Momentary Stress and Social Context among Adolescents at Risk for Suicide: An Experience Sampling Study

Adolescent suicide is a public health emergency with interpersonal factors playing a critical role in risk for suicidal thoughts and behaviors (STB). This study examined whether smartphone-based ecological momentary assessment (EMA) surveys capturing stress and social context could enhance the identification of youth at risk for STB. Adolescents ages 13-18-years-old (N=207, 166 female sex) reporting depressive, anxiety, and/or substance use disorders were recruited from psychiatric outpatient programs, emergency departments, medical research registries, and social media. Participants with STB history were oversampled; 66% reported current suicidal ideation and 27% had a past-year attempt. Assessments of suicidal events (attempts, emergency department visits, hospitalizations for suicide concerns) were completed at baseline, 1-, 3-, and 6-month follow-up assessments. EMA probed momentary stress severity, affect, and recent social context (time spent with peers, family, or alone) 4-7x/day. Compared to psychiatric controls (N=64), adolescents with STB history (N=143) were more likely to report spending time alone (aOR=1.75, 95% CI=[1.15, 2.39]), less time with family (aOR=0.59, 95% CI=[0.31, 0.91]), and higher stress (d=0.28). Further, EMA of stress (aOR=1.86, 95% CI=[1.11, 3.26]) and negative affect (aOR=2.32, 95% CI=[1.34, 4.36]) were prospectively associated with suicidal events above and beyond prior STB history. Broadly, results were similar between EMA measures of stress and negative affect, indicating such responses may reflect shared underlying processes. These findings underscore the importance of evaluating dynamic family and peer contact among adolescents at risk for STB and highlight EMA as a potential tool for assessing interpersonal exposures related to STB risk.