JMIR Publications

ABSTRACT

Background:

India has the world’s largest number of suicides but there is little research on the trends in suicidal thoughts, in particular when a person is at risk (e.g., person with psychosis), which is necessary to develop preventive interventions. Smartphone-based Ecological Momentary Assessments (EMAs) can assess dynamic symptoms, but most EMA studies are conducted in higher-income settings and have shorter (≤1 month) follow-up periods.

Objective:

This study aimed to examine the duration of onset to offset of suicidal ideation (SI) in tertiary hospital outpatients with psychosis in India.

Methods:

This study is an exploratory, secondary analysis of smartphone EMA data nested within the ongoing ‘SHARP’ project. Tertiary hospital outpatients (n=50) with early course schizophrenia at two socio-culturally different sites in India were recruited and given the ‘mindLAMP’ application for monitoring mood through daily EMA surveys over 15 months. The mood survey matched the nine-item Patient Health Questionnaire (PHQ-9) – the 9th item was used to define an instance of SI (score ≥ 1). Fourteen patients with ≥1 SI and ≥20% EMA survey compliance were included. We calculated between- and within-person variability in SI and ‘episodic’ patterns of SI (sequences of consecutive daily observations that show SI score ≥1). Positive and Negative Syndrome Scale (PANSS) was used to assess changes in symptoms of psychosis and its relationship with the temporality of SI.

Results:

Over ~11 months (IQR: 9-13) of EMA data reporting on average (326 days), and an average of 34.7% (IQR: 24.5 to 41.7) EMA survey compliance showed by patients, 3253 total mood surveys were filled by the 14 participants (232 surveys on average, IQR: 147-256). A total of 521 instances of SI were reported. Monthly SI instances showed substantial within and between-person variations. Time-scale summary statistics revealed episodic SI patterns in 11 patients, with an average of 5.9 episodes (range: 1-14, SD: 4.4, 65 total episodes) with an episode lasting for 2.5 days on average (range: 1-5.3, SD: 1.5, total 27 days). There was an average lag of ~59 days, 66 days and 81 days between the time of the first drop in PANSS positive, negative and general psychopathology scores respectively, and the last reported instance of SI. This indicated that SI was an enduring vulnerability subsequent to the beginning of clinical improvement in psychosis.

Conclusions:

Our study adds to the much-needed evidence base in India to measure the dynamics of suicidal thinking within an individual, for more targeted preventive interventions. Further steps in EMA research are highlighted such as the use of higher frequency ‘burst’ surveys to assess the duration of an episode of suicidal ideation in hours or even minutes, and inclusion of both active and passive SI markers to measure the timescale of suicidal thinking.