Objective: Digital monitoring technologies (e.g., smartphones and wearable devices) provide unprecedented opportunities to study potentially harmful behaviors such as suicide, violence, and alcohol/substance use in realtime. The use of these new technologies has the potential to significantly advance the understanding, prediction, and prevention of these behaviors. However, such technologies also introduce myriad ethical and safety concerns, such as deciding when and how to intervene if a participant's responses indicate elevated risk during the study?Methods: We used a modified Delphi process to develop a consensus among a diverse panel of experts on the ethical and safety practices for conducting digital monitoring studies with those at risk for suicide and related behaviors. Twenty-four experts including scientists, clinicians, ethicists, legal experts, and those with lived experience provided input into an iterative, multi-stage survey, and discussion process.Results: Consensus was reached on multiple aspects of such studies, including: inclusion criteria, informed consent elements, technical and safety procedures, data review practices during the study, responding to various levels of participant risk in real-time, and data and safety monitoring.Conclusions: This consensus statement provides guidance for researchers, funding agencies, and institutional review boards regarding expert views on current best practices for conducting digital monitoring studies with those at risk for suicide-with relevance to the study of a range of other potentially harmful behaviors (e.g., alcohol/substance use and violence). This statement also highlights areas in which more data are needed before consensus can be reached regarding best ethical and safety practices for digital monitoring studies.

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Suicide is a leading cause of death. Rich descriptions of suicidal phenomena are critical to advancing understanding. Research on goal-directed behavior suggests that actions require both a motivation and a cognitive representation of the behavior. Therefore, we measured motivational (e.g., desire or urge) and intentional (e.g., intent) suicidal states as well as suicidal thought content (e.g., verbal thoughts, imagery and planning) using momentary (9,786 responses) and daily (2,335 responses) assessment over 42 days in 105 suicidal adults. Results revealed, first that suicidal imagery was more common than verbal suicidal thoughts, and suicide plans co-occurred with imagery approximately 70% of the time. Second, high levels of suicidal desire, urge and intent were frequently accompanied by active suicidal thought content, the reverse was not true: active thought content was frequently present during low or absent motivational/intentional states. These results paint a nuanced and complex picture regarding the phenomenology of suicidal thoughts.