Ecological assessment of daily suicidal thoughts and attempts among suicidal teens after psychiatric hospitalization: lessons about feasibility and acceptability
Open accessAbstract
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.
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Most reviewed studies (78%, n = 18) were conducted in adult samples, and less frequently in adolescent samples (22%, n = 5).
“Most studies (78%, n = 18) were conducted in adult, and less frequently in adolescent samples [22%, n = 5; (45, 67, 72, 80, 85)].”
From Don't Miss the Moment: A Systematic Review of Ecological Momentary Assessment in Suicide Research (2022) · cites this paper as [80]
All reviewed studies included EMA items on suicidal ideation, and four studies (18%) also assessed the occurrence of suicide attempts via EMA.
“While all studies included EMA items on suicidal ideation, four studies (18%) also assessed the occurrence of suicide attempts via EMA (45, 80, 82, 88)”
From Don't Miss the Moment: A Systematic Review of Ecological Momentary Assessment in Suicide Research (2022) · cites this paper as [80]
Studies frequently (57%, n = 13) reported that participants could provide input about their daily schedules, allowing EMA prompt windows to be adjusted for each participant.
“Studies frequently (57%, n = 13; (47, 51, 58, 60, 61, 69, 71, 79–81, 85, 86)) reported that participants could provide input about their daily schedules (incl. sleep and wake times), allowing EMA prompt windows to be adjusted for each participant”
From Don't Miss the Moment: A Systematic Review of Ecological Momentary Assessment in Suicide Research (2022) · cites this paper as [80]
Studies examining day-to-day rather than within-day changes in suicidal ideation were less likely to report positive findings.
“Studies examining day-to-day rather than within-day changes in suicidal ideation were less likely to report positive findings (55, 80).”
From Don't Miss the Moment: A Systematic Review of Ecological Momentary Assessment in Suicide Research (2022) · cites this paper as [80]
In a sample of adolescents assessed after 1 month of EMA, most participants reported no change in mood after filling out EMA (69%) or that they felt better (28%); one participant reported worse mood after completing EMA.
“In a sample of adolescents assessed after 1-month of EMA, most participants reported that they generally felt no change in mood after filling out EMA (69%) or that they felt better (28%); one participant reported that they had worse mood after completing EMA (80).”
From Don't Miss the Moment: A Systematic Review of Ecological Momentary Assessment in Suicide Research (2022) · cites this paper as [80]
In an adolescent sample, suicidal ideation was reported in EMA by 71% of the participants, and in 45% of the interviews post-EMA.
“In an adolescent sample, suicidal ideation was reported in EMA by 71% of the participants, and in 45% of the interviews post-EMA (80).”
From Don't Miss the Moment: A Systematic Review of Ecological Momentary Assessment in Suicide Research (2022) · cites this paper as [80]
In a 4-week study, compliance decreased by twenty percentage points from the first to the fourth week of EMA assessment.
“In a 4-week study, compliance decreased by twenty percentage points from the first to the fourth week of EMA assessment (80).”
From Don't Miss the Moment: A Systematic Review of Ecological Momentary Assessment in Suicide Research (2022) · cites this paper as [80]
Compliance rates declined over time, indicating participant fatigue effects.
“Compliance rates declined over time (i.e., participants exhibited fatigue effects) (80, 84, 85).”
From Don't Miss the Moment: A Systematic Review of Ecological Momentary Assessment in Suicide Research (2022) · cites this paper as [80]
In another study, the EMA software was programmed to send automatic email alerts to the study's on-call clinician if the participant endorsed a suicide attempt or severe ideation with suicidal intent and/or a plan, in which case the clinician made contact; less than 1% of responses met this threshold and required contact.
“In another study, the EMA software was programmed to send out automatic email alerts to the study's on-call clinician if the participant endorsed a suicide attempt or severe ideation with suicidal intent and/or a plan, in which case the clinician made contact with the participant; <1% of the responses recorded met this threshold and required contact by the study personnel (80).”
From Don't Miss the Moment: A Systematic Review of Ecological Momentary Assessment in Suicide Research (2022) · cites this paper as [80]
In general, participants reported their experiences overall as neutral-to-positive but time consuming or burdensome, and that they would be open to participating in similar research in the future.
“In general, participants reported their experiences overall as neutral-to-positive but time consuming (or burdensome), and that they would be open to participating in similar research in the future (80, 84, 85).”
From Don't Miss the Moment: A Systematic Review of Ecological Momentary Assessment in Suicide Research (2022) · cites this paper as [80]
Three reviewed studies employed ongoing monitoring of the participant's responses.
“Three studies employed ongoing monitoring of the participant's responses (45, 72, 80).”
From Don't Miss the Moment: A Systematic Review of Ecological Momentary Assessment in Suicide Research (2022) · cites this paper as [80]
Maintaining compliance with EMA remains a challenge, especially when assessment periods grow long, as compliance decreases over time with each subsequent week of EMA.
“Regardless, maintaining compliance with EMA remains a challenge, especially when assessment periods grow long, as compliance decreases over time with each subsequent week of EMA [see e.g., (80, 85)].”
From Don't Miss the Moment: A Systematic Review of Ecological Momentary Assessment in Suicide Research (2022) · cites this paper as [80]
Using ecological momentary assessment to assess emotion regulation directly in daily life would help clinicians identify strategies to target in therapy and recognize triggers and consequences of maladaptive strategy implementation.
“In turn, this would help clinicians to identify strategies that are to be targeted in the therapeutic process, as well as recognizing triggers and/or consequences of maladaptive strategies implementation on patients’ life (see, for example Anestis et al., 2010; Czyz et al., 2018).”
From New Technologies for the Understanding, Assessment, and Intervention of Emotion Regulation (2019) · cites this paper as Czyz et al., 2018
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- Authors
- Czyz, E. K., King, C. A., & Nahum-Shani, I.
- Affiliations
- University of Michigan (US)
- Corresponding author
- Czyz, E.K.
- Venue
- Psychiatry Research
- Publisher
- Elsevier BV
- Published
- 2018-09
- Volume
- 267
- Pages
- 566-574
- ISSN
- 0165-1781 (ISSN-L)
- PMC
- PMC6857454
- OpenAlex
- W2808809177
- Cited by
- 112
- References
- 56
- Citations by year
- 2026: 12 · 2025: 9 · 2024: 12 · 2023: 17 · 2022: 22 · 2021: 18 · 2020: 11 · 2019: 8 · 2018: 3
- FWCI
- 11.73
- Type
- journal article
- Language
- en
- Open access
- green
- www.ncbi.nlm.nih.gov
- Locations
- Psychiatry Research (publishedVersion)
- PubMed (publishedVersion)
- Europe PMC (PubMed Central) (acceptedVersion)
- PubMed Central (acceptedVersion)
- Funders
- American Foundation for Suicide Prevention
- Michigan Institute for Clinical and Health Research
- University of Michigan
- Topics
- Social Sciences › Psychology › Clinical Psychology › Suicide and Self-Harm Studies
- Social Sciences › Psychology › Experimental and Cognitive Psychology › Mental Health Research Topics
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- Keywords
- ecological momentary assessment, suicidal ideation, suicide attempts, adolescents, psychiatric hospitalization, daily diary, post-discharge follow-up, feasibility and acceptability, suicide prevention, mood changes
- MeSH terms
- Ecological Momentary Assessment, Adolescent, Feasibility Studies, Female, Hospitalization, Hospitals, Psychiatric, Humans, Inpatients, Male, Patient Discharge, Surveys and Questionnaires, Suicide, Attempted, Thinking, Suicidal Ideation
About these checks
Registry, retraction, Cites and statistics results are computed, not judged, with one exception: a printed reference that no index lists is read once by a model before it counts as a citation error. Claims are extracted by a model and kept only when their quote appears verbatim in the text; each cited source is then checked, with a model’s help, for whether it says what the claim relies on. Those verdicts can be wrong — read the claim’s quote and the cited source before relying on one.
Statistics and arithmetic are recomputed, not judged.
Confidence bands are shown only for fields calibrated on our annotated test set. None is calibrated yet, so no band is shown.
What counts as a claim ›How we measure confidence ›How we check this ›
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