assessments in our lab to re-administer lab-based behavioral assessments
and collect outcome data including suicidal ideation, suicidal behavior, and re-hospitalization. The proposed
study aims to identify proximal risk factors for suicide and use intensive longitudinal methods to characterize the
relationships among affective and contextual proximal risk factors while also examining how distal risk factors
moderate the relationships among proximal risk factors and between proximal risk factors and suicidal ideation
and behavior. We will examine these relationships both before and after discharge from psychiatric
hospitalization. The results of this study have the potential to substantially enhance our understanding of suicide
phenomenology as it exists in the real world, particularly across the high-risk period following psychiatric
hospitalization, with the potential to improve our ability to predict, prevent, and ultimately treat suicidal thoughts
and behaviors using traditional and technology-enhanced interventions.

Grant Number: 5R01MH128248-04
NIH Institute/Center: NIH
Principal Investigator: Michael Armey