JMIR Publications

ABSTRACT

People with prior suicidal thoughts and behavior (STB) are often excluded from digital mental health intervention (DMHI) treatment trials. This may perpetuate barriers to care and reduce treatment generalizability, especially in populations with elevated rates of STB, like body dysmorphic disorder (BDD). To address this, a recent randomized controlled trial (RCT) of a smartphone-based DMHI for BDD included people with prior STB, excluding only for past-month active suicidal ideation. We reviewed the suicide-risk mitigation procedures and completed secondary data analyses to (1) characterize the sample’s lifetime prevalence of STB and (2) estimate and predict STB incidence during the trial. At baseline, 40% of participants reported lifetime active suicidal thoughts and 10% reported lifetime suicide attempts. During the three-month trial, 42.5% reporting thinking about death- and/or suicide via weekly assessment. No participants reported frequent/acute suicidal thoughts, plans, or attempts. Lifetime suicide attempt (OR = 11.0, p < .01) and lifetime severity of suicidal thoughts (OR = 1.76, p < .01) were significant bivariate predictors of death-/suicide-related thought incidence reported during the trial. Multivariate models including STB risk factor covariates (e.g., age, sexual orientation) modestly improved prediction of death-/suicide-related thoughts (e.g., PPV = .91, NPV = .75, AUC =.83). Although some participants may think about death and/or suicide during a DMHI trial, it may be safe and feasible to include participants with most forms of past STB. Among other procedures, researchers should carefully select eligibility criteria, use frequent, ongoing, low-burden, and valid monitoring procedures, and implement risk mitigation protocols tailored to the presenting problem.