A Digital Companion, the Emma App, for Ecological Momentary Assessment and Prevention of Suicide: Quantitative Case Series Study

Abstract

Background Many suicide risk factors have been identified, but traditional clinical methods do not allow for the accurate prediction of suicide behaviors. To face this challenge, emma, an app for ecological momentary assessment (EMA), ecological momentary intervention (EMI), and prediction of suicide risk in high-risk patients, was developed. Objective The aim of this case report study was to describe how subjects at high risk of suicide use the emma app in real-world conditions. Methods The Ecological Mental Momentary Assessment (EMMA) study is an ongoing, longitudinal, interventional, multicenter trial in which patients at high risk for suicide are recruited to test emma, an app designed to be used as a self-help tool for suicidal crisis management. Participants undergo clinical assessment at months 0, 1, 3, and 6 after inclusion, mainly to assess and characterize the presence of mental disorders and suicidal thoughts and behaviors. Patient recruitment is still ongoing. Some data from the first 14 participants who already completed the 6-month follow-up were selected for this case report study, which evaluated the following: (1) data collected by emma (ie, responses to EMAs), (2) metadata on emma use, (3) clinical data, and (4) qualitative assessment of the participants' experiences. Results EMA completion rates were extremely heterogeneous with a sharp decrease over time. The completion rates of the weekly EMAs (25%-87%) were higher than those of the daily EMAs (0%-53%). Most patients (10/14, 71%) answered the EMA questionnaires spontaneously. Similarly, the use of the Safety Plan Modules was very heterogeneous (2-75 times). Specifically, 11 patients out of 14 (79%) used the Call Module (1-29 times), which was designed by our team to help them get in touch with health care professionals and/or relatives during a crisis. The diversity of patient profiles and use of the EMA and EMI modules proposed by emma were highlighted by three case reports. Conclusions These preliminary results indicate that patients have different clinical and digital profiles and needs that require a highly scalable, interactive, and customizable app. They also suggest that it is possible and acceptable to collect longitudinal, fine-grained, contextualized data (ie, EMA) and to offer personalized intervention (ie, EMI) in real time to people at high risk of suicide. To become a complementary tool for suicide prevention, emma should be integrated into existing emergency procedures. Trial Registration ClinicalTrials.gov NCT03410381; https://clinicaltrials.gov/ct2/show/NCT03410381

Ecological momentary interventions for mental health: A scoping review

“…Two of the studies used a website to supplement individual CBT [ 19 ] and group CBT [ 20 , 21 ], one to provide psychoeducation and feedback [ 40 ], one to assign additional interventions and monitor participant’s progress [ 22 ], one to assign additional interventions and set EMA schedules [ 63 ], and one to provide just-in-time support by the clinicians that reviewed participants entries on the mobile phone [ 64 ]. The widespread adoption of smartphones has made ecologically valid deployments easier to implement; twenty four of the studies delivered intervention content to smartphones that were owned by the participants [ 18 , 21 , 22 , 30 , 31 , 33 – 35 , 43 , 44 , 47 , 48 , 51 , 52 , 55 , 56 , 60 , 62 , 64 – 66 , 68 , 70 , 71 ]. Five of the studies provided smartphones to participants if they did not own one [ 14 , 39 , 46 , 49 , 50 ].…”

“…Four of those studies provided a linear program, delivering the content to participants in a predefined manner [ 29 , 54 , 64 , 67 ]. The remaining applications allowed participants to access the different intervention components at any time [ 19 – 22 , 31 – 34 , 36 , 40 , 44 , 45 , 47 – 51 , 60 , 62 , 63 , 65 , 69 – 71 , 77 ]. One intervention contained only one component [ 29 ] while the rest offered a variety of components to users.…”

“…A distinct category of support feature relates to functionality that is used by clients when they feel they are particularly in need, or at risk (e.g. at risk of relapse) [ 32 , 44 , 49 , 51 , 63 , 69 ]. One of the interventions integrated additional components to provide in-app and on-demand support with the provision of immediate help to avoid an imminent relapse, alerts to key people who may reach out to the participant, and recovery experiences [ 44 ].…”

“…One of the interventions integrated additional components to provide in-app and on-demand support with the provision of immediate help to avoid an imminent relapse, alerts to key people who may reach out to the participant, and recovery experiences [ 44 ]. Other studies offered in-app support by providing the options to contact a social network of relatives or a mental health professional [ 51 ], or by automatically contacting a list of contacts identified by the participants in case they travel to a gambling venue [ 69 ]. On-demand support was provided in two studies by integrating weekly exercises based on topics covered in previous therapy sessions [ 32 ], or by presenting intervention strategies previously selected by the participants [ 49 ].…”

“…Some interventions provide links to external resources outside of the intervention. Six of the studies in this corpus implemented a resources feature with links to external web resources [ 44 , 46 , 51 ] or through the app [ 31 , 47 , 63 ].…”