Capturing crisis dynamics: a novel personalized approach using multilevel hidden Markov modeling.

Background: Prevention of (suicidal) crisis starts with appreciating its dynamics. However, crisis is a complex multidimensional phenomenon and how it evolves over time is still poorly understood. This study aims to clarify crisis dynamics by clustering fluctuations in the interplay of cognitive, affective, and behavioral (CAB) crisis factors within persons over time into latent states. Methods: To allow for fine grained information on CAB factors over a prolonged period of time, ecological momentary assessment data comprised of self-report questionnaires (3 × daily) on five CAB symptoms (self-control, negative affect, contact avoidance, contact desire and suicidal ideation) was collected in twenty-six patients (60 measurements per patient). Empirically-derived crisis states and personalized state dynamics were isolated utilizing multilevel hidden Markov models. Results: In this proof-of-concept study, four distinct and ascending CAB-based crisis states were derived. At the sample level, remaining within the current CAB crisis state from one five-hour interval to the next was most likely, with staying likeliness decreasing with ascending states. When residing in CAB crisis state 2 or higher, it was least likely to transition back to CAB crisis state 1. However, large patient heterogeneity was observed both in the tendency to remain within a certain CAB crisis state and transitioning between crisis states. Conclusion: The uncovered crisis states using multilevel HMM quantify and visualize the pattern of crisis trajectories at the patient individual level. The observed differences between patients underlines the need for future innovation in personalized crisis prevention, and statistical models that facilitate such a personalized approach.