Examining the predictive utility of suicidal ideation characteristics in relation to real-time monitoring of suicidal ideation and suicide attempts at follow-up.

INTRODUCTION: Several characteristics of suicidal ideation, including frequency, duration, perceived controllability, and intensity, have been identified. The present study examined whether these characteristics of baseline suicidal ideation uniquely predicted (1) the severity, variability, and frequency of suicidal ideation assessed through real-time monitoring; and (2) suicide attempts at 3-week and 6-month follow-up among recently discharged psychiatric inpatients. METHODS: A sample of 249 adults (Mage = 40.43, 55.1% female, 91.4% White) completed a baseline assessment of their suicidal ideation characteristics during psychiatric hospitalization, five daily ecological momentary assessments (EMA) for 21 days following discharge, and follow-up assessments of suicide-related outcomes at 3-week and 6-month follow-up. RESULTS: Perceived controllability of suicidal thoughts was uniquely associated with the variability of EMA-assessed suicidal ideation and the presence of suicide attempts at 3-week, but not 6-month follow-up. No other characteristic of baseline suicidal ideation was uniquely associated with EMA-assessed suicidal ideation or the presence of suicide attempts at follow-up. CONCLUSIONS: Given links between the perceived controllability of suicidal ideation and (1) momentary variability of suicidal ideation and (2) suicide attempts over the subsequent 3 weeks, perceived controllability of suicidal thinking may be a useful marker of short-term risk that may be malleable to clinical intervention.

Daily Levels and Dynamic Metrics of Affective-Cognitive Constructs Associate With Suicidal Thoughts and Behaviours in Adults After Psychiatric Hospitalization.

The period after psychiatric hospitalization is an extraordinarily high-risk period for suicidal thoughts and behaviours (STBs). Affective-cognitive constructs (ACCs) are salient risk factors for STBs, and intensive longitudinal metrics of these constructs may improve personalized risk detection and intervention. However, limited research has examined how within-person daily levels and between-person dynamic metrics of ACCs relate to STBs after hospital discharge. Adult psychiatric inpatients (N = 95) completed a 65-day ecological momentary assessment protocol after discharge as part of a 6-month follow-up period. Using dynamic structural equation models, we examined both within-person daily levels and between-person dynamic metrics (intensity, variability and inertia) of positive and negative affect, rumination, distress intolerance and emotion dysregulation as risk factors for STBs. Within-person lower daily levels of positive affect and higher daily levels of negative affect, rumination, distress intolerance and emotion dysregulation were risk factors for next-day suicidal ideation (SI). Same-day within-person higher rumination and negative affect were also risk factors for same-day SI. At the between-person level, higher overall positive affect was protective against active SI and suicidal behaviour over the 6-month follow-up, while greater variability of rumination and distress intolerance increased risk for active SI, suicidal behaviour and suicide attempt. The present study provides the most comprehensive examination to date of intensive longitudinal metrics of ACCs as risk factors for STBs. Results support the continued use of intensive longitudinal methods to improve STB risk detection. Interventions focusing on rumination and distress intolerance may specifically help to prevent suicidal crises during critical transitions in care.

A Hybrid Type 1 trial of a multi-component mHealth intervention to improve post-hospital transitions of care for patients with serious mental illness: Study protocol.

BACKGROUND: The transition from acute (e.g., psychiatric hospitalization) to outpatient care is associated with increased risk for rehospitalization, treatment disengagement, and suicide among people with serious mental illness (SMI). Mobile interventions (i.e., mHealth) have the potential to increase monitoring and improve coping post-acute care for this population. This protocol paper describes a Hybrid Type 1 effectiveness-implementation study, in which a randomized controlled trial will be conducted to determine the effectiveness of a multi-component mHealth intervention (tFOCUS) for improving outcomes for adults with SMI transitioning from acute to outpatient care. METHODS: Adults meeting criteria for schizophrenia-spectrum or major mood disorders (n = 180) will be recruited from a psychiatric hospital and randomized to treatment-as-usual (TAU) plus standard discharge planning and aftercare (CHECK-IN) or TAU plus tFOCUS. tFOCUS is a 12-week intervention, consisting of: (a) a patient-facing mHealth smartphone app with daily self-assessment prompts and targeted coping strategies; (b) a clinician-facing web dashboard; and, (c) mHealth aftercare advisors, who will conduct brief post-hospital clinical calls with patients (e.g., safety concerns, treatment engagement) and encourage app use. Follow-ups will be conducted at 6-, 12-, and 24-weeks post-discharge to assess primary and secondary outcomes, as well as target mechanisms. We also will assess barriers and facilitators to future implementation of tFOCUS via qualitative interviews of stakeholders and input from a Community Advisory Board throughout the project. CONCLUSIONS: Information gathered during this project, in combination with successful study outcomes, will inform a potential tFOCUS intervention scale-up across a range of psychiatric hospitals and healthcare systems. CLINICALTRIALS: govregistration: NCT05703412.

Emotional change in its "natural habitat": Measuring everyday emotion regulation with passive and active ambulatory assessment methods.

Ambulatory assessment methods have made it possible to study psychological phenomena in real-time, with translational potential for psychotherapy process research. This article uses case example data to demonstrate applications of ambulatory assessment to measuring emotion regulation, a process with relevance across diagnoses and treatment modalities that may be particularly important to measure in situ. Two methods are reviewed: Ecological Momentary Assessment (EMA), which enables self-reported momentary assessments as people go about their days, and the Electronically Activated Recorder (EAR), an unobtrusive naturalistic observation methodology that collects short audio recordings from participants' moment-to-moment environments, capturing an acoustic diary of their social interactions, daily behaviors, and natural daily language use. Using case example data from research applying EMA and EAR methods in the context of adolescent self-injurious thoughts and behaviors, we illustrate how EMA can be used to measure emotion regulation over time and across contexts, and how EAR can assess the behaviors and social-environmental factors that interact with emotion regulation in clinically important ways. We suggest applications of this measurement approach for investigations of clients' emotional change over the course of psychotherapy, as well as potential clinical applications of these methods.

Emotion dysregulation as a mechanism linking posttraumatic stress disorder to subsequent suicidal thoughts and behaviors following inpatient psychiatric discharge.

Posttraumatic stress disorder (PTSD) is a well-known risk factor for suicidal thoughts and behaviors (STBs). However, there is a scarcity of longitudinal studies exploring underlying pathways. This study sought to examine the mechanistic role of emotion dysregulation in the relations between PTSD and STBs following discharge from psychiatric inpatient treatment, a particularly high-risk period for suicide. Participants were 362 trauma-exposed psychiatric inpatients (45% female, 77% white, Mage = 40.37). PTSD was assessed via a clinical interview (Columbia Suicide Severity Rating Scale) during hospitalization, emotion dysregulation was assessed via self-report 3-weeks post-discharge, and STBs were assessed via a clinical interview 6-months post-discharge. St'1ructural equation modeling showed that emotion dysregulation significantly mediated the relation between PTSD and suicidal thoughts (ß = 0.10, SE = 0.04, p = .01, 95%CI [0.04, 0.39]) but not suicide attempts (ß = 0.04, SE = 0.04, p = .29, 95%CI [-0.03, 0.12]) post-discharge. Findings highlight a potential clinical utility of targeting emotion dysregulation among individuals with PTSD to prevent suicidal thoughts following discharge from psychiatric inpatient treatment.

Innovations in Technology and Mechanisms of Change in Behavioral Interventions.

The purpose of this manuscript is to provide an overview of, and rationale for, the increasing adoption of a wide range of cutting-edge technological methods in assessment and intervention which are relevant for treatment. First, we review traditional approaches to measuring and monitoring affect, behavior, and cognition in behavior and cognitive-behavioral therapy. Second, we describe evolving active and passive technology-enabled approaches to behavior assessment including emerging applications of digital phenotyping facilitated through fitness trackers, smartwatches, and social media. Third, we describe ways that these emerging technologies may be used for intervention, focusing on novel applications for the use of technology in intervention efforts. Importantly, though some of the methods and approaches we describe here warrant future testing, many aspects of technology can already be easily incorporated within an established treatment framework.

Daily reciprocal relations between emotion dysregulation and non-suicidal self-injury among individuals with a history of sexual assault: The influence of posttraumatic stress symptoms.

INTRODUCTION: Non-suicidal self-injury (NSSI) is a serious public health concern that can be understood within an emotion dysregulation framework. The current study adds to the literature by utilizing a micro-longitudinal design and novel statistical modeling to test reciprocal associations between emotion dysregulation and NSSI, as well as the potential moderating effect of posttraumatic stress symptoms (PTSS). METHODS: Participants were 81 individuals with a history of sexual assault and NSSI (Mage  = 33.80; 67.9% women; 80.2% white) recruited from the community who self-reported on symptoms of emotion dysregulation and NSSI thoughts/behaviors once daily for 7 days. Average compliance rate was 72.8% (SD = 31.3%) and 34 participants (42.0%) endorsed NSSI thoughts/behaviors over the course of the study. RESULTS: Findings revealed a significant positive effect of NSSI thoughts/behaviors on subsequent abilities to regulate negative emotions. Furthermore, while results did not detect a moderating influence of baseline PTSS on the relation between emotion dysregulation and NSSI thoughts/behaviors over time, individuals with higher baseline PTSS were found to experience heightened levels of NSSI thoughts/behaviors and emotion dysregulation on average. CONCLUSION: Information from this study may be useful for future research and intervention development focused on the intersection of NSSI, PTSS, and emotion dysregulation.

Evaluating Potential Iatrogenic Effects of a Suicide-Focused Research Protocol.

Background: Concerns regarding the potential iatrogenic effects of suicide assessment have long impeded suicide research. Aims: We sought to examine the effects of an intensive, suicide-focused assessment protocol on mood, suicidality, and urges to harm oneself or others. Method: Participants were adults admitted to a psychiatric inpatient unit for recent suicidal ideation or behavior, or reasons unrelated to suicide. Our study protocol included clinical interviews evaluating suicide history and laboratory tasks with suicide-related stimuli. We modified an existing measure to create a brief, 6-item interview, the Assessment Session Check-In, which was administered before and after research procedures. Results: These indicated overall reductions in distress, suicidal intent, and urges to harm oneself or others from preassessment to postassessment. Postassessment reductions in stress predicted lower likelihood of a suicide attempt at follow-up. Limitations: Although beneficial to examine a high-risk sample, it is possible that an intensive suicide-focused protocol could prove more problematic for those with lower baseline levels of negative affect and suicidal thoughts. Conclusions: Results challenge the belief that assessing suicide elevates distress or suicidality, even among a high-risk sample of adults admitted to a psychiatric inpatient unit.

Validation of an emotional stop-signal task to probe individual differences in emotional response inhibition: Relationships with positive and negative urgency.

Performance on an emotional stop-signal task designed to assess emotional response inhibition has been associated with Negative Urgency and psychopathology, particularly self-injurious behaviors. Indeed, difficulty inhibiting prepotent negative responses to aversive stimuli on the emotional stop-signal task (i.e. poor negative emotional response inhibition) partially explains the association between Negative Urgency and non-suicidal self-injury. Here, we combine existing data sets from clinical (hospitalised psychiatric inpatients) and non-clinical (community/student participants) samples aged 18-65 years (N = 450) to examine the psychometric properties of this behavioural task and evaluate hypotheses that emotional stop-signal task metrics relate to distinct impulsive traits among participants who also completed the UPPS-P (n = 223). We specifically predicted associations between worse negative emotional response inhibition (i.e. commission errors during stop-signal trials representing negative reactions to unpleasant images) and Negative Urgency, whereas commission errors to positive stimuli - reflecting worse positive emotional response inhibition - would relate to Positive Urgency. Results support the emotional stop-signal task's convergent and discriminant validity: as hypothesised, poor negative emotional response inhibition was specifically associated with Negative Urgency and no other impulsive traits on the UPPS-P. However, we did not find the hypothesised association between positive emotional response inhibition and Positive Urgency. Correlations between emotional stop-signal task performance and self-report measures were the modest, similar to other behavioural tasks. Participants who completed the emotional stop-signal task twice (n = 61) additionally provide preliminary evidence for test-retest reliability. Together, findings suggest adequate reliability and validity of the emotional stop-signal task to derive candidate behavioural markers of neurocognitive functioning associated with Negative Urgency and psychopathology.

Childhood Maltreatment, Emotional Response Inhibition, and Suicide in Psychiatric Inpatients.

Childhood abuse and/or neglect adversely influences development of neurocognitive systems that regulate affect and behavior. Poor inhibitory control over emotional reactions is thus one potential pathway from maltreatment to suicide. Adult psychiatric inpatients completed the Childhood Trauma Questionnaire and an emotional stop-signal task indexing negative emotional action termination (NEAT): the ability to inhibit ongoing motor reactions to aversive stimuli triggered by negative affect. Clinical interviews assessed suicidal thoughts and behaviors during hospitalization (n = 131) and at follow-up assessments 6 months later (n = 87). Our primary aim was to examine whether maltreatment history and NEAT explain overlapping variance in suicidal behaviors (1) retrospectively and (2) 6 months following hospital discharge. Contrary to prediction, childhood maltreatment was unrelated to history of suicidal behaviors. However, NEAT was consistently associated with prior suicidal acts, even controlling for suicidal ideation and demographic covariates. NEAT similarly contributed to the prediction of post-discharge suicidal behaviors, whereas we found no effect of maltreatment history. The present study suggests that NEAT captures suicide risk independently of childhood maltreatment. Results implicated NEAT impairment specifically, rather than broader response inhibition deficits (e.g., to positive stimuli), in past and future suicidal behaviors. These findings provide preliminary support for NEAT as a behavioral vulnerability marker for suicide, with implications for understanding links between maltreatment history and suicidal acts.

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

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

Translating Interventional Neuroscience to Suicide: It's About Time.

Despite significant advances in psychiatric and psychological treatment over the last 30 years, suicide deaths have increased. Unfortunately, neuroscience insights have yielded few translational interventions that specifically target suicidal thoughts and behaviors. In our view, this is attributable to two factors. The first factor is our limited integration of neurocircuitry models with contemporary suicide theory. The second challenge is inherent to the variable nature of suicide risk over time. Few interventional neuroscience studies evaluate how temporal fluctuations in risk affect treatment, despite evidence that temporality is a key component distinguishing suicide phenotypes. To wit, individual variability in risk trajectories may provide different treatment targets to engage as a patient moves between suicidal ideation and attempt. Here, we first review contemporary ideation-to-action theories of suicide from a neurobiological perspective, focusing on valence and executive function circuits and the key role of state-induced (e.g., within stressful contexts) functional modulation on longitudinal risk trajectories. We then describe neural correlates of suicide reduction following various interventions, ranging from circuit specific (i.e., transcranial magnetic stimulation) to broader pharmacological (i.e., ketamine, lithium) to psychological (i.e., brief cognitive therapy). We then introduce novel strategies for tracking risk in naturalistic settings and real time using ecological momentary interventions. We provide a critical integration of the literature focusing on the intersection between targets and temporality, and we conclude by proposing novel research designs integrating real-time and biologically based interventions to generate novel strategies for future suicide reduction research.

Positive Emotion Dysregulation Identifies Trauma-Exposed Community Individuals at Risk for Suicide and Nonsuicidal Self-Injury.

ABSTRACT: Emotion dysregulation is associated with increased risk for suicidal thoughts and behaviors (STBs) and nonsuicidal self-injury (NSSI). However, research in this area has focused almost exclusively on dysregulation stemming from negative emotions. The present study aimed to address this gap in the literature by examining the associations between the specific domains of positive emotion dysregulation and both STBs and NSSI. Participants included 397 trauma-exposed community adults (Mage = 35.95; 57.7% female; 76.8% White). Results demonstrated significant associations between positive emotion dysregulation and both STBs and NSSI. In particular, higher levels of nonacceptance of positive emotions were found to be significantly related to risk for STBs (versus no risk), higher severity of STBs, and history of NSSI (versus no history). Findings suggest positive emotion dysregulation may play an important role in the etiology and treatment of both STBs and NSSI among trauma-exposed individuals.

Media guidelines for the responsible reporting and depicting of non-suicidal self-injury.

Media coverage of non-suicidal self-injury (NSSI) ranges from providing helpful education to displaying graphic images. We offer the first research-informed, consensus-based guidelines for the responsible reporting and depicting of NSSI in the media, while also advising on ideas for dissemination and collaboration between media professionals and healthcare experts.

Project CHOICE: Choosing healthy options in coping with emotions, an EMA/EMI plus in-person intervention for alcohol use.

Background: Emerging adulthood (18-25 years) represents a risky time for mental health and substance use. Emerging adults are particularly susceptible to problematic patterns of substance use, especially if they experience anxiety and/or depression and use substances as a way to cope with such issues. However, many mental health treatments do not address substance use. We developed an ecological momentary assessment and intervention (EMA/EMI) to specifically target the motive of drinking to cope with anxiety/depression. Methods: Project CHOICE was a 6-week intervention that paired in-person normative feedback with daily EMA and, if an individual reported negative affect and intent to drink, an EMI was immediately sent to their phone (a personally-chosen coping skill). We recruited n = 20 (55% female, mean age 21.74, 85% Caucasian and 75% non-Hispanic/Latino) individuals from a psychiatric partial hospitalization program for a 6-week open trial of the CHOICE intervention and re-assessed at the 6-week follow-up point. Results: Results indicated that drinking variables and coping motives were highly correlated at baseline. Days of drinking, alcohol-related problems, and coping motives significantly decreased over time following the intervention. Results indicated high levels of feasibility and acceptability. Conclusions: This open pilot represents a feasible, acceptable, and promising direction in delivering interventions in the moment when risk is highest, utilizing smartphone capabilities.

The role of emotion dysregulation in the association between posttraumatic stress disorder symptoms and suicidal thoughts and behaviors among veterans.

OBJECTIVE: Although research has established a link between posttraumatic stress disorder (PTSD) symptoms and suicidal thoughts and behaviors (STBs), little is known about factors that may accentuate this relation. This study evaluated the influences of negative and positive emotion dysregulation on the association between PTSD symptoms and STBs among veterans. METHODS: Four-hundred and sixty-five trauma-exposed military veterans in the community (M age = 38.00, 71.4% male, 69.5% White) completed online questionnaires. RESULTS: Negative emotion dysregulation did not moderate the relation between PTSD symptoms and STBs. Results showed significant interactive effects of PTSD symptoms and positive emotion dysregulation on STBs, such that PTSD symptoms were more strongly related to STBs at high (vs. low) levels of positive emotion dysregulation. This effect was sustained across domains of positive emotion dysregulation. CONCLUSIONS: Findings suggest a potential need to consider positive emotion dysregulation in the assessment and treatment of STBs among veterans with PTSD symptoms.

Moderators of treatment response to an intervention for nonsuicidal self-injury in young adults.

Objective: Despite the prevalence and impact of nonsuicidal self-injury (NSSI), there are few treatments developed to treat the behavior specifically, and little is known about moderators of treatment response. The Treatment for Self-Injurious Behaviors (T-SIB), a brief, behavioral intervention, was developed to treat NSSI in young adults; a previous pilot randomized controlled trial (RCT) comparing T-SIB with treatment as usual (TAU) provided support for the intervention. This study examined demographic, clinical, and NSSI-related predictors of treatment outcome in the pilot RCT for T-SIB. Method: Young adults (N = 33) were randomized to receive T-SIB or treatment as usual; all participants were included in intent-to-treat analyses. The primary outcome of NSSI behaviors was assessed at baseline, posttreatment (9 weeks), and 3-month follow up, and potential moderators were assessed at baseline. Results: Greater lifetime and last year NSSI frequency was associated with fewer NSSI behaviors at posttreatment and follow up among participants in T-SIB. Anxious symptoms also moderated treatment outcomes, but other demographic and clinical variables did not. Conclusion: Previous research has shown that T-SIB is more effective than TAU overall; the current study suggests that T-SIB may be effective for individuals with more frequent NSSI and those with elevated anxiety. A larger evaluation of T-SIB is supported. (PsycInfo Database Record (c) 2020 APA, all rights reserved).

Monitoring, assessing, and responding to suicide risk in clinical research.

It is essential that investigators in clinical research settings follow ethical guidelines for monitoring, assessing, and responding to suicide risk. Given the unique considerations associated with suicide risk assessment in a research context, resources informing the development of research-specific suicide risk management procedures are needed. With decades of collective experience across heterogeneous contexts, we discuss approaches to monitoring, assessing, and responding to suicide risk as a function of study sample (e.g., students, psychiatric inpatients), data collection methodologies (e.g., interview, self-report, or ecological momentary assessment), and study design (e.g., treatment research). Additional considerations include training and supervision of staff to identify suicide risk, coordination of others to respond to risk, and documentation of procedures. Finally, we attend to the impact of these procedures on the external validity of outcome data. (PsycINFO Database Record (c) 2019 APA, all rights reserved).

Higher Educational Attainment is Associated with Lower Risk of a Future Suicide Attempt Among Non-Hispanic Whites but not Non-Hispanic Blacks.

PURPOSE: In a sample of patients presenting to the emergency department (ED), the current study was conducted with two aims: (1) to investigate the protective effects of educational attainment (i.e., completing college) on subsequent risk of suicide attempt/death among patients presenting to the ED and (2) to compare this effect between non-Hispanic Black and non-Hispanic White ED patients. METHODS: The current study analyzed data from the Emergency Department Safety Assessment and Follow-Up Evaluation (ED-SAFE) study, a quasi-experimental, eight-center study of universal suicide screening and follow-up of ED patients presenting for suicidal ideation and behavior. Our sample included 937 non-Hispanic White and 211 non-Hispanic Blacks. The dependent variable was suicide attempt/death during the 52-week follow-up. The independent variable was completing college. Age, gender, lesbian/gay/bisexual status, psychiatric history, and previous suicide attempts at baseline were covariates. Race/ethnicity was the focal effect modifier. Logistic regression models were used to test the protective effects of educational attainment on suicide risk in the overall sample and by race/ethnicity. RESULTS: In the overall sample, educational attainment was not associated with suicide risk over the follow-up period. A significant interaction was found between race/ethnicity and educational attainment on suicide risk, suggesting a larger protective effect for non-Hispanic Whites compared with non-Hispanic Blacks. In race/ethnicity-specific models, completing college was associated with decreased future suicide risk for non-Hispanic Whites but not Blacks. CONCLUSIONS: Consistent with the Minorities' Diminished Return theory, educational attainment better protected non-Hispanic White than non-Hispanic Blacks against future suicide attempt/death. While Whites who have not completed college may be at an increased risk of suicide, risk of suicide seems to be independent of educational attainment for non-Hispanic Blacks.