Engagement in Ecological Momentary Assessment of Suicidal Thoughts and Behaviors: A Mixed Methods Study

Ecological momentary assessment (EMA) holds great potential for understanding suicidal thoughts and behaviors (STBs) in real time. However, since the burden of EMA can lower participant engagement, more research is needed to understand how individuals engage with it, particularly during high suicide risk periods. This study aims to better understand participant engagement with EMA using both qualitative and quantitative indices. One hundred adults were enrolled in an EMA study during psychiatric inpatient hospitalization for STBs and completed six brief EMA surveys per day assessing STBs and related factors during hospitalization and for four weeks after. At the end of the study, participants completed a qualitative interview assessing motivations to participate, study perceptions, perspectives on EMA, engagement barriers, and recommendations. Participants completed 14,464 EMA surveys in total, with an average completion rate of 58%. Engagement was higher during hospitalization (66%) than after (54%). In interviews, most found EMA acceptable (59% enjoyed participation), noting that surveys often increased emotional awareness (51%). Some found EMA repetitive or tedious, and only a small minority found it distressing. Primary motivations were financial compensation (73%) and contributing to research (69%). Main barriers were schedules (92%) and momentary distress (60%). Recommendations largely focused on improving EMA administration, such as survey frequency. Most qualitative themes did not significantly differ by EMA engagement, although lower engagers gave more recommendations and had more unique barriers than high engagers. Quantitative and qualitative findings indicate EMA of STBs is generally acceptable during and after psychiatric hospitalization, with important recommendations for improvement. Integrating participant experiences is critical as researchers and clinicians work to optimize EMA with individuals at risk for suicide.