Digital self-help interventions for suicidal ideation and behaviour
Authors: Eirini Karyotaki, Wouter van Ballegooijen
Journal: The Lancet Digital Health (2019)

Suicide is widely recognised as a major public health issue that affects individuals, families, and society as a whole. Every year, suicide claims roughly 800 000 lives worldwide, making its prevention a global imperative.1WHOSuicide.https//www.who.int/news-room/fact-sheets/detail/suicideDate: Sept 2, 2019Date accessed: November 13, 2019Google Scholar Although suicide is preventable by various evidence-based strategies,2Zalsman G Hawton K Wasserman D et al.Suicide prevention strategies revisited: 10-year systematic review.Lancet Psychiatry. 2016; 3: 646-659Summary Full Text Full Text PDF PubMed Scopus (880) Google Scholar many individuals with suicidal ideation do not seek or receive treatment. Barriers to treatment include stigma, low perceived need, and preference of self-management of suicidal thoughts, among others.3Bruffaerts R Demyttenaere K Hwang I et al.Treatment of suicidal people around the world.Br J Psychiatry. 2011; 199: 64-70Crossref PubMed Scopus (232) Google Scholar Digital interventions (ie, online or app based) provide a promising strategy to address many of the treatment barriers because these interventions are confidential, can be timely accessed from everywhere, and empower the individuals to help themselves. Because of the scalability of digital interventions, populations could be reached that cannot be reached by conventional mental health care.4Fairburn CG Patel V The impact of digital technology on psychological treatments and their dissemination.Behav Res Ther. 2017; 88: 19-25Crossref PubMed Scopus (209) Google Scholar In The Lancet Digital Health, Michelle Torok and colleagues5Torok M Han J Baker S et al.Suicide prevention using self-guided digital interventions: a systematic review and meta-analysis of randomised controlled trials.Lancet Digital Health. 2019; (published online Nov 28)https://doi.org/10.1016/S2589-7500(19)30199-2Summary Full Text Full Text PDF Scopus (79) Google Scholar aimed to provide cutting-edge evidence for the effectiveness of self-help digital interventions for reducing suicidal ideation and behaviours in both the short term and the long term. Given the increasing number of randomised controlled trials in this field, a meaningful summary of the latest evidence is necessary. Moreover, the authors aimed to examine the relative effects of direct and indirect interventions for suicidal ideation. To our knowledge, this is the first systematic review and meta-analysis to compare the effects of direct and indirect digital interventions. Suicidal ideation and behaviour are transdiagnostic phenomena, which are common among patients with depression. Trials of interventions that target depression involve patients who also have suicide ideation (although the moderate-to-severe cases are typically excluded), and it has been postulated that these interventions might have some effect on suicidal ideation and behaviour.6Cuijpers P de Beurs DP van Spijker BA Berking M Andersson G Kerkhof AJ The effects of psychotherapy for adult depression on suicidality and hopelessness: a systematic review and meta-analysis.J Affect Disord. 2013; 144: 183-190Crossref PubMed Scopus (104) Google Scholar Torok and colleagues5Torok M Han J Baker S et al.Suicide prevention using self-guided digital interventions: a systematic review and meta-analysis of randomised controlled trials.Lancet Digital Health. 2019; (published online Nov 28)https://doi.org/10.1016/S2589-7500(19)30199-2Summary Full Text Full Text PDF Scopus (79) Google Scholar did a comprehensive systematic review and meta-analyses of 16 studies, comprising 4398 participants in total. The authors found that digital interventions resulted in a small but significant effect in reducing suicidal ideation after the end of treatment (Hedges' g −0·18, 95% CI −0·27 to −0·10; p<0·0001) when compared with heterogeneous control groups. However, this effect was not maintained over the long term (mean duration of follow-up was 15·60 weeks [SD 6·39] post-intervention in the five eligible studies with these data available). Concerning direct and indirect interventions, Torok and colleagues5Torok M Han J Baker S et al.Suicide prevention using self-guided digital interventions: a systematic review and meta-analysis of randomised controlled trials.Lancet Digital Health. 2019; (published online Nov 28)https://doi.org/10.1016/S2589-7500(19)30199-2Summary Full Text Full Text PDF Scopus (79) Google Scholar found a small significant effect in favour of direct intervention, which was not present for the indirect interventions. The authors concluded that direct self-help digital interventions hold promise in reducing suicidal thoughts immediately after treatment. Thus, these interventions should be widely disseminated in light of the increased demand for suicide prevention, especially in low-resourced settings. Torok and colleagues5Torok M Han J Baker S et al.Suicide prevention using self-guided digital interventions: a systematic review and meta-analysis of randomised controlled trials.Lancet Digital Health. 2019; (published online Nov 28)https://doi.org/10.1016/S2589-7500(19)30199-2Summary Full Text Full Text PDF Scopus (79) Google Scholar found that digital interventions do not have a significant effect on suicidal behaviour. However, the number of studies reporting suicidal behaviours as an outcome was small (n=5), and thus more studies are needed to conclude firmly on this outcome. Torok and colleagues5Torok M Han J Baker S et al.Suicide prevention using self-guided digital interventions: a systematic review and meta-analysis of randomised controlled trials.Lancet Digital Health. 2019; (published online Nov 28)https://doi.org/10.1016/S2589-7500(19)30199-2Summary Full Text Full Text PDF Scopus (79) Google Scholar also gave a preliminary indication of the relative effects of direct and indirect interventions by comparing the subgroups of studies that focused on each of those interventions. However, the effect sizes of the trials on indirect interventions were based on one-item or few-item measures, and in several of these trials, patients with moderate-to-severe suicide ideation were excluded. Therefore, to investigate indirect effects of depression interventions on suicide-related outcomes, future trials on online depression interventions should include patients with moderate-to-severe suicidal ideation and incorporate instruments measuring suicidal ideation and behaviour. Finally, to draw robust conclusions regarding the relative effectiveness of direct and indirect interventions, there is a need for randomised controlled trials directly comparing effects of direct versus indirect interventions in a head-to-head manner. That being said, the results of Torok and colleagues' systematic review5Torok M Han J Baker S et al.Suicide prevention using self-guided digital interventions: a systematic review and meta-analysis of randomised controlled trials.Lancet Digital Health. 2019; (published online Nov 28)https://doi.org/10.1016/S2589-7500(19)30199-2Summary Full Text Full Text PDF Scopus (79) Google Scholar are promising and highlight the need for further development in this field. Further research is needed to examine ways of sustaining favourable treatment effects over the long term. For example, future trials might consider adding booster sessions to the self-help interventions, which might help in maintaining treatment effects over longer periods of time. Furthermore, Torok and colleagues5Torok M Han J Baker S et al.Suicide prevention using self-guided digital interventions: a systematic review and meta-analysis of randomised controlled trials.Lancet Digital Health. 2019; (published online Nov 28)https://doi.org/10.1016/S2589-7500(19)30199-2Summary Full Text Full Text PDF Scopus (79) Google Scholar reported low treatment adherence, with nearly two-thirds of studies reporting that participants completed less than 50% of the treatment modules. Previous studies on digital interventions have emphasised the association between treatment adherence and treatment outcomes, suggesting that the actual effect of the treatment is higher for individuals who complete more treatment sessions than those who complete fewer sessions.7Karyotaki E Riper H Twisk J et al.Efficacy of self-guided internet-based cognitive behavioral therapy in the treatment of depressive symptoms: a meta-analysis of individual participant data.JAMA Psychiatry. 2017; 74: 351-359Crossref PubMed Scopus (387) Google Scholar Additionally, the systematic review by Torok and colleagues5Torok M Han J Baker S et al.Suicide prevention using self-guided digital interventions: a systematic review and meta-analysis of randomised controlled trials.Lancet Digital Health. 2019; (published online Nov 28)https://doi.org/10.1016/S2589-7500(19)30199-2Summary Full Text Full Text PDF Scopus (79) Google Scholar focused exclusively on self-guided interventions. The advantage of self-guided digital interventions is scalability, but research in the field of depression suggests that interventions that include face-to-face therapeutic support have overall better treatment outcomes and adherence than do unguided interventions.8Cuijpers P Noma H Karyotaki E Cipriani A Furukawa TA Effectiveness and acceptability of cognitive behavior therapy delivery formats in adults with depression: a network meta-analysis.JAMA Psychiatry. 2019; 76: 700-707Crossref PubMed Scopus (156) Google Scholar Similarly, guided interventions might have a larger effect than unguided interventions in reducing suicidal thoughts and behaviours. Despite the small effects, digital interventions that directly target suicidal thoughts can be available on a large scale and reach individuals who cannot be reached through conventional treatment services. Delivering these interventions without therapeutic guidance can further reduce the treatment costs and improve the scalability of digital interventions. We declare no competing interests. Suicide prevention using self-guided digital interventions: a systematic review and meta-analysis of randomised controlled trialsSelf-guided digital interventions directly targeting suicidal ideation are effective immediately post-intervention. Indirect interventions were not significant for reducing suicidal ideation. Our findings suggest that digital interventions should be promoted and disseminated widely, especially where there is a lack of, or minimal access to, health services. Full-Text PDF Open Access