Published on in Vol 11, No 5 (2022): May

This is a member publication of Imperial College London (Jisc)

Preprints (earlier versions) of this paper are available at, first published .
The Association Between Sleep Disturbance and Suicidality in Psychiatric Inpatients Transitioning to the Community: Protocol for an Ecological Momentary Assessment Study

The Association Between Sleep Disturbance and Suicidality in Psychiatric Inpatients Transitioning to the Community: Protocol for an Ecological Momentary Assessment Study

The Association Between Sleep Disturbance and Suicidality in Psychiatric Inpatients Transitioning to the Community: Protocol for an Ecological Momentary Assessment Study


1School of Public Health, Imperial College London, London, United Kingdom

2National Institute for Health and Care Research Imperial Patient Safety Translational Research Centre, Imperial College London, London, United Kingdom

3West London National Health Service Trust, London, United Kingdom

4Department of Brain Sciences, Imperial College London, London, United Kingdom

5Department of Community Mental Health, University of Haifa, Haifa, Israel

6Division of Psychiatry, University College London, London, United Kingdom

7Applied Research Collaboration Northwest London, Imperial College London, London, United Kingdom

Corresponding Author:

Lindsay H Dewa, BA, MSc, PhD

School of Public Health

Imperial College London

Reynolds Building

St Dunstan's Road

London, W6 8RP

United Kingdom

Phone: 44 020 7594 0815


Background: Patients are at high risk of suicidal behavior and death by suicide immediately following discharge from inpatient psychiatric hospitals. Furthermore, there is a high prevalence of sleep problems in inpatient settings, which is associated with worse outcomes following hospitalization. However, it is unknown whether poor sleep is associated with suicidality following initial hospital discharge.

Objective: Our study objective is to describe a protocol for an ecological momentary assessment (EMA) study that aims to examine the relationship between sleep and suicidality in discharged patients.

Methods: Our study will use an EMA design based on a wearable device to examine the sleep-suicide relationship during the transition from acute inpatient care to the community. Prospectively discharged inpatients 18 to 35 years old with mental disorders (N=50) will be assessed for eligibility and recruited across 2 sites. Data on suicidal ideation, behavior, and imagery; nonsuicidal self-harm and imagery; defeat, entrapment, and hopelessness; affect; and sleep will be collected on the Pro-Diary V wrist-worn electronic watch for up to 14 days. Objective sleep and daytime activity will be measured using the inbuilt MotionWare software. Questionnaires will be administered face-to-face at baseline and follow up, and data will also be collected on the acceptability and feasibility of using the Pro-Diary V watch to monitor the transition following discharge. The study has been, and will continue to be, coproduced with young people with experience of being in an inpatient setting and suicidality.

Results: South Birmingham Research Ethics Committee (21/WM/0128) approved the study on June 28, 2021. We expect to see a relationship between poor sleep and postdischarge suicidality. Results will be available in 2022.

Conclusions: This protocol describes the first coproduced EMA study to examine the relationship between sleep and suicidality and to apply the integrated motivational volitional model in young patients transitioning from a psychiatric hospital to the community. We expect our findings will inform coproduction in suicidology research and clarify the role of digital monitoring of suicidality and sleep before and after initial hospital discharge.

International Registered Report Identifier (IRRID): PRR1-10.2196/33817

JMIR Res Protoc 2022;11(5):e33817



Suicidal Ideation and Behavior After Psychiatric Hospital Discharge

The prevention of suicide is a well-established goal for patient safety and a national and global public health priority. Suicide risk is increased after discharge from a psychiatric hospital [1], regardless of previous suicidal behavior. In the United Kingdom, there were 1988 deaths by suicide between 2008 and 2018 within 3 months of discharge from inpatient care, which amounts to 15% of all suicides [2]. Suicide is most frequent in the first week following discharge, making the transition period from hospital to the community one of the riskiest for suicidal behavior in adults and young people. In fact, this risk is highest on day 2, yet follow up with support services sometimes does not occur until day 7 [3]. Thus, the first week is a critical period for immediate aftercare and treatment planning following discharge from psychiatric inpatient care. The risk is significantly increased in patients with various individual factors, including previous self-inflicted violence (eg, self-harm and suicidal behavior), intoxication, and health conditions. Risk is further elevated when patients experience insomnia, nightmares, or sleep disturbance that results in being awake at night [4]. This is particularly troublesome as immediate support (eg, clinical services or social support networks) is typically limited during the night.

The Relationship Between Sleep, Suicidal Ideation, and Behavior

There is increasing evidence that sleep dysfunction is an independent risk factor for suicidal ideation and behavior (SIB) [5]. Several systematic reviews have explored the epidemiological relationship between sleep and SIB in different population groups (eg, in mixed samples [6], nonpsychiatric adolescent patients [7,8], and psychiatric patients [9]), examined prospective suicide incidents, and more recently, explored the underlying mechanisms of this relationship [9]. All these studies have showed a strong correlation between sleep and SIB; however, most studies have been cross-sectional or retrospective in design. The temporal nature of the relationship between sleep disturbance and suicidality was the focus of the most recent systematic review [10]. Of the 41 included studies, only 1 measured insomnia as a predictor of suicidal ideation in real time (over a 24-hour period) in the United Kingdom [11]. The lack of studies may be due to the challenge and expense of monitoring sleep and suicidality without using self-reported data. However, the scarcity of data is problematic, since both sleep and suicidality fluctuate; therefore, current studies do not account for temporality [12-15].

Measuring Sleep and SIB in Real Time Using Technology

Ecological momentary assessment (EMA) is an intensive self-report method that can be used to assess experiences, symptoms and behaviors in real-time at multiple times of the day [16,17]. EMA monitors people within their natural environment, usually with the aid of a smartphone or wearable smart device (such as a wrist-worn electronic watch) to reduce recall bias, leading to greater efficiency, ecological validity, and accuracy than more traditional research methods [18]. The use of EMA in the study of SIB has shown great promise because of its ability to monitor and identify proximal factors (eg, sleep) associated with SIB in daily routines; the use of EMA has increased dramatically in the last 5 years [19,20]. However, only a few EMA studies have been conducted in high-risk groups with experience of suicidal ideation and behavior during inpatient hospitalization or following discharge [12,21-24]. Most recently, Glenn and colleagues [22,25] performed an EMA study with a 28-day period to examine the relationship between sleep and suicidality in adolescents (12-18 years old) following discharge from acute psychiatric care in the United States. Notably, EMA was deemed feasible in this high-risk group, with adherence being highest in the first week following discharge; participants found that wearing an actigraphy device (eg, a wearable device to measure the sleep-wake cycle) was acceptable. Similarly, EMA has also been deemed feasible to measure SIB in patients undergoing community mental health support [25] and acceptable as a data collection method in young adult cohorts [25,26]. However, to our knowledge, no studies have used EMA to monitor sleep and suicidality during the transition from psychiatric inpatient care to the community.

Application of Sleep to the Integrated Motivational Volitional Model

While there is increasing evidence of a prospective relationship between sleep problems and suicide, not everyone who experiences sleep problems will develop suicidal thoughts and behavior, or vice versa. Therefore, it is vital to investigate the underlying mechanisms by which disturbed sleep may lead to suicidality. The integrated motivational volitional (IMV) model is an established theoretical model that proposes that people transition from ideation to suicidal behavior because of the complex interplay of multiple factors, including core psychological mechanisms, such as defeat and entrapment, and background factors (eg, life events such as being in hospital) [27,28]. Littlewood and colleagues [29] recognised the potential importance of suicidal imagery (ie, “flashforwards” of future events involving one’s suicide or the aftermath of death) when studying the relationship between sleep and suicide. Moreover, suicidal imagery might also trigger entrapment or hopelessness, resulting in suicidal ideation and behavior [28,29]. These conceptualizations are promising, but to date have not been examined in young adults transitioning from the hospital to the community. This proposal therefore presents a unique opportunity to address these gaps in research and patient safety in this vulnerable population.

The primary aim of this paper is to describe and outline an exploratory EMA study protocol that examines sleep as a possible measure of deterioration and a potential predictive factor for SIB in young patients during the transition period from an inpatient setting to the community. We will address the following research questions: (1) Is there a difference between predischarge and postdischarge sleep in young adult patients? (2) Does sleep disturbance pre- and postdischarge predict postdischarge SIB in young patients? and (3) Is it acceptable and feasible to use EMA to monitor SIB postdischarge in young adults?

We hypothesize that there will be a difference between pre- and postdischarge sleep in young patients (this is hypothesis 1). Additionally, based on previous research, we hypothesize that sleep disturbance (ie, insomnia and short sleep duration) postdischarge will predict SIB while controlling for depression and baseline sleep (this is hypothesis 2). We will also explore the conceptual model in our patient sample; we expect that sleep disturbance will be associated with defeat, entrapment, and hopelessness postdischarge (this is hypothesis 3). We also expect that EMA will be deemed both feasible and acceptable for inpatients transitioning from the inpatient setting to the community.

Study Design and Setting

This is a prospective, repeated-measures EMA study with inbuilt evaluation. Wrist-worn digital devices will be used to explore the relationship between sleep and SIB during an acute psychiatric transition while also evaluating defeat, entrapment, hopelessness, and suicidal imagery. Our conceptual model integrates key aspects of the IMV model [27,28] and is one of only two psychological models to integrate sleep [29] (Figure 1).

Recruitment will take place in 2 acute psychiatric hospitals in West London that provide support and care for mental health problems or mental health crises (Hammersmith and Fulham Mental Health Unit and Lakeside Mental Health Unit). EMA using smartphones is a practical option; however, it is difficult to accurately measure the sleep-wake cycle with this method [30] and there are potential privacy issues [31] in retrieving data due to connectivity; moreover, some patients might not have access to a smartphone within an acute hospital environment in England. Hence, we opted for the Pro-Diary V device (Camntech), which has inbuilt actimetry, and short questionnaires as the most viable options for accuracy and ease of use within the flow of daily life.

Figure 1. Adapted conceptual model of sleep and suicide in young transitioning inpatients.
View this figure

Ethics Approval

This study received ethical approval from South Birmingham Research Ethics Committee (21/WM/0128) on June 28, 2021. The study will be registered on the Observational Studies Register.


Participants will be inpatients in an acute psychiatric ward due to be discharged within a 4-week period, age 18 to 35 years old, with a diagnosis of a mental disorder confirmed by the Structured Clinical Interview from the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, in their clinical records [18]. Participants will be excluded if they are outside the age range, not fluent in English, or using sleep medication (ie, hypnotic medication such as zopiclone or zolpidem). We will not exclude participants on anxiolytics (ie, benzodiazepines) as most patients discharged will likely be on medication with some sedative effect.


Clinicians at West London National Health Service (NHS) Trust (WLT) will initially approach eligible participants in the acute psychiatric hospitals participating in the study. Prospective participants will be given an information sheet and asked if they would be happy for a researcher to approach them. If they agree, a trained researcher will approach them, explain the study, and answer any questions. After at least 24 hours, the patient will be approached for a second time to ask if they would be happy to take part in the study; consent will then be obtained.


Following screening and informed consent, key demographic factors will be collected via medical records. These will include gender, age, ethnicity, marital status, length of time in hospital, mental health diagnosis, prescribed medication (historic and current), sleep history, family history of suicide, previous suicidal thoughts, and suicide plans and attempts. The researcher will then administer the baseline questionnaires face-to-face at a date and time convenient to the participant.

The researchers will then brief each participant during a 15-minute one-on-one session on the purpose of the Pro-Diary V watch, procedures needed to complete the study, and the method of using the watch, and will give accompanying written guidance on how to use the wearable device (eg, not to take the watch off unless having a shower or bath, how to use the menus, and how to answer the questions). The researchers will show the participants a demonstration version of the Pro-Diary V watch (demo beeps will be enabled for user training), and will prompt the participants with a timed questionnaire to allow the participants to learn the operation of the device. The participants will not need to charge the watch, as it has a battery life longer than the duration of the data collection period. The researchers will go through the written guidance with the participants to make sure they have a good understanding of what is expected of them and will answer any questions they might have. Selected onsite staff at each inpatient unit will be trained in the use of the watch and will assist the participants daily until discharge.

The participants will wear the watch for a maximum of 14 days, including 1 to 4 days before discharge, to determine the baseline profile and a minimum of 10 days after discharge (ie, the riskiest period for SIB and death by suicide). During this period, the watch will prompt each participant 4 times per day by vibrating to answer brief questions (Figure 2, Figure 3). The start point of the daily prompts will be decided by each participant based on their sleep-wake schedule. The start point of the day will normally be 30 minutes after their usual waking time. Between-prompt intervals will be delivered using a fixed time sampling schedule. Fixed time points were chosen to reduce study burden in this high-risk group of participants and increase compliance. Participants will be able to delay the prompt for 20 minutes if they are not able to answer straight away (eg, if they are undergoing inpatient activity). Each participant will receive a £15 (US $18.78) e-voucher after each stage (ie, they will receive a voucher after baseline assessment, after EMA, and after follow-up assessment), following a suggestion by our young coresearchers.

Figure 2. Study schedule. EMA: ecological momentary assessment.
View this figure
Figure 3. Example of Pro-Diary V watch with question about suicidal ideation.
View this figure

After discharge, the participants will receive 2 follow-up calls (once a week) to resolve any problems arising from the EMA method and the use of the watch, including technical issues, and to answer any queries from the participants, following existing guidance [32]. The researchers will contact the participants again toward the end of the EMA period to arrange a date to administer the follow-up questionnaires. The researchers will administer the questionnaires face-to-face in a private room at a WLT community site at a time convenient to the participant. At the end of the study period, deidentified EMA data will be collected from each participant, downloaded to a secure enclave at Imperial College London, and analyzed within the secure platform.

Patient and Public Involvement

This study will build on our extensive experience of working with young people with mental health difficulties [26,33,34] to conduct meaningful patient and public involvement. We issued a call for young people with experience of psychiatric inpatient care and suicidality (eg, ideation or behavior) in November 2020 through existing advisory groups, email distribution lists, and social media (eg, Twitter) and asked prospective participants to fill out a short application form. After internal selection, 3 participants were selected to inform most research stages, serving as coresearchers. These coresearchers were consulted on (1) design and ethics, (2) recruitment, (3) management, (4) data interpretation, (5) dissemination of findings, and (6) evaluation. The coresearchers have already reviewed the research documentation (eg, the information sheet, protocol, and consent form) and subsequently, changes were made to the documents. For example, the language was revised into plain English and the “nightmares” variable was added to the design. A recruitment poster was also coproduced with the coresearchers. One coresearcher also attended the NHS Research Ethics Committee meeting. The coresearchers have been trained in a basic understanding of EMA and sleep. Based on a suggestion from a previous coresearcher, [26] we expect to cofacilitate a face-to-face “meet and greet” event at the acute hospital for the research team to meet the potential study participants and encourage participation. We have set up a project-specific WhatsApp (Facebook Inc) group to make sure everyone is easily involved in decision-making, and we will have 4 virtual team meetings per year on Zoom (Zoom Inc). Coresearchers will also be listed as coauthors on all study outputs, including academic papers. Disclosure and Barring Service certificates have been obtained or are currently being obtained for coresearchers to ensure that all are deemed capable of safely interacting with patients with mental health difficulties.

Baseline and Follow-up Questionnaires

Participants will complete a baseline assessment (Table 1) that will cover sleep with the Sleep Condition Indicator (SCI) and Pittsburgh Sleep Quality Index (PSQI) [35,36], nightmares with the Disturbing Dream and Nightmare Severity Index [37], sleep environment with the Hospital Environment Sleep Questionnaire [38], affect with the Positive and Negative Affect Scale [39], depression with the Patient Health Questionnaire (PHQ-9) [40], anxiety with Generalized Anxiety Disorder-7 scale [41], defeat and entrapment with the Short Defeat and Entrapment Scale [42]), mental imagery with the Impact of Future Events Scale [43], and lifetime suicidal and nonsuicidal ideation and behavior with the Self-injurious Thoughts and Behavior Interview [44]. Additional follow-up questions will cover medication use, access to hospital and primary care, and informal or formal support received since discharge. Questions on the acceptability of using EMA and a wearable device to monitor the transition were adapted from another study that used EMA (questions included, for example, “I found the questions easy to understand” [45]) or were included after discussion with the study authors and our wider team. Feasibility will be measured by participation rate, adherence to the EMA protocol, and adherence to wearing the device.

Table 1. Baseline and follow-up measures.
VariableQuestionnaireItemsScoringUsed at baseline, follow up, or both
Sleep environmentHospital Environment Sleep Questionnaire160-64Baseline
SleepSleep Condition Indicator80-32Both
SleepPittsburgh Sleep Quality Index190-21Both
NightmaresDisturbing Dream and Nightmare Severity Index6Unique to itemBoth
AffectPositive and Negative Affect Scale2010-50Both
DepressionPatient Health Questionnaire-990-27Both
AnxietyGeneralized Anxiety Disorder-7 scale70-21Both
Mental imageryImpact of Future Events Scale240-96Both
Defeat and entrapmentShort Defeat and Entrapment Scale80-16 for defeat and 0-16 for entrapmentBoth
Lifetime and current suicidal and nonsuicidal self-injury ideation and behaviorSelf-injurious Thoughts and Behavior Interview-Short FormN/AaUnique to item, including open ended, counts, and 0-4 scaleBaseline (lifetime) and follow up (current only)
Feasibility and acceptabilityBespoke questionnaire designed to measure feasibility and acceptability of ecological momentary assessment for mental health following discharge101-50 and open endedFollow up

aN/A: not applicable.

EMA Measures

EMA items were selected according to use in previous studies [46], adapted from standardized measures, or taken from the experience sampling methodology (ESM) item repository [47] (Table 2 and Table 3). Some were adapted after discussion with the young coresearchers. For example, “Right now, I am feeling suicidal” was revised to “Right now, I feel suicidal,” as it was deemed simpler to read and more in line with the structure of the other items. Similarly, questionnaire density, sampling scheme, and momentary assessment frequency were informed by the considerations of the coresearchers, by the characteristics of the high-risk population, and by previous literature. Previous literature shows that participants in studies with a shorter duration and a lower number of question prompts per day had higher compliance [48]. Therefore, we considered that minimizing the number of prompts per day and limiting the study period to 14 days would result in the highest participant compliance rate [21]. We discussed this idea with the coresearchers and decided that 4 was a reasonable number of prompts. This was based on consideration of the high-risk population and an opinion that 4 prompts did not impose an undue burden and would still provide enough data to capture different times of the day.

Table 2. Ecological momentary assessment measures. Measures were taken 4 times daily and used a 7-point Likert scale, ranging from 1 (“not at all”) to 7 (“very much so”).
Suicidal ideation [11]
  • Right now, I feel suicidal
Self-harm ideation [46]
  • Right now, I feel like harming myself without the intention to die
Defeat [42]
  • Right now, I feel defeated by life
  • Right now, I feel powerless
Entrapment [42]
  • Right now, I feel trapped
  • Right now, I want to escape my emotional pain
Positive affecta
  • Right now, I feel excited
  • Right now, I feel cheerful
  • Right now, I feel satisfied
  • Right now, I feel relaxed
Negative affecta
  • Right now, I feel stressed
  • Right now, I feel irritated
  • Right now, I feel anxious
  • Right now, I feel sad
  • Right now, I feel insecure
  • Right now, I feel hopeless

aTaken from the experience sampling methodology (ESM) item repository [47].

Table 3. Daily measures.
VariableItemFrequencyResponse scale
Suicidal behaviorI tried to kill myself todayLast beep of the dayBinarya
Self-harmI have self-harmed todayLast beep of the dayBinary
Suicidal imageryI have had images of making a suicide attempt todayLast beep of the dayBinary
Self-harm imageryI have had images of hurting myself todayLast beep of the dayBinary
Nightmares [49]Did you have nightmares of a traumatic experience last night?First beep of the dayBinary
Subjective sleep parameters [50]What time did you get into bed?First beep of the dayTime
What time did you try and to go to sleep?First beep of the dayTime
How long did it take you to fall asleep?First beep of the dayMinutes
How many times did you wake up, not counting your final awakening? In total, how long did these awakenings last?First beep of the dayNumber
What time was your final awakening?First beep of the dayTime
What time did you get out of bed for the day?First beep of the dayTime
How would you rate the quality of your sleep?First beep of the dayLikertb

aIn binary scales, 0 indicated “no” and 1 indicated “yes.”

bFive-point Likert scale, ranging from 1 (“very poor”) to 5 (“very good”).

Objective and Subjective Sleep Parameters

A total of 5 key parameters will be objectively measured via inbuilt actimetry in the Pro-Diary V watch: total sleep time, sleep efficiency, wake after onset, sleep latency, and the number of awakenings. The same parameters will be measured through self-reporting using the Pro-Diary V software sleep diary, based on the Consensus Sleep Diary [50], to validate the objective reporting. This is recommended practice to establish the key period for analyzing sleep parameters [51].

Statistical Analysis

The lme4 and nlme R CRAN packages (CRAN R Project) for mixed effects models will be used. We will measure subjective sleep and objective sleep (via actigraphy) separately; this will be accounted for in independent models. Suicidal ideation will be measured multiple times a day. We will calculate the next-day worst point levels (eg, the highest score each day) for the suicide parameters [22] (eg, postdischarge sleep and early morning suicidal ideation), as this is deemed to be the best predictor of suicidal behavior [52]. In the first instance, analysis will be conducted to answer the primary research questions and hypotheses with specified confounders. A secondary analysis will be conducted for more exploratory work and to determine the conceptual model relationships between subjects and data. To address hypothesis 1, we will analyze both person-level baseline sleep problems (determined by the SCI and PSQI) and within-person sleep diary predictors (determined by EMA and actigraphy). We will first compare baseline sleep problems for mean values and follow-up mean values with the t test. Next, we will conduct a linear regression analysis to examine the grand-mean centered daily level (within-person) sleep diary variables from the night before (total sleep time, sleep efficiency, wake after onset, sleep quality, sleep latency, the number of awakenings, and nightmares) in the inpatient hospital (days 1-4) and post-discharge sleep parameters by data number (ie, time-related variables). A similar approach will be taken with the actigraphy data. To address hypothesis 2, all models will have random intercepts and use either postdischarge worst-point suicidal ideation across any day (days 5-14) or day-level suicidal behavior. Our first mixed effects model will include EMA (day level) sleep parameter predictors: total sleep time, sleep efficiency, wake after onset, sleep quality, sleep latency, the number of awakenings, and “nightmares.” Our second mixed effects model will add person-level variables, including baseline sleep (SCI and PSQI) and depression (PHQ-9). Our final model will add in the interactions between ESM day-level parameters and person-level variables that are significant (P<.05). The same models will be applied for the secondary outcomes (nonsuicidal self-injury ideation and behavior), and objective sleep parameters (the actigraphy data). We will then explore the conceptual model and specifically address hypothesis 3. We will use separate mixed effects models to examine the impact of EMA (momentary) entrapment, defeat, and hopelessness on awakening suicidal ideation (the start of day prompt) while moderating for each day-level sleep parameter predictor (EMA and actigraphy).

Sample Size Calculation

Sample size calculations for EMA studies differ from traditional calculations due to the inherent multi-level structure of the design, with multiple assessment periods. However, to answer our primary research question (ie, “Does sleep disturbance pre- and postdischarge predict postdischarge SIB in young patients?), we need to calculate our sample size based on 3 levels of data: momentary assessments nested within days, nested within persons. Specifically, these are day-level observations of suicide (the worst point level for suicidal ideation among 4 momentary assessments) and sleep. In the absence of pilot data for this specific population, we estimated sample size based on several factors. First, the only 2 (to our knowledge) ESM studies [11,22] that examined sleep and suicide with similar clinical populations had roughly 50 participants (N=48 and N=51, respectively). Second, from this, we noted that a sample size of 50 was recognized as an acceptable sample size number for multi-level analyses, in line with guidance and simulation studies [53]. Third, we entered a sample size of 50 into an EMA calculator [54] to estimate the power with 14 days and 1 response (the worst point level of suicidal ideation) per day. This showed that a total of 50 participants was sufficient to achieve 90% power and detect large effect sizes, allowing for a 75% completion rate. To guard against possible dropout or incomplete EMA completion, we will dedicate time to the initial EMA briefing session with the participants and regularly check in with them to help maximize retention, in line with previous guidance [55] Notably, to our knowledge, few ESM studies have given justifications for sample size; therefore, we have tried to be as transparent as possible about our calculations. We will also extend the recruitment period if required. If there are missing data, we will apply maximum likelihood estimation to allow all data to be testable across the multilevel modeling.

Ethical Approval, Considerations and Safeguarding

Ethical approval was obtained from NHS Ethics Committee and Health Research Authority (21/WM/0128). Upon discharge, as part of standard care, participants will receive a leaflet containing key contact details for their community support team and an additional booklet containing key numbers for each relevant informal support service (eg, Shout and Samaritans). These were co-designed with young people with lived experience. Participants will also be contacted by a member of the community mental health team within a week of discharge.

All participants involved in the study will be assessed for suicidal ideation and behavior at each EMA assessment using brief questions. After each assessment, a message will be displayed on the Pro-Diary V watch giving them contact information for their mental health services. This will be either their clinical team or the 24-hour single point of access (telephone number 0300 1234 244 in the United Kingdom); they will also be advised to go to the emergency department at their nearest hospital or call Shout—a 24-hour, 7-day-a-week crisis text line (available at 85258 in the United Kingdom) that aims to bring texters from a “hot moment” to “cool calm” through active listening and collaborative problem solving. Live, trained crisis counsellors receive text messages and immediately respond from a secure online platform. Participants will also be called by the researcher every week for a study check in.

Throughout the study, participants may be become incapacitated or rehospitalized and will therefore will be unable to continue. If this happens, we will contact the participant, if we are able to, and collect the wearable device. If we cannot contact the participant, we will ask the study inpatient clinician to collect it for us. We will explain that the data collected up until the point of being rehospitalized will be included in the data analysis, in line with the consent form and information sheet declaration.

Study recruitment was due to start in November 2021, and we expect results to be available in 2022. To date, we have reflected on the working relationship with the young coresearchers across each research stage. Researcher and coresearcher reflections indicate that establishing and maintaining a safe environment for open discussion and continued communication (eg, via a WhatsApp group) have been vital to effectively share power and decision-making. Safeguarding and support needs for both coresearchers (eg, an individualized strategy) and researchers (eg, clinical supervision) have also been particularly evident. To date, the coproduced design, recruitment poster, documentation (eg, the information sheet, protocol, and consent form), and this research paper have demonstrated significant impact.

EMA is a promising methodology that could monitor and identify factors (eg, sleep) associated with suicidality. In our qualitative study, we found that wearables were deemed acceptable and feasible by young patients to monitor sleep and activity and to detect mental deterioration [26]. However, it is unknown if wearables can be used in the real world to measure sleep and activity. This study is a unique opportunity to address these gaps in research and patient safety in this vulnerable population. We expect to find a relationship between poor sleep and next-day suicidal ideation. If successful, we expect to build on this work and examine this relationship, determining mechanisms with the adapted IMV model in a larger study sample. We also expect to implement and test sleep treatment for transitioning high-risk young patients to reduce suicidality.

There are potential key limitations to our study. First, our study sample is small. While adequately powered for our within-sample analyses, it will be less powered for the between-subjects analyses. Second, most momentary analyses will be exploratory, and we therefore will not be able to give a precise impression of the application of the adapted IMV model to sleep. However, we expect to develop this work in the future and conduct more highly powered studies. Lastly, unlike the gold standard measure of polysomnography, actigraphy cannot characterize a full sleep architecture. However, it does provide an objective measurement of sleep that is obtained within a natural environment, increasing ecological validity.


Funding was provided by a National Institute for Health Research Patient Safety Translational Research Centre program grant (PSTRC-2016-004) and the Institute of Global Health Innovation. We are also grateful for support from the National Institute for Health Research under the Applied Research Collaboration program for North West London, and the Imperial National Institute for Health Research Biomedical Research Centre. The views expressed in this publication are those of the authors and not necessarily those of the National Health Service, the National Institute for Health Research, or the Department of Health and Social Care.

Authors' Contributions

LD led on conceptualization, patient and public involvement, project management, and drafting and finalizing the paper. MS and SP provided clinical guidance on project setup and safeguarding. TG and TW advised on statistical analysis. TG advised on ecological momentary assessment methodology and analysis. LD, JC, LM, MH, MDS, SP, PA, TG and TW co-designed the study and reviewed and approved the final paper.

Conflicts of Interest

PA is the principal investigator for a research grant provided by Dr Foster Ltd (a wholly owned subsidiary of Telstra Health). No other authors declare any competing interests.

  1. Haglund A, Lysell H, Larsson H, Lichtenstein P, Runeson B. Suicide Immediately After Discharge From Psychiatric Inpatient Care: A Cohort Study of Nearly 2.9 Million Discharges. J Clin Psychiatry 2019;80(2):18m12172. [CrossRef]
  2. National Confidential Inquiry into Suicide and Safety in Mental Health Annual report 2021: England, Northern Ireland, Scotland and Wales. The University of Manchester.   URL: [accessed 2022-05-05]
  3. Transition between inpatient mental health settings and community or care home settings. National Institute for Clinical Excellence.   URL: https:/​/www.​​guidance/​ng53/​resources/​transition-between-inpatient-mental-health-settings-and-community-or-care-home-settings-pdf-1837511615941 [accessed 2022-05-05]
  4. Perlis M, Ellis JG, Kloss JD, Riemann DW. Chapter 82 - Etiology and Pathophysiology of Insomnia. In: Kryger M, Roth T, Dement WC, editors. Principles and Practice of Sleep Medicine (Sixth Edition). Amsterdam, the Netherlands: Elsevier; 2017:e4-784.
  5. Bernert RA, Kim JS, Iwata NG, Perlis ML. Sleep disturbances as an evidence-based suicide risk factor. Curr Psychiatry Rep 2015 Mar;17(3):554 [FREE Full text] [CrossRef] [Medline]
  6. Pigeon WR, Pinquart M, Conner K. Meta-Analysis of Sleep Disturbance and Suicidal Thoughts and Behaviors. J Clin Psychiatry 2012 Sep 15;73(09):e1160-e1167. [CrossRef]
  7. Chiu H, Lee H, Chen P, Lai Y, Tu Y. Associations between sleep duration and suicidality in adolescents: A systematic review and dose-response meta-analysis. Sleep Med Rev 2018 Dec;42:119-126. [CrossRef] [Medline]
  8. Kearns JC, Coppersmith DD, Santee AC, Insel C, Pigeon WR, Glenn CR. Sleep problems and suicide risk in youth: A systematic review, developmental framework, and implications for hospital treatment. Gen Hosp Psychiatry 2020;63:141-151. [CrossRef] [Medline]
  9. Malik S, Kanwar A, Sim LA, Prokop LJ, Wang Z, Benkhadra K, et al. The association between sleep disturbances and suicidal behaviors in patients with psychiatric diagnoses: a systematic review and meta-analysis. Syst Rev 2014 Feb 25;3:18 [FREE Full text] [CrossRef] [Medline]
  10. Liu RT, Steele SJ, Hamilton JL, Do QB, Furbish K, Burke TA, et al. Sleep and suicide: A systematic review and meta-analysis of longitudinal studies. Clin Psychol Rev 2020 Nov;81:101895 [FREE Full text] [CrossRef] [Medline]
  11. Littlewood DL, Kyle SD, Carter L, Peters S, Pratt D, Gooding P. Short sleep duration and poor sleep quality predict next-day suicidal ideation: an ecological momentary assessment study. Psychol Med 2019 Feb;49(3):403-411 [FREE Full text] [CrossRef] [Medline]
  12. Kleiman EM, Turner BJ, Fedor S, Beale EE, Huffman JC, Nock MK. Examination of real-time fluctuations in suicidal ideation and its risk factors: Results from two ecological momentary assessment studies. J Abnorm Psychol 2017 Aug;126(6):726-738. [CrossRef] [Medline]
  13. Vallières A, Ivers H, Bastien CH, Beaulieu-Bonneau S, Morin CM. Variability and predictability in sleep patterns of chronic insomniacs. J Sleep Res 2005 Dec;14(4):447-453 [FREE Full text] [CrossRef] [Medline]
  14. Lemola S, Ledermann T, Friedman EM. Variability of sleep duration is related to subjective sleep quality and subjective well-being: an actigraphy study. PLoS One 2013;8(8):e71292 [FREE Full text] [CrossRef] [Medline]
  15. Hektner JM, Schmidt JA, Csikszentmihalyi M. Experience sampling method: Measuring the quality of everyday life. New York, NY: Sage; 2007.
  16. Husky M, Olié E, Guillaume S, Genty C, Swendsen J, Courtet P. Feasibility and validity of ecological momentary assessment in the investigation of suicide risk. Psychiatry Res 2014 Dec 15;220(1-2):564-570. [CrossRef] [Medline]
  17. Shiffman S, Stone AA, Hufford MR. Ecological momentary assessment. Annu Rev Clin Psychol 2008;4(1):1-32. [CrossRef] [Medline]
  18. Torous J, Kiang MV, Lorme J, Onnela J. New Tools for New Research in Psychiatry: A Scalable and Customizable Platform to Empower Data Driven Smartphone Research. JMIR Ment Health 2016 May 05;3(2):e16 [FREE Full text] [CrossRef] [Medline]
  19. Sedano-Capdevila A, Porras-Segovia A, Bello HJ, Baca-García E, Barrigon ML. Use of Ecological Momentary Assessment to Study Suicidal Thoughts and Behavior: a Systematic Review. Curr Psychiatry Rep 2021 May 18;23(7):41-17. [CrossRef] [Medline]
  20. Gee BL, Han J, Benassi H, Batterham PJ. Suicidal thoughts, suicidal behaviours and self-harm in daily life: A systematic review of ecological momentary assessment studies. Digit Health 2020;6:2055207620963958 [FREE Full text] [CrossRef] [Medline]
  21. Czyz E, King C, Nahum-Shani I. Ecological assessment of daily suicidal thoughts and attempts among suicidal teens after psychiatric hospitalization: Lessons about feasibility and acceptability. Psychiatry Res 2018 Sep;267:566-574 [FREE Full text] [CrossRef] [Medline]
  22. Glenn CR, Kleiman EM, Kearns JC, Boatman AE, Conwell Y, Alpert-Gillis LJ, et al. Sleep problems predict next-day suicidal thinking among adolescents: A multimodal real-time monitoring study following discharge from acute psychiatric care. Dev Psychopathol 2021 Dec 07;33(5):1701-1721. [CrossRef]
  23. Czyz EK, Berona J, King CA. A prospective examination of the interpersonal-psychological theory of suicidal behavior among psychiatric adolescent inpatients. Suicide Life Threat Behav 2015 Apr 29;45(2):243-259 [FREE Full text] [CrossRef] [Medline]
  24. Czyz EK, King CA. Longitudinal trajectories of suicidal ideation and subsequent suicide attempts among adolescent inpatients. J Clin Child Adolesc Psychol 2015;44(1):181-193 [FREE Full text] [CrossRef] [Medline]
  25. Glenn CR, Kleiman EM, Kearns JC, Santee AC, Esposito EC, Conwell Y, et al. Feasibility and Acceptability of Ecological Momentary Assessment with High-Risk Suicidal Adolescents Following Acute Psychiatric Care. J Clin Child Adolesc Psychol 2022;51(1):32-48. [CrossRef] [Medline]
  26. Dewa LH, Lavelle M, Pickles K, Kalorkoti C, Jaques J, Pappa S, et al. Young adults' perceptions of using wearables, social media and other technologies to detect worsening mental health: A qualitative study. PLoS One 2019;14(9):e0222655 [FREE Full text] [CrossRef] [Medline]
  27. O'Connor RC. The integrated motivational-volitional model of suicidal behavior. Crisis 2011;32(6):295-298. [CrossRef] [Medline]
  28. O'Connor RC, Kirtley OJ. The integrated motivational-volitional model of suicidal behaviour. Philos Trans R Soc Lond B Biol Sci 2018 Sep 05;373(1754):20170268 [FREE Full text] [CrossRef] [Medline]
  29. Littlewood D, Kyle S, Pratt D, Peters S, Gooding P. Examining the role of psychological factors in the relationship between sleep problems and suicide. Clin Psychol Rev 2017 Jun;54:1-16 [FREE Full text] [CrossRef] [Medline]
  30. Patel P, Kim JY, Brooks LJ. Accuracy of a smartphone application in estimating sleep in children. Sleep Breath 2017 May;21(2):505-511. [CrossRef] [Medline]
  31. Myin-Germeys I, Kuppens P, editors. The Open Handbook of Sampling Methodology: A Step-by-step Guide to Designing, Conducting, and Analyzing ESM Studies, 2nd ed. Leuven, Belgium: Center for Research on Experience Sampling and Ambulatory Methods; 2022.
  32. Mulligan L, Haddock G, Littlewood D, Kyle SD. Experience sampling in the study of sleep and wakefulness. In: Palmier-Claus J, Haddock G, Varese F, editors. Experience Sampling in Mental Health Research. London, UK: Routledge; Jan 2019:12-20.
  33. Dewa LH, Crandell C, Choong E, Jaques J, Bottle A, Kilkenny C, et al. CCopeY: A Mixed-Methods Coproduced Study on the Mental Health Status and Coping Strategies of Young People During COVID-19 UK Lockdown. J Adolesc Health 2021 Apr;68(4):666-675. [CrossRef] [Medline]
  34. Dewa LH, Lawrence-Jones A, Crandell C, Jaques J, Pickles K, Lavelle M, et al. Reflections, impact and recommendations of a co-produced qualitative study with young people who have experience of mental health difficulties. Health Expect 2021 May;24 Suppl 1(S1):134-146 [FREE Full text] [CrossRef] [Medline]
  35. Buysse DJ, Reynolds CF, Monk TH, Berman SR, Kupfer DJ. The Pittsburgh Sleep Quality Index: a new instrument for psychiatric practice and research. Psychiatry Res 1989 May;28(2):193-213. [CrossRef] [Medline]
  36. Espie CA, Kyle SD, Hames P, Gardani M, Fleming L, Cape J. The Sleep Condition Indicator: a clinical screening tool to evaluate insomnia disorder. BMJ Open 2014 Mar 18;4(3):e004183 [FREE Full text] [CrossRef] [Medline]
  37. Krakow B, Schrader R, Tandberg D, Hollifield M, Koss MP, Yau C, et al. Nightmare frequency in sexual assault survivors with PTSD. J Anxiety Disord 2002;16(2):175-190. [CrossRef] [Medline]
  38. Dewa LH, Hassan L, Shaw JJ, Senior J. Trouble sleeping inside: a cross-sectional study of the prevalence and associated risk factors of insomnia in adult prison populations in England. Sleep Med 2017 Apr;32:129-136 [FREE Full text] [CrossRef] [Medline]
  39. Watson D, Clark LA, Tellegen A. Development and validation of brief measures of positive and negative affect: the PANAS scales. J Pers Soc Psychol 1988 Jun;54(6):1063-1070. [CrossRef] [Medline]
  40. Kroenke K, Spitzer RL, Williams JBW. The PHQ-9: validity of a brief depression severity measure. J Gen Intern Med 2001 Sep;16(9):606-613 [FREE Full text] [CrossRef] [Medline]
  41. Spitzer RL, Kroenke K, Williams JBW, Löwe B. A brief measure for assessing generalized anxiety disorder: the GAD-7. Arch Intern Med 2006 May 22;166(10):1092-1097. [CrossRef] [Medline]
  42. Griffiths AW, Wood AM, Maltby J, Taylor PJ, Panagioti M, Tai S. The development of the Short Defeat and Entrapment Scale (SDES). Psychol Assess 2015 Dec;27(4):1182-1194. [CrossRef] [Medline]
  43. Deeprose C, Holmes EA. An exploration of prospective imagery: the impact of future events scale. Behav Cogn Psychother 2010 Mar;38(2):201-209. [CrossRef] [Medline]
  44. Nock MK, Holmberg EB, Photos VI, Michel BD. Self-Injurious Thoughts and Behaviors Interview: development, reliability, and validity in an adolescent sample. Psychol Assess 2007 Sep;19(3):309-317. [CrossRef] [Medline]
  45. Bell IH, Rossell SL, Farhall J, Hayward M, Lim MH, Fielding-Smith SF, et al. Pilot randomised controlled trial of a brief coping-focused intervention for hearing voices blended with smartphone-based ecological momentary assessment and intervention (SAVVy): Feasibility, acceptability and preliminary clinical outcomes. Schizophr Res 2020 Feb;216:479-487. [CrossRef] [Medline]
  46. Kiekens G, Hasking P, Nock MK, Boyes M, Kirtley O, Bruffaerts R, et al. Fluctuations in Affective States and Self-Efficacy to Resist Non-Suicidal Self-Injury as Real-Time Predictors of Non-Suicidal Self-Injurious Thoughts and Behaviors. Front Psychiatry 2020;11:214 [FREE Full text] [CrossRef] [Medline]
  47. Kirtley O. The Experience Sampling Method (ESM) Item Repository. Center for Open Science.   URL: [accessed 2022-05-05]
  48. Eisele G, Vachon H, Lafit G, Kuppens P, Houben M, Myin-Germeys I, et al. The Effects of Sampling Frequency and Questionnaire Length on Perceived Burden, Compliance, and Careless Responding in Experience Sampling Data in a Student Population. Assessment 2022 Mar;29(2):136-151. [CrossRef] [Medline]
  49. Germain A, Hall M, Krakow B, Katherine Shear M, Buysse DJ. A brief sleep scale for Posttraumatic Stress Disorder: Pittsburgh Sleep Quality Index Addendum for PTSD. J Anxiety Disord 2005;19(2):233-244. [CrossRef] [Medline]
  50. Carney CE, Buysse DJ, Ancoli-Israel S, Edinger JD, Krystal AD, Lichstein KL, et al. The consensus sleep diary: standardizing prospective sleep self-monitoring. Sleep 2012 Feb 01;35(2):287-302 [FREE Full text] [CrossRef] [Medline]
  51. Martin JL, Hakim AD. Wrist actigraphy. Chest 2011 Jun;139(6):1514-1527 [FREE Full text] [CrossRef] [Medline]
  52. Beck AT, Brown GK, Steer RA, Dahlsgaard KK, Grisham JR. Suicide ideation at its worst point: a predictor of eventual suicide in psychiatric outpatients. Suicide Life Threat Behav 1999;29(1):1-9. [Medline]
  53. Moineddin R, Matheson FI, Glazier RH. A simulation study of sample size for multilevel logistic regression models. BMC Med Res Methodol 2007 Jul 16;7:34 [FREE Full text] [CrossRef] [Medline]
  54. Power curves for multi-level studies. Kleiman Lab at Rutgers.   URL: [accessed 2022-03-01]
  55. Palmier-Claus JE, Myin-Germeys I, Barkus E, Bentley L, Udachina A, Delespaul PAEG, et al. Experience sampling research in individuals with mental illness: reflections and guidance. Acta Psychiatr Scand 2011 Jan;123(1):12-20. [CrossRef] [Medline]

EMA: ecological momentary assessment
ESM: Experience Sampling Methodology
IMV: integrated motivational volitional
NHS: National Health Service
PHQ-9: Patient Health Questionnaire
PSQI: Pittsburgh Sleep Quality Index
SCI: Sleep Condition Indicator
SIB: suicidal ideation and behavior
WLT: West London National Health Service Trust

Edited by T Leung; submitted 27.09.21; peer-reviewed by S Schneider, F Bos, S Wang; comments to author 08.01.22; revised version received 16.03.22; accepted 22.04.22; published 17.05.22


©Lindsay H Dewa, Sofia Pappa, Talya Greene, James Cooke, Lizzie Mitchell, Molly Hadley, Martina Di Simplicio, Thomas Woodcock, Paul Aylin. Originally published in JMIR Research Protocols (, 17.05.2022.

This is an open-access article distributed under the terms of the Creative Commons Attribution License (, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work, first published in JMIR Research Protocols, is properly cited. The complete bibliographic information, a link to the original publication on, as well as this copyright and license information must be included.