How to Prevent Suicidal Behavior: Ecological Momentary Assessment

As of today, suicide is one of the most important public health issues sieging among the top twenty causes of deaths in the world and reaching second place in the 15-29 age group. It leads to more deaths than war, breast cancer or homicide. With one suicide estimated every 40 seconds almost 800 000 people die due to it and for each of them there could be around 20 other attempting suicide. But how to prevent suicidal behavior? The essay will explore a modern way to tackle this urgent issue with the use of Ecological Momentary Assessment (EMA).

Not only does it cost lives but suicide also brings a huge psychological burden to individuals, families, and communities with a far-reaching and devastating effect. Adding to this comes the economic cost of suicides and suicide attempts. Direct costs include the costs of care in the health sectors as well as other public and family-related expenses, while indirect costs measure the loss of productivity to the victim due to suicide or attempted suicide. Among first-world countries the costs often add up to a few billions of dollars while sitting at almost 10 billion euros in France.

How to Prevent/Predict Suicidal Behavior?

To tackle the on-going issue of suicides, prevention seems mandatory. However, prevention requires the acknowledgment of the complexity and numerous factors that lead to suicide or self-harm. Out of the major predictors of death by suicide, the most prominent is a previous attempt, followed by self-harm. Moreover, suicidal ideation is almost always present before a suicide attempt regardless of social and demographic background and has already been demonstrated as a predictor in patients suffering from a depressive disorder. Individually vulnerability factors are multiples, they can be related to past suicidal behavior in the family, different personality traits such as impulsivity, anger or pessimism or a higher perception of psychological pain during a major depressive disorder. Other factors reported include substance misusage, life events in general, sexual abuse and particularly adverse childhood experiences. While these, as well as other, environmental and other clinical  factors seem obvious at first glance, genetic and neurobiology need to be taken into consideration too. Several impairments in the cerebral system are expected to be involved in suicidal behavior and have been brought up to light with the advances in neuro and functional imaging, especially in the prefrontal cortex comprising the orbitofrontal cortex, the anterior cingulate cortex and the amygdala  and in the fronto-limbic and fronto-parietal-cerebellar pathways. Other studies reveal dysfunction of the hypothalamic-pituitary-adrenal axis or dysfunction in the serotoninergic system, especially the gene coding for the serotonin transporter 5-HTTLPR  or the biding index of the 5-HT2a receptor. By being closely correlated to the mechanisms of emotional management, these dysfunctions could be related to the impaired decision making in suicide attempters. While well-known psychiatric disorders themselves represent a potentially important predictor, as detailed above, they seem insufficient alone to explain suicides. This brings us to consider suicidal behavior as a specific entity within psychiatry itself, with its own genetics, physiopathology, and clinic. Thus, Suicidal Behavior Disorder has made its appearance in the fifth edition of the Diagnostic Manual of Mental Disorders as an independent clinical entity as there is a large amount of evidence of specific pathophysiology for this disorder. This underscores the need to consider the suicidal process as a priority target.

Despite many risks factor identified, studies rarely measure their predictive value and if they do results are often disappointing. This leads to imprecise predictive models which hinder our ability to identify at-risk subjects and thus optimize interventions, the low predictive value of individual risk factors inevitably leads to a large number of false positives or false negatives. Yet, physicians are often faced in everyday practice with the need to identify the most at-risk subjects, in fact up to 40% of suicide victims had consulted a general practitioner within one month before and up to 80% within the year of the suicide.

E-Health/EMA Prevention of Suicidal Behaviour

Thankfully, the fast pace of digital revolution during those last 10 years have paved the way for a wide range of possible innovations in the field of mental health. E-health and mHealth (defined by the WHO “as the use of mobile and wireless technologies to support the achievement of health goals”) represent various possibilities for diagnosis, treatment, remote monitoring, data collection, therapeutic education, and training tools. One of the key advantages is its trend to multiply the networking possibilities between a patient and its clinician, increase access to health services as well as adherence to treatment and reduce costs by decreasing the need for hospitalization and intensive care. This implies that smartphones, mobile apps, machine learning, big data, sensors, wearables and other forms of digital technology should be considered to address the scale and size of the mental health issue and thus have the potential to better assess suicide risk and thus reduce suicide.

In fact, technology nowadays allows people to self-monitor and manage themselves in a whole new approach markedly different from classical face-to-to face interviews or paper-based assessment. Here Ecological Momentary Assessment (EMA), who uses repeated sampling in the natural environment, has an important part to play. Being assessed in real-time and in a natural environment they allow for the collection of a high number of observations over time even several times a day thus reducing the biases associated with retrospective data collection and increasing ecological validity and generalizability by avoiding 'laboratory bias'. These multiple assessments allow for a more complex and nuanced research, increased statistical power, and clinical debate about the dynamic associations between observed processes. EMA isn’t new, but used to be a hassle with paper-and-pencil questionnaires repeated over time, and has already been used in a wide variety of psychiatric disorders. In 2017, Husky et al. used EMA through personal digital assistants to examine the predictive role of fluctuations in daily life mood, social contexts, and behavior on subsequent suicidal ideation. But as technology advances the development of today’s smartphones makes them the go-to support for EMA by offering new possibilities for data collection and transmission. With over 3 billion people owning a smartphone, it has become an integral part of an individual's social life including among psychiatric patients. This makes it possible to reach a greater number of patients in a simple, fast and effective way. Using smartphones creates an opportunity for questionnaires on the current psychological state of patients, real-time tracking of feelings, emotions, life-events and much more. Further ahead the collection resulting from these evaluations then enables for Ecological Momentary Intervention (EMI) to be carried out, which is, for example, particularly useful for proposing interventions at the time of a suicidal crisis despite being underused for a period of time. It is now considered a safe way of monitoring suicidal thoughts without increasing suicidal behavior or having a negative impact on patients, moreover in the perpetual evolution of the clinician-patient relationship it seems patient may have a certain ease in being honest to their phones rather than to their doctor. People will then more likely disclose sensitive information about their lives (substance misusage, suicidal thoughts, suicidal thoughts…) online of or a mobile app than in real life interviews. Unlike other risk factors, suicidal thoughts, emotions, feelings, psychological pain change frequently and therefore their prediction must be dynamic. Regular longitudinal data collection, through EMA, can provide a more accurate picture of the emotional and cognitive context in which suicidal thoughts appear. Thus, applying EMA to these factors offers us the opportunity to determine immediate precursors predictive of the risk of a suicidal event in daily life. In consideration of everything that we mentioned above the use of a mobile app seems the most appropriate manner of using EMA as a mean to prevent suicide. In 2019, 204 billion apps have been downloaded across all app stores, there were 2,57 million apps available to download on Google’s Android Play Store and 1,84 million Apple’s IOS Apple Store.

Guidelines based on evidence-based clinical guidelines from the USA, the UK and the WHO have already been proposed for the development of mobile applications to prevent suicidal behavior and include: tracking of mood and suicidal thoughts, development of a safety plan, recommendation of activities, information and education, access to support networks, access to emergency counseling, and trustworthiness of information. But also, mention of the source of funding and developers of the application (clinicians, experts...), evaluation of the satisfaction of the application, protected access (login, password), mention of data confidentiality and information on the subsequent use of the data, ease of use, ergonomics, target audience… The online help functionality in the event of a suicidal crisis is the most effective strategy for the prevention of suicidal behavior, including links with relatives. Although most mobile applications for suicide prevention offer similar functionality, few meet all of these recommendations.

More broadly, in smartphone application development, the goal is to ensure application security and cost-effectiveness while engaging patients and users to optimize their integration into the decision-making process and thus requires multidisciplinary teams of clinical experts (psychologist, psychiatrists, pharmacologist…) and technologists (software programmers, network systems engineers, data scientists…) to work together throughout the project to produce mobile health interventions that are effectively designed, deployed and adapted.


The application we have developed, EMA, responds to all of these recommendations and offers additional functionalities relevant to the prevention of suicidal behavior. Suicide and suicide attempts are preventable. Since the publication of the WHO Global Suicide Report in 2014 and the WHO Mental Health Gap Action Programme (mhGAP), the WHO has recognized suicide prevention as a public health priority and have launched their Mental Health Action Plan (2013-2020) with the objective of reducing to reduces suicide rates by 10%. Other key quantitative indicators would be a decrease in the number of hospitalizations based on suicide attempts and an increase in effective suicide prevention interventions. Since we assessed that Suicidal Behavior is the result of a multifactorial process that integrates cultural, socio-economic, psychological and neurobiological elements in varying degrees of complexity. It is essential to understand the psychological mechanisms involved both in the development of suicidal ideation and in the translation of these ideas into suicidal acts, in order to develop effective prevention activities and psychosocial interventions who should be both pragmatic and innovative.

03 July 2023
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