Evaluation of the 113Online Suicide Prevention Crisis Chat Service: Outcomes, Helper Behaviors and Comparison to Telephone Hotlines

Evaluating the Experience of Teen-to-Teen Crisis Line Volunteers: A Pilot Study

Teen-to-teen (t2t) crisis lines are a special type of crisis service where youth volunteers help their peers. Although prior research has examined the experience of adult crisis line responders, no research has examined the experience of adolescents who do this work. In collaboration with two of the largest t2t lines in the U.S., this pilot study is the first examination of t2t crisis line work. Volunteers (ages 14-20) reported: their primary motivation for joining the crisis lines was to help others and give back to the community; responding to a range of peers' problems on the t2t crisis line, including high-risk suicide contacts; and a range of ways the crisis line work impacted their lives. Findings provide preliminary information about the experience of adolescents engaging in t2t crisis line work. Additional research is needed in larger and more diverse samples to understand the impact of crisis line work for youth.

The Most Effective Interventions for Classification Model Development to Predict Chat Outcomes Based on the Conversation Content in Online Suicide Prevention Chats: Machine Learning Approach

BACKGROUND

For the provision of optimal care in a suicide prevention helpline, it is important to know what contributes to positive or negative effects on help seekers. Helplines can often be contacted through text-based chat services, which produce large amounts of text data for use in large-scale analysis.

OBJECTIVE

We trained a machine learning classification model to predict chat outcomes based on the content of the chat conversations in suicide helplines and identified the counsellor utterances that had the most impact on its outputs.

METHODS

From August 2021 until January 2023, help seekers (N=6903) scored themselves on factors known to be associated with suicidality (eg, hopelessness, feeling entrapped, will to live) before and after a chat conversation with the suicide prevention helpline in the Netherlands (113 Suicide Prevention). Machine learning text analysis was used to predict help seeker scores on these factors. Using 2 approaches for interpreting machine learning models, we identified text messages from helpers in a chat that contributed the most to the prediction of the model.

RESULTS

According to the machine learning model, helpers' positive affirmations and expressing involvement contributed to improved scores of the help seekers. Use of macros and ending the chat prematurely due to the help seeker being in an unsafe situation had negative effects on help seekers.

CONCLUSIONS

This study reveals insights for improving helpline chats, emphasizing the value of an evocative style with questions, positive affirmations, and practical advice. It also underscores the potential of machine learning in helpline chat analysis.

Breaking Down Barriers to a Suicide Prevention Helpline: Web-Based Randomized Controlled Trial

Background

Every month, around 3800 people complete an anonymous self-test for suicidal thoughts on the website of the Dutch suicide prevention helpline. Although 70% score high on the severity of suicidal thoughts, <10% navigate to the web page about contacting the helpline.

Objective

This study aimed to test the effectiveness of a brief barrier reduction intervention (BRI) in motivating people with severe suicidal thoughts to contact the suicide prevention helpline, specifically in high-risk groups such as men and middle-aged people.

Methods

We conducted a fully automated, web-based, randomized controlled trial. Respondents with severe suicidal thoughts and little motivation to contact the helpline were randomly allocated either to a brief BRI, in which they received a short, tailored message based on their self-reported barrier to the helpline (n=610), or a general advisory text (care as usual as the control group: n=612). Effectiveness was evaluated using both behavioral and attitudinal measurements. The primary outcome measure was the use of a direct link to contact the helpline after completing the intervention or control condition. Secondary outcomes were the self-reported likelihood of contacting the helpline and satisfaction with the received self-test.

Results

In total, 2124 website visitors completed the Suicidal Ideation Attributes Scale and the demographic questions in the entry screening questionnaire. Among them, 1222 were randomized into the intervention or control group. Eventually, 772 respondents completed the randomized controlled trial (intervention group: n=369; control group: n=403). The most selected barrier in both groups was "I don't think that my problems are serious enough." At the end of the trial, 33.1% (n=122) of the respondents in the intervention group used the direct link to the helpline. This was not significantly different from the respondents in the control group (144/403, 35.7%; odds ratio 0.87, 95% CI 0.64-1.18, P=.38). However, the respondents who received the BRI did score higher on their self-reported likelihood of contacting the helpline at a later point in time (B=0.22, 95% CI 0.12-0.32, P≤.001) and on satisfaction with the self-test (B=0.27, 95% CI 0.01-0.53, P=.04). For male and middle-aged respondents specifically, the results were comparable to that of the whole group.

Conclusions

This trial was the first time the helpline was able to connect with high-risk website visitors who were hesitant to contact the helpline. Although the BRI could not ensure that those respondents immediately used the direct link to the helpline at the end of the trial, it is encouraging that respondents indicated that they were more likely to contact the helpline at a later point in time. In addition, this low-cost intervention provided greater insight into the perceived barriers to service. Follow-up research should be focused on identifying the added value of other components (eg, video or photo material) in the BRI and increasing its effectiveness, especially for men and middle-aged people.

Mindsets of suicide trajectories: An Linguistic Inquiry and Word Count analysis of suicide hotline conversations

OBJECTIVE

The aim of the study was to explore the psychological characteristics of the individuals with various suicide risks using computerized text analysis, in the hopes of a better understanding of suicide trajectories.

METHODS

627 first-time callers' records were randomly selected from Taiwan An-Shin Hotline database between 2013 and 2018. The voice records were evaluated by two psychologists to determine the levels of suicide risk (156 with uncertainty of risk, 177 with low suicidal ideation, 157 with high suicidal ideation, and 137 with suicide preparation/attempt) and transcribed into text. The Linguistic Inquiry and Word Count 2015 (LIWC2015) program combined with Chinese dictionary were then used to calculate the frequency of word categories.

RESULTS

Exploratory factor analysis identified four mindsets of language characteristics, named "opposition and questioning", "active engagement", "negative rumination", and "focus on death". Psychological descriptions of the mindsets were also obtained through correlation analysis with the LIWC2015 categories and indicators. The four mindsets effectively distinguished the callers with different levels of suicide risk.

CONCLUSION

The psychological characteristics of people with various suicide risks can be described and differentiated via the closed-word categories and composite indicators. These results provide useful information for practitioners and researchers.

Users' Perspectives on Crisis Helplines in Relation to Professional Mental Health Services

Background: Crisis helplines aim to provide a short-term intervention or guide users to professional mental health services, but many users return to helplines despite having professional mental health contacts. Aims: To contribute knowledge on users' perspectives on the role of crisis helplines in relation to their professional mental health contacts, we aimed to investigate how online helpline users describe such services. Methods: We used thematic analysis of 100 naturally occurring interactions from a Swedish online crisis helpline. Results: The users viewed the helpline as a safe space, a partner, or an alternative to bad professional services. Users oriented to ongoing helpline usage as crucial for their well-being while they described using professional mental health services to be able to stay alive. Limitations: The findings are limited to the nature of the different themes. Conclusion: The view on crisis helplines as a short-term intervention relies on an idealized view on crisis intervention that does not represent users' views. User control is at the core of the appeal of helplines, but it is also a key challenge for organizations and volunteers.

Development and Evaluation of Online Suicide Preventive Tool iAlive to Increase Competences in Engaging With a Suicidal Person

Background: Online implementation of suicide prevention interventions offers many advantages, facilitating the dissemination of large-scale suicide prevention interventions. An online tool iAlive aimed at raising awareness and increasing suicide prevention competences in lay people was developed and implemented in Slovenia. Aims: To develop, implement, and evaluate the iAlive tool. Method: Following the development and implementation of the tool, a nonrandomized controlled study with 310 participants was conducted. One hundred fifty-six of them fully completed the study [intervention group (used the iAlive tool): N = 85, control group (did not use the tool): N = 71]. Perceived competences in engaging with a suicidal person were assessed in both groups at baseline and at follow-up (3-4 weeks apart), which also represents the time of the intervention. Results: A significant effect of time and condition [F(1,149) = 6.62, p = .011, ηp2 = .043] showed that the intervention group assessed their perceived competences on intervention exposure more positively compared to the control group. Limitations: Additional data on different populations and people's engagement with the tool in relation to perceived competences are needed. Conclusion: The study suggests that the interactive online tool iAlive effectively increases perceived competences in engaging with a suicidal person. These results provide a background for further dissemination of the tool.

Evaluation of the Effectiveness of Suicide.ca, Quebec's Digital Suicide Prevention Strategy Platform: Cross-Sectional Descriptive Study

BACKGROUND

In 2017, the Quebec government assigned the Association québécoise de prévention du suicide (AQPS) to develop a digital suicide prevention strategy (DSPS). The AQPS responded by creating a centralized website that provides information on suicide and mental health, identifies at-risk individuals on the internet, and offers direct crisis intervention support via chat and text.

OBJECTIVE

This study aims to evaluate the effectiveness of suicide.ca, Quebec's DSPS platform.

METHODS

This study used a cross-sectional descriptive design. The study population comprised internet users from Quebec, Canada, who visited the suicide.ca platform between October 2020 and October 2021. Various data sources, such as Google Analytics, Firebase Console, and Customer Relation Management data, were analyzed to document the use of the platform. To understand the profile of suicide.ca users, frequency analyses were conducted using data from the self-assessment module questionnaires, the intervention service's triage questionnaire, and the counselors' intervention reports. The effectiveness of the platform's promotional activities on social media was assessed by examining traffic peaks. Google Analytics was used to evaluate the effectiveness of AQPS' strategy for identifying at-risk internet users. The impact of the intervention service was evaluated through an analysis of counselors' intervention reports and postintervention survey results.

RESULTS

The platform received traffic from a diverse range of sources, with promotional efforts on social media directly contributing to the increased traffic. The requirement of a user account posed a barrier to the use of the mobile app, and a triage question that involved personal information led to a substantial number of dropouts during the intervention service triage. AdWords campaigns and fact sheets addressing suicide risk factors played a crucial role in driving traffic to the platform. With regard to the profile of suicide.ca users, the findings revealed that the platform engaged individuals with diverse levels of suicidal risk. Notably, users of the chat service displayed a higher suicide risk than those who used the self-assessment module. Crisis chat counselors reported a positive impact on approximately half of the contacts, and overall, intervention service users expressed satisfaction with the support they received.

CONCLUSIONS

A centralized digital platform can be used to implement a DSPS, effectively reaching the general population, individuals with risk factors for suicide, and those facing suicidal issues.

Linguistic Variables and Gender Differences Within a Messenger-Based Psychosocial Chat Counseling Service for Children and Adolescents: Cross-Sectional Study

BACKGROUND

Text messaging is widely used by young people for communicating and seeking mental health support through chat-based helplines. However, written communication lacks nonverbal cues, and language usage is an important source of information about a person's mental health state and is known to be a marker for psychopathology.

OBJECTIVE

The aim of the study was to investigate language usage, and its gender differences and associations with the presence of psychiatric symptoms within a chat counseling service for adolescents and young adults.

METHODS

For this study, the anonymized chat content of a German messenger-based psychosocial chat counseling service for children and adolescents ("krisenchat") between May 2020 and July 2021 was analyzed. In total, 661,131 messages from 6962 users were evaluated using Linguistic Inquiry and Word Count, considering the following linguistic variables: first-person singular and plural pronouns, negations, positive and negative emotion words, insight words, and causation words. Descriptive analyses were performed, and gender differences of those variables were evaluated. Finally, a binary logistic regression analysis examined the predictive value of linguistic variables on the presence of psychiatric symptoms.

RESULTS

Across all analyzed chats, first-person singular pronouns were used most frequently (965,542/8,328,309, 11.6%), followed by positive emotion words (408,087/8,328,309, 4.9%), insight words (341,460/8,328,309, 4.1%), negations (316,475/8,328,309, 3.8%), negative emotion words (266,505/8,328,309, 3.2%), causation words (241,520/8,328,309, 2.9%), and first-person plural pronouns (499,698/8,328,309, 0.6%). Female users and users identifying as diverse used significantly more first-person singular pronouns and insight words than male users (both P<.001). Negations were significantly more used by female users than male users or users identifying as diverse (P=.007). Similar findings were noted for negative emotion words (P=.01). The regression model of predicting psychiatric symptoms by linguistic variables was significant and indicated that increased use of first-person singular pronouns (odds ratio [OR] 1.05), negations (OR 1.11), and negative emotion words (OR 1.15) was positively associated with the presence of psychiatric symptoms, whereas increased use of first-person plural pronouns (OR 0.39) and causation words (OR 0.90) was negatively associated with the presence of psychiatric symptoms. Suicidality, self-harm, and depression showed the most significant correlations with linguistic variables.

CONCLUSIONS

This study highlights the importance of examining linguistic features in chat counseling contexts. By integrating psycholinguistic findings into counseling practice, counselors may better understand users' psychological processes and provide more targeted support. For instance, certain linguistic features, such as high use of first-person singular pronouns, negations, or negative emotion words, may indicate the presence of psychiatric symptoms, particularly among female users and users identifying as diverse. Further research is needed to provide an in-depth look into language processes within chat counseling services.

The Impact of the COVID-19 Pandemic on Calls to a National Suicide Prevention Hotline in Taiwan: An Analysis of Time Trend and Characteristics of Calls

We investigated the impact of the COVID-19 pandemic on call volumes and call characteristics using data from a national crisis helpline. Data were extracted for 215,066 calls to Taiwan's national suicide prevention hotline (January 2018-May 2020). We used negative binomial regression to investigate changes in the weekly number of calls during the early period of the COVID-19 outbreak (January 21, 2020-May 25, 2020), relative to that expected according to the pre-pandemic trend. The call characteristics during the pandemic period (February 18, 2020-May 31, 2020) were compared between COVID-19 related vs unrelated calls. Higher-than-expected call volumes started from the 6th week of the pandemic and reached a peak in the 14th week, which was 38% (rate ratio = 1.38, 95% confidence interval 1.26-1.51) higher than that expected based on the pre-pandemic trend. The higher-than-expected call volumes were mainly attributable to higher-than-expected calls from non-suicidal and male callers. Calls in which COVID-19 was mentioned (13.2%) were more likely to be from male and first-time callers, occur outside 12 am-6 am, last less than 5 min, and were less likely to be from callers who had previous suicide attempts, recent suicidal ideation or suicide plans or actions than COVID-19 unrelated calls. Callers who made COVID-19 related calls were more likely to request information than other callers. Crisis helplines should strategically adapt to the increased need and callers' specific concerns related to the outbreak.

Who are frequent chatters? Characterization of frequent users in a 24/7 messenger-based psychological chat counseling service for children and adolescents

Background

Online helplines have shown a high acceptance, feasibility, and usability, especially with young people. Helplines usually aim to provide one-time crisis intervention; however, there are users who frequently use such services, tying a disproportionately large proportion of service capacities. To date, there is no research on the characterization of frequent users of online helplines. Therefore, the aim of the present study is to characterize frequent chatters in a chat-based counseling context.

Methods

This cross-sectional study retrospectively analyzed anonymous data of users who approached the German messenger-based psychological chat counseling service krisenchat between May 2020 and July 2021 (N = 6657), with a focus on frequent users - the "frequent chatters". Frequent chatters were defined as those who received an above average (M + 2 ∗ SD) amount of messages from counselors over a period of one week and had at least 7 days of contact with the service over the entire data collection period. Chi-square-tests and Mann-Whitney-U tests were conducted to identify differences between frequent users and the population of all users.

Results

In total, n = 99 (1.5 %) users met the definition for frequent chatters and accounted for roughly a tenth (9.85 %) of all chats of the service. The mean frequent chatter was 17 years old (M = 17.29, SD = 3.56), female (n = 78, 82.1 %), and approached the service in the late afternoon (M = 5:00 pm, SD = 5:25 h). Compared to the general user population, frequent chatters reported significantly more severe concerns to counselors, of which 81.8 % included psychiatric symptoms, such as suicidality (43.4 %) and non-suicidal self-injury (41.4 %). In addition, frequent chatters were significantly more likely to contact krisenchat alongside the use of other professional help services. Further, frequent chatters wrote significantly longer and more messages during the counseling process and within a session than the general user population of krisenchat. Compared to the general user population, frequent chatters did not differ in their satisfaction with the service.

Conclusion

Frequent users are known from telephone helplines and are also represented in a chat-based context. Compared to the general user population, they are more likely to report serious mental health conditions and half of them currently receive professional help, suggesting a high need for social support. In light of the increasing development of chat-based helplines, there is a need for further research on frequent chatters to develop tailored counseling strategies for their needs and to analyze options for an optimized service provision.

Study registration

DRKS00026671.

The Impact of COVID-19 on the Suicide Prevention Helpline in The Netherlands

Background: Although the number of suicides did not increase in 2020, there are concerns about the mental health consequences of the COVID-19 pandemic. Aims: To present the demand for the Dutch suicide prevention helpline during times of lockdown and to describe the coronavirus-related problems discussed. Methods: An observational and exploratory study analyzing the frequency of helpline requests and registration data (n = 893 conversations). Results: Demand for the helpline did increase, but with no distinctive relation with the lockdown measures. During the first lockdown, approximately a quarter of the analyzed helpline conversations were registered as coronavirus-related by the counselors. Most frequently mentioned conversation topics were the interruption to or changes in professional help, social isolation and loss of structure, and ways to find a distraction from suicidal thoughts/rumination. Limitations: Observational study design prevents causal inferences, and demand for the helpline is impacted by multiple factors. Conclusion: These coronavirus-related problems made help-seekers vulnerable to suicidal thoughts and a reduced desire to live. That many suffered from loneliness is concerning as this contributes to the risk of suicidal ideation. The distress among help-seekers due to the sudden loss of mental health care underscores the importance of maintaining contact with those in care and lowering the threshold for help.

Forecasting call and chat volumes at online helplines for mental health

BACKGROUND

Each year, many help seekers in need contact health helplines for mental support. It is crucial that they receive support immediately, and that waiting times are minimal. In order to minimize delay, helplines must have adequate staffing levels, especially during peak hours. This has raised the need for means to predict the call and chat volumes ahead of time accurately. Motivated by this, in this paper, we analyze real-life data to develop models for accurately forecasting call volumes, for both phone and chat conversations for online mental health support.

METHODS

This research was conducted on real call and chat data (adequately anonymized) provided by 113 Suicide Prevention (Over ons | 113 Zelfmoordpreventie) (throughout referred to as '113'), the online helpline for suicide prevention in the Netherlands. Chat and phone call data were analyzed to better understand the important factors that influence the call arrival process. These factors were then used as input to several Machine Learning (ML) models to forecast the number of call and chat arrivals. Next to that, senior counselors of the helpline completed a web-based questionnaire after each shift to assess their perception of the workload.

RESULTS

This study has led to several remarkable and key insights. First, the most important factors that determine the call volumes for the helpline are the trend, and weekly and daily cyclic patterns (cycles), while monthly and yearly cycles were found to be non-significant predictors for the number of phone and chat conversations. Second, media events that were included in this study only have limited-and only short-term-impact on the call volumes. Third, so-called (S)ARIMA models are shown to lead to the most accurate prediction in the case of short-term forecasting, while simple linear models work best for long-term forecasting. Fourth, questionnaires filled in by senior counselors show that the experienced workload is mainly correlated to the number of chat conversations compared to phone calls.

CONCLUSION

(S)ARIMA models can best be used to forecast the number of daily chats and phone calls with a MAPE of less than 10 in short-term forecasting. These models perform better than other models showing that the number of arrivals depends on historical data. These forecasts can be used as support for planning the number of counselors needed. Furthermore, the questionnaire data show that the workload experienced by senior counselors is more dependent on the number of chat arrivals and less on the number of available agents, showing the value of insight into the arrival process of conversations.

Eliciting Insights From Chat Logs of the 25X5 Symposium to Reduce Documentation Burden: Novel Application of Topic Modeling

BACKGROUND

Addressing clinician documentation burden through "targeted solutions" is a growing priority for many organizations ranging from government and academia to industry. Between January and February 2021, the 25 by 5: Symposium to Reduce Documentation Burden on US Clinicians by 75% (25X5 Symposium) convened across 2 weekly 2-hour sessions among experts and stakeholders to generate actionable goals for reducing clinician documentation over the next 5 years. Throughout this web-based symposium, we passively collected attendees' contributions to a chat functionality-with their knowledge that the content would be deidentified and made publicly available. This presented a novel opportunity to synthesize and understand participants' perceptions and interests from chat messages. We performed a content analysis of 25X5 Symposium chat logs to identify themes about reducing clinician documentation burden.

OBJECTIVE

The objective of this study was to explore unstructured chat log content from the web-based 25X5 Symposium to elicit latent insights on clinician documentation burden among clinicians, health care leaders, and other stakeholders using topic modeling.

METHODS

Across the 6 sessions, we captured 1787 messages among 167 unique chat participants cumulatively; 14 were private messages not included in the analysis. We implemented a latent Dirichlet allocation (LDA) topic model on the aggregated dataset to identify clinician documentation burden topics mentioned in the chat logs. Coherence scores and manual examination informed optimal model selection. Next, 5 domain experts independently and qualitatively assigned descriptive labels to model-identified topics and classified them into higher-level categories, which were finalized through a panel consensus.

RESULTS

We uncovered ten topics using the LDA model: (1) determining data and documentation needs (422/1773, 23.8%); (2) collectively reassessing documentation requirements in electronic health records (EHRs) (252/1773, 14.2%); (3) focusing documentation on patient narrative (162/1773, 9.1%); (4) documentation that adds value (147/1773, 8.3%); (5) regulatory impact on clinician burden (142/1773, 8%); (6) improved EHR user interface and design (128/1773, 7.2%); (7) addressing poor usability (122/1773, 6.9%); (8) sharing 25X5 Symposium resources (122/1773, 6.9%); (9) capturing data related to clinician practice (113/1773, 6.4%); and (10) the role of quality measures and technology in burnout (110/1773, 6.2%). Among these 10 topics, 5 high-level categories emerged: consensus building (821/1773, 46.3%), burden sources (365/1773, 20.6%), EHR design (250/1773, 14.1%), patient-centered care (162/1773, 9.1%), and symposium comments (122/1773, 6.9%).

CONCLUSIONS

We conducted a topic modeling analysis on 25X5 Symposium multiparticipant chat logs to explore the feasibility of this novel application and elicit additional insights on clinician documentation burden among attendees. Based on the results of our LDA analysis, consensus building, burden sources, EHR design, and patient-centered care may be important themes to consider when addressing clinician documentation burden. Our findings demonstrate the value of topic modeling in discovering topics associated with clinician documentation burden using unstructured textual content. Topic modeling may be a suitable approach to examine latent themes presented in web-based symposium chat logs.

A machine learning approach to identifying suicide risk among text-based crisis counseling encounters

Introduction

With the increasing utilization of text-based suicide crisis counseling, new means of identifying at risk clients must be explored. Natural language processing (NLP) holds promise for evaluating the content of crisis counseling; here we use a data-driven approach to evaluate NLP methods in identifying client suicide risk.

Methods

De-identified crisis counseling data from a regional text-based crisis encounter and mobile tipline application were used to evaluate two modeling approaches in classifying client suicide risk levels. A manual evaluation of model errors and system behavior was conducted.

Results

The neural model outperformed a term frequency-inverse document frequency (tf-idf) model in the false-negative rate. While 75% of the neural model's false negative encounters had some discussion of suicidality, 62.5% saw a resolution of the client's initial concerns. Similarly, the neural model detected signals of suicidality in 60.6% of false-positive encounters.

Discussion

The neural model demonstrated greater sensitivity in the detection of client suicide risk. A manual assessment of errors and model performance reflected these same findings, detecting higher levels of risk in many of the false-positive encounters and lower levels of risk in many of the false negatives. NLP-based models can detect the suicide risk of text-based crisis encounters from the encounter's content.

Scoping review: Alternatives to self-harm recommended on mental health self-help websites

Less than half of all young people with mental health difficulties will seek professional treatment. Due to the private nature of self-harm it is estimated that only 1:28 young males and 1:18 young females who self-harm ever present to hospital. Self-help supports improved coping strategies and life changes without reliance on a clinical intervention which could be used to reduce self-harming behaviours. The study objective is to review self-help alternatives to self-harm on mental health websites that can be accessed by young people. Google, Bing, and Yahoo search engines were used to search for appropriate websites. Eighty-two unique websites on mental health were identified, of which 55 met the inclusion criteria. A total of 1177 self-help suggestions were found for those struggling with self-harm urges. The average number of suggestions per site was 42 (Range 3-252). The main techniques suggested were: seeking social contact/help, physical activity, displacement/mimicking techniques, relaxing/comforting techniques, sensory techniques, fun/diverting techniques, aggressive techniques, creative/reflective techniques. This review found not all strategies were suitable for young people and that the large number of possible strategies could be challenging for a young person to navigate. However, mental health self-help websites were generally of high quality and gave a range of potentially helpful strategies. The categories created from this review could be used as a guide to consider with the young person when making an individualized self-help plan to manage self-harm urges. Further research is required to assess if and how these techniques could be used individually or in combination to reduce self-harm.

Crisis Lines: Current Status and Recommendations for Research and Policy

OBJECTIVE

The 988 telephone number was established by the National Suicide Hotline Designation Act of 2020 and implemented in July 2022 as a more accessible way to reach the National Suicide Prevention Lifeline. Current financial and training resources, however, are insufficient to ensure effective implementation.

METHODS

To better understand the state of the literature on crisis support lines in light of the 988 transition, the authors summarized research on suicidal and nonsuicidal outcomes of callers, research on other types of crisis support services, and the benefits of text- and chat-based crisis lines.

RESULTS

Overall, existing evidence for the effectiveness of crisis lines has been weak and has primarily focused on short-term improvements in user distress and on user satisfaction. In addition, research on crisis lines specifically targeted to marginalized populations (e.g., sexual minority groups) and on text- or chat-based crisis lines is lacking.

CONCLUSIONS

The policy-focused recommendations derived from this review include the need for additional research on crisis lines, design and evaluation of culturally tailored training for volunteers and staff, and ethical oversight of private data collected from crisis services. Scaling up state-level planning and comprehensive crisis systems is necessary to successfully implement 988 and to fill current training and research gaps.

Effect of helping suicidal people using text messaging: An evaluation of effects and best practices of the Canadian suicide prevention Service's text helpline

BACKGROUND

Empirical research on best practices in suicide prevention text intervention is scarce. We present analyses of exchanges concerning suicide on the Canadian Suicide Prevention Service (CSPS) text helpline.

OBJECTIVE

To describe the users of the CSPS text service, explore the perceived impact of the service, and identify intervention characteristics associated with a greater likelihood of positive or negative effects of the exchanges.

METHODS

We analyzed data from 112 transcripts using quantitative content analysis, counselor assessments of the calls, and responses by callers to pre-call questionnaires.

RESULTS

Counselors infrequently conducted a complete suicide risk assessment, but almost always thoroughly explored resources and discussed possible solutions to callers' problems. An operational action plan was rarely developed. Only one technique, reinforcing a strength or a positive action of the caller, was a significant predictor of positive effects of the call. The number of words exchanged during the intervention was positively correlated with the completeness of explorations of resources and solutions and the development of an action plan.

CONCLUSIONS

High-quality effective interventions can be delivered via text messages. Using reinforcement of strengths and encouraging longer calls is recommended. Intervention effects were comparable to those reported in studies of telephone and chat services.

Can Outcomes of a Chat-Based Suicide Prevention Helpline Be Improved by Training Counselors in Motivational Interviewing? A Non-randomized Controlled Trial

Objective

To examine whether the outcomes of a chat-based suicide-prevention helpline could be improved by training counselors in motivational interviewing (MI).

Methods

In a pre- and post-test design, visitors of a chat-based suicide prevention helpline received either the Five-Phase Model (treatment as usual [TAU]) or MI. They completed a pre- and post-chat questionnaire on several suicide-related risk factors. Linear mixed modeling was used to estimate the effect of the condition. Furthermore, the treatment proficiency of newly trained counselors was assessed using MI-Scope.

Results

A total of 756 visitors and 55 counselors were included in this study. The visitors showed an improvement in suicidal ideation and psychological risk factors after a chat conversation. However, there were no significant differences between the MI and TAU conditions (β = 0.03, 95% CI [−0.23–0.30], p = 0.80). The treatment integrity indices showed that the counselors mostly used MI-consistent techniques but were unable to strategically employ these techniques to evoke enough change talk.

Conclusions

MI and TAU led to comparable outcomes in a chat-based suicide prevention helpline. The effectiveness of MI might improve by intensifying or improving the training of counselors, keeping the process of engaging more concise or offering visitors multiple sessions of MI.

Lifeline Crisis Chat: Coding form development and findings on chatters' risk status and counselor behaviors

OBJECTIVE

This study aimed to develop a reliable tool for the abstraction of data from crisis chat transcripts; to describe chatters' suicide risk status and selected counselor behaviors; and to examine the relationship of chatters' self-reported pre-chat suicidal thoughts to counselor behaviors and to chatters' disclosures of suicide risk during the chat conversation.

METHODS

Coders used an instrument developed for this study to abstract data from 1034 crisis chats handled by the National Suicide Prevention Lifeline Crisis Chat network in 2015. The relationship of transcript coding data to data from an automated pre-chat survey (PCS) was examined.

RESULTS

Lifeline Crisis Chat serves a young (median age = 21), high-risk population: 84.0% of chats (869/1034) came from chatters endorsing current or recent suicidal thoughts on the PCS. Counselors engaged in rapport-building on 93.3%, problem-solving on 70.1%, and suicide risk assessment on 67.7% of these 869 chats. Counselor risk assessment behavior, and the availability of information on suicide risk in the chat transcript, varied significantly by the chatter's PCS response.

CONCLUSION

Crisis counselors are able to implement keystones of Lifeline's crisis intervention model over the medium of online chat. Additional efforts are needed to ensure that suicide risk is assessed on every chat.

Crisis text-line interventions: Evaluation of texters' perceptions of effectiveness

OBJECTIVE

Crisis Text Line (CTL), the largest provider of text-based crisis intervention services in the U.S., has answered nearly 7 million conversations since its inception in 2013. The study's objective was to assess texter's perceptions of the effectiveness of CTL crisis interventions.

METHOD

Survey data completed by 85,877 texters linked to volunteer crisis counselor (CC) reports from October 12, 2017, to October 11, 2018 were analyzed. The relationship of several effectiveness measures with texters' demographic and psychosocial characteristics, frequency of CTL usage, and texters' perceptions of engagement with their CCs was examined using a series of logistic regression analyses.

RESULTS

By the end of the text-based conversation, nearly 90% of suicidal texters reported that the conversation was helpful, and nearly half reported being less suicidal.

CONCLUSIONS

Our study offers evidence for CTL's perceived effectiveness. These findings are of critical importance in light of the launch of a nationwide three-digit number (988) for suicide prevention and mental health crisis supports in the U.S., which will include texting.

What twitter can tell us about user experiences of crisis text lines: A qualitative study

Mental health problems are the leading cause of disability worldwide. Despite the prevalence and cost of mental illness, there are insufficient health services to meet this demand. Crisis hotlines have a number of advantages for addressing mental health challenges and reducing barriers to support. Mental health crisis services have recently expanded beyond telephone hotlines to include other communication modalities such as chat and text messaging services, largely in response to the increased use of mobile phones and text messaging for social communication. Despite the high uptake of crisis text line services (CTLs) and rising mental health problems worldwide, CTLs remain understudied. The current study aimed to address an urgent need to evaluate user experiences with text-based crisis services. This study explored user experiences of CTLs by accessing users' publicly available Twitter posts that describe personal use and experience with CTLs. Data were qualitatively analyzed using thematic analysis. Six main themes were identified from 776 tweets: (1) approval of CTLs, (2) helpful counselling, (3) invalidating or unhelpful counselling, (4) problems with how the service is delivered, (5) features of the service that facilitate accessibility, and (6) indication that the service suits multiple needs. Overall, results provide evidence for the value of text-based crisis support, as many users reported positive experiences of effective counselling that provided helpful coping skills, de-escalation, and reduction of harm. Results also identified areas for improvement, particularly ensuring more timely service delivery and effective communication of empathy. Text-based services may require targeted training to apply methods that effectively convey empathy in this medium. Moving forward, CTL services will require systematic attention in the clinical research literature to ensure their continued success and popularity among users.

Suicidal Ideation Among Children and Young Adults in a 24/7 Messenger-Based Psychological Chat Counseling Service

BACKGROUND

Suicidality in children and young adults is a pervasive problem: approximately 40% of respondents in epidemiological surveys in German schools reported suicidal ideation, while up to 9% reported a suicide attempt in the past. While there is compelling evidence for the effectiveness of telephone-based hotline services, an increasing preference of adolescents for messenger-based counseling services can be observed. Therefore, the present study aims to investigate the utilization behavior and user satisfaction of users contacting a German messenger-based chat counseling service ("krisenchat") regarding suicidal ideation.

METHODS

The present cross-sectional study analyzed retrospective anonymous data on sociodemographic variables, utilization behavior, and user satisfaction of krisenchat users who used the service between May 2020 and July 2021. Chi-square-tests were used to identify associations of sociodemographic characteristics and utilization behavior with suicidal ideation. Mann-Whitney-U-tests were used to compare the user satisfaction and the recommendation-to-others-rate between suicidal and non-suicidal krisenchat-users.

RESULTS

In total, chat data of N = 11,031 users were collected. Of the n = 6,962 users included in the final analysis, n = 1,444 (20.7%) contacted krisenchat because of suicidal ideation. The average user experiencing suicidal ideation was 17 years old, female and currently not receiving other treatment. Further, suicidal ideation was significantly and positively associated with age and non-suicidal self-injury. Regarding utilization patterns, there were significant positive associations between suicidal ideation and counseling session count, mean amount of messages sent, and mean amount of words used per message by the user. User satisfaction was high, with 64.7% (n = 413) of users that answered the feedback survey and experiencing suicidal ideation rating the help they received as at least "good" and a recommendation rate of 89.6% (n = 571). Most importantly, no differences were found between users reporting suicidal ideation and those that do not regarding satisfaction and the probability of recommending the service.

CONCLUSION

Results imply satisfaction with the counseling service among users with suicidal ideation. Nevertheless, there is a need for further research into messenger-based counseling services regarding the prevention of suicidal behavior in children, youths, and young adults. Longitudinal studies are especially needed to assess the effectiveness of messenger-based interventions.

STUDY REGISTRATION

DRKS00026671.

How the helping process unfolds for clients in suicidal crises: Linking helping-style trajectories with outcomes in online crisis chats

OBJECTIVES

Crisis counselors' active listening and collaborative problem-solving helping styles have been associated with outcomes for clients in suicidal crises. These associations have been based on static conceptualizations of helping (i.e., helping style for the entire session). Our aim was to further understand how the crisis counseling helping process unfolds (i.e., helping trajectory) and helping trajectories' association with clients' outcomes.

METHODS

Online crisis chats (N = 269) with suicidal adults were coded for crisis counselors' helping styles (i.e., active listening and collaborative problem-solving) and clients' outcomes (i.e., resolved or unresolved). Each talk-turn was coded for helping style, which were used to examine helping-style trajectories.

RESULTS

Growth-curve models indicated that helping styles varied over the course of chats and that helping trajectories were different for resolved and unresolved chats. In resolved chats, helping styles moved from primarily active listening to primarily problem-solving-with a deceleration in the middle of chats. In unresolved chats, helping initially moved from primarily active listening to primarily problem-solving, but this trajectory decelerated in the middle of chats and then turned back toward primarily active listening.

CONCLUSION

Our findings demonstrate that how the helping process unfolds is related to clients' outcomes. Implications for practice and research are discussed.

National Suicide Prevention Lifeline crisis chat interventions: Evaluation of chatters' perceptions of effectiveness

OBJECTIVE

As part of the National Suicide Prevention Lifeline's crisis response system, the Lifeline Crisis Chat Network (LCC) answers chats from hundreds of thousands of at-risk individuals yearly. The study's objective was to assess the effectiveness of these online crisis interventions.

METHOD

Data from 39,911 pre-chat surveys and 13,130 linked pre- and post-chat surveys completed by LCC chatters from October 2017-June 2018 were analyzed. The relationship of several effectiveness measures with chatter demographics, pre-chat distress, suicidal ideation, and chatters' perceptions of engagement with their counselors was examined using a series of logistic regression analyses.

RESULTS

Chatters were significantly and substantially less distressed at the end of the chat intervention than at the beginning. By the end of the chat, two-thirds of suicidal chatters reported that the chat had been helpful, while just under half reported being less suicidal.

CONCLUSIONS

Our study offers empirical evidence for the Lifeline's online crisis chat services' effectiveness, but also highlights areas for improvement. This is of critical import in light of the recent designation of 988 as the nationwide number for the Lifeline beginning in 2022, which will increase the Lifeline's prominence in providing suicide prevention and mental health crisis interventions in the United States.

Detecting premature departure in online text-based counseling using logic-based pattern matching

BACKGROUND

More so than face-to-face counseling, users of online text-based services might drop out from a session before establishing a clear closure or expressing the intention to leave. Such premature departure may be indicative of heightened risk or dissatisfaction with the service or counselor. However, there is no systematic way to identify this understudied phenomenon.

PURPOSE

This study has two objectives. First, we developed a set of rules and used logic-based pattern matching techniques to systematically identify premature departures in an online text-based counseling service. Second, we validated the importance of premature departure by examining its association with user satisfaction. We hypothesized that the users who rated the session as less helpful were more likely to have departed prematurely.

METHOD

We developed and tested a classification model using a sample of 575 human-annotated sessions from an online text-based counseling platform. We used 80% of the dataset to train and develop the model and 20% of the dataset to evaluate the model performance. We further applied the model to the full dataset (34,821 sessions). We compared user satisfaction between premature departure and completed sessions based on data from a post-session survey.

RESULTS

The resulting model achieved 97% and 92% F1 score in detecting premature departure cases in the training and test sets, respectively, suggesting it is highly consistent with the judgment of human coders. When applied to the full dataset, the model classified 15,150 (43.5%) sessions as premature departure and the remaining 19,671 (56.5%) as completed sessions. Completed cases (15.2%) were more likely to fill the post-chat survey than premature departure cases (4.0%). Premature departure was significantly associated with lower perceived helpfulness and effectiveness in distress reduction.

CONCLUSIONS

The model is the first that systematically and accurately identifies premature departure in online text-based counseling. It can be readily modified and transferred to other contexts for the purpose of risk mitigation and service evaluation and improvement.

Assessing Crisis Chat Visitors' Capacity to Regulate Thoughts Related to Suicide

Background: Regulation of suicidal thoughts may be defined as a person's beliefs about their capacity to control affective and cognitive processes related to suicide. The inability to regulate suicidal thoughts is related to persistent suicidal thoughts, intentions, attempts, and suicide. Aims: The purpose of this study was to validate a scale that counselors could use to assess chat visitors' capacity to regulate suicidal thoughts. Method: The validity and reliability of the Regulation of Suicidal Thoughts Scale (RSTS) was evaluated using two different samples (n = 1,162, n = 241). Results: All items correlated with the theoretical construct regulation of suicidal thoughts, and the structural model showed the RSTS predicted perceived certainty to attempt suicide. Construct and criterion validity were inferred from a decrease in visitors' ability to control their thoughts of suicide from pre-chat to post-chat (Cohen's d = 91). Greater regulation in thoughts was also related to less certainty to attempt suicide. Limitations: Additional evidence is needed to validate the RSTS, especially among diverse populations. Conclusion: Counselors could use RSTS pre-chat scores to match counseling skills with specific affective and cognitive processes related to visitors' suicidal thoughts.

Suicide-related calls to a national crisis chat hotline service during the COVID-19 pandemic and lockdown

BACKGROUND

A COVID-19 pandemic-related rise in suicide rates has been predicted due to social isolation, fear, uncertainty, economic turndown and grief. Detecting an increase in suicide rates is difficult in the absence of real-time data. Alternative data sources for such trends in psychopathology and suicidal behavior must be sought.

METHODS

Data from a national chat-based crisis hotline for the first half of 2019 (pre-COVID-19), were compared to data from the first half of 2020 (during COVID-19). Chat sessions were classified by content and demographics and the data compared between the two time periods.

OUTCOME

Total chats (n = 6756) were 48% higher during COVID-19 (p < .05). Suicide-related chat (SRC) number was also higher, although the proportion relative to all chats was slightly lower during COVID-19, compared to pre-COVID-19 (p < .05). SRCs increased during the COVID-19 lockdown. The number of severe SRCs resulting in urgent police intervention, increased during the lockdown (April-May 2020) compared with the same period in 2019 (p = .04). Issues of anxiety were higher in 2020 (19.4%) vs. 2019 (16.5%) (p < .00001) while issues of depression were lower (22.4% vs 33%, respectively) (p < .00001). The overall use of chats among adults aged >50 yrs increased during COVID-19 and likewise, the rate of SRCs in this age-group increased 30-fold in this period when compared to pre-COVID-19 (p < .00001). SRCs included more women than men (p < .0001) in both pre-COVID-19 and during the COVID-19 period, when the proportion of women increased from 62% in 2019 to 73% during COVID-19 (p < .0001).

INTERPRETATION

The rise in total chats, SRCs and SRCs resulting in police action, commenced during lockdown and was ameliorated by end of the lockdown, indicating that distress created by the lockdown was more impactful than mourning deaths of loved ones, fear and uncertainty, because all these factors persisted beyond the end of the lockdown. Older populations were probably more distressed due to greater risk and less adaptability to isolation, social media and staying home. More calls by women may reflect women's better help-seeking capacity. The increase in SRCs indicates the potential for more suicides and the need for bolstering mental health services and reach-out to older people during pandemic lock-downs.

Information and Communication Technology Use in Suicide Prevention: Scoping Review

BACKGROUND

The use of information and communication technology (ICT) in suicide prevention has progressed rapidly over the past decade. ICT plays a major role in suicide prevention, but research on best and promising practices has been slow.

OBJECTIVE

This paper aims to explore the existing literature on ICT use in suicide prevention to answer the following question: what are the best and most promising ICT practices for suicide prevention?

METHODS

A scoping search was conducted using the following databases: PubMed, PsycINFO, Sociological Abstracts, and IEEE Xplore. These databases were searched for articles published between January 1, 2013, and December 31, 2018. The five stages of the scoping review process were as follows: identifying research questions; targeting relevant studies; selecting studies; charting data; and collating, summarizing, and reporting the results. The World Health Organization suicide prevention model was used according to the continuum of universal, selective, and indicated prevention.

RESULTS

Of the 3848 studies identified, 115 (2.99%) were selected. Of these, 10 regarded the use of ICT in universal suicide prevention, 53 referred to the use of ICT in selective suicide prevention, and 52 dealt with the use of ICT in indicated suicide prevention.

CONCLUSIONS

The use of ICT plays a major role in suicide prevention, and many promising programs were identified through this scoping review. However, large-scale evaluation studies are needed to further examine the effectiveness of these programs and strategies. In addition, safety and ethics protocols for ICT-based interventions are recommended.

Implementation of a Pilot SMS-Based Crisis Support Service in Australia

Background: Australia's first short message service (SMS) crisis support service was launched by Lifeline Australia in July 2018. The pilot program was independently evaluated over a 240-day period. Aims: We aimed to examine the experiences of key staff employed in the Lifeline Text pilot and identify the skills and types of support required to deliver a high-quality SMS-based crisis support service. Method: In total, 22 interviews were conducted with 14 Lifeline Text crisis supporters and in-shift supervisors (supervisors) at two time points in September 2018 and March 2019. A modified framework approach was adopted to undertake qualitative data analyses. Results: Delivering crisis support via text was initially challenging as a result of the need to translate skills from telephone crisis support to the SMS platform. This was compounded by the high degree of suicidality of help-seekers and volatility in demand for the service. Limitations: The independent evaluators were not involved in the design of the pilot. Conclusion: Lifeline text is providing an important and necessary service, using a novel mode of delivery in Australia. Maintaining service quality at peak demand, with many distressed and suicidal help-seekers, requires specialized training, experience, and exceptional skills.

Content-Based Recommender Support System for Counselors in a Suicide Prevention Chat Helpline: Design and Evaluation Study

BACKGROUND

The working environment of a suicide prevention helpline requires high emotional and cognitive awareness from chat counselors. A shared opinion among counselors is that as a chat conversation becomes more difficult, it takes more effort and a longer amount of time to compose a response, which, in turn, can lead to writer's block.

OBJECTIVE

This study evaluates and then designs supportive technology to determine if a support system that provides inspiration can help counselors resolve writer's block when they encounter difficult situations in chats with help-seekers.

METHODS

A content-based recommender system with sentence embedding was used to search a chat corpus for similar chat situations. The system showed a counselor the most similar parts of former chat conversations so that the counselor would be able to use approaches previously taken by their colleagues as inspiration. In a within-subject experiment, counselors' chat replies when confronted with a difficult situation were analyzed to determine if experts could see a noticeable difference in chat replies that were obtained in 3 conditions: (1) with the help of the support system, (2) with written advice from a senior counselor, or (3) when receiving no help. In addition, the system's utility and usability were measured, and the validity of the algorithm was examined.

RESULTS

A total of 24 counselors used a prototype of the support system; the results showed that, by reading chat replies, experts were able to significantly predict if counselors had received help from the support system or from a senior counselor (P=.004). Counselors scored the information they received from a senior counselor (M=1.46, SD 1.91) as significantly more helpful than the information received from the support system or when no help was given at all (M=-0.21, SD 2.26). Finally, compared with randomly selected former chat conversations, counselors rated the ones identified by the content-based recommendation system as significantly more similar to their current chats (β=.30, P<.001).

CONCLUSIONS

Support given to counselors influenced how they responded in difficult conversations. However, the higher utility scores given for the advice from senior counselors seem to indicate that specific actionable instructions are preferred. We expect that these findings will be beneficial for developing a system that can use similar chat situations to generate advice in a descriptive style, hence helping counselors through writer's block.

A Systematic Review of User Expectations and Outcomes of Crisis Support Services

Background: Crisis support services play an important role in providing free, immediate access to support people in the community experiencing a personal crisis. Recently, services have expanded from telephone to digital modalities including online chat and text message services. This raises the question of what outcomes are being achieved for increasingly diverse service users across different modalities. Aims: This systematic review aimed to determine the expectations and outcomes of users of crisis support services across three modalities (telephone, online chat, and text message/SMS). Method: Online databases (CINAHL, MEDLINE, PsycARTICLES, PsycINFO, Psychological and Behavioural Sciences Collection) and gray literature were searched for studies measuring expectations and outcomes of crisis support services. Results: A total of 31 studies were included in the review, the majority of which were telephone-based. Similar expectations were found for telephone and online chat modalities, as well as consistently positive outcomes, measured by changes in emotional state, satisfaction, and referral plans. Limitations/Conclusion: There is a paucity of consistent outcome measures across and within modalities and limited research about users of text message/SMS services.

Situation Analysis for Promotion of Hot-Lines: An Experience from Iran

Background:

The hot line services were developed in response to the perceived need for 24-hour help services in crises ranging from suicide to unwanted pregnancy. This study is aimed at analyzing the strengths, weaknesses, challenges, and suggestions of improving the performance of the help centers from the perspective of key stakeholders.

Methods:

We conducted a qualitative study to elicit the key informants' opinion regarding the performance of Iranian hot-lines. All the conversations were audio-recorded with the permission of the participants. To reach the saturation limit, the number of interviews was completed in the saturation of data. Data was gathered from 15 individual in-depth interviews. Collecting and analyses of data was based on content analysis through which simultaneously during texts open coding, main concepts were extracted and then in axial coding similar concepts were categorized.

Results:

According to the study results, there is no specific and independent system for assessing the hot- lines. One of the major weaknesses was the lack of standard protocols. Most participants believed that most of these guidelines came from the general principles of counseling and are not standard. As another point, the existence of referral services is one of the main problems of counseling lines. The most important suggestion from the majority of experts were the development of services and modification of their investments.

Conclusions:

The findings, in addition to providing the applied data for policy-making in the health system, will significantly contribute to the creation of scientific, technical, and skillful personnel in the community of researchers.

Exploration of Benefits and Potential Harmful Effects of an Online Forum for Visitors to the Suicide Prevention Platform in The Netherlands

Abstract. Background: Online forums that enable peer-to-peer interaction are widespread and readily available. Aim: This study aimed to identify the reach, benefits, and potential harmful effects for visitors to an online forum embedded in a suicide prevention platform in The Netherlands. Method: The study collected web-based questionnaires from online forum users and moderated posts. Descriptive quantitative and qualitative analyses were performed. Results: The online forum had 330 members in 2017, of whom 130 were active users (posting at least one message). Respondents ( n = 106) experienced from a high severity of suicidal ideation (78%). A minority (12%) visited the forum to find suicide methods and 3% to find a suicide partner. Among respondents who had visited the forum more than once ( n = 49), 53% reported no changes in feelings directly after forum use, 35% felt better and 12% felt worse. Peer support and anonymity were the most mentioned benefits, whereas no personal contacts and few reactions to postings were perceived as limitations. Suicide threats and the search for methods were the main reasons for moderating posts. Limitations: Usage habits and user experiences were available from a relatively small group that visited the forum more than once. Conclusion: In its current form, the forum has a low reach with few benefits and a potential for harm for its users. With a questionable benefit-to-risk ratio, the added value of the online forum appears to be small.

Engagement With Crisis Text Line Among Subgroups of Users Who Reported Suicidality

OBJECTIVE

Despite the interest in technology-enhanced preventive interventions for suicidality, there is minimal peer-reviewed research on conversations of text message hotlines. In this large-scale study, the authors explored distinct classes of users of the Crisis Text Line who reported suicidality. Classes were based on texters' presenting psychosocial issues and were explored across frequency of hotline use and conversation number.

METHODS

Data included 153,514 conversations from 122,909 individuals collected by the Crisis Text Line (2013-2017). Analyses were restricted to conversations from users who mentioned current or previous suicidality and excluded texters who discussed a third party. The authors used latent class analysis to identify distinct classes of texters on the basis of crisis counselor-assigned issue tags and across subgroups reflecting whether the conversation was the first or last contact with the hotline and frequency of use (one-time, two-time, or ≥3-time texters).

RESULTS

Three classes emerged in all subsamples. The largest class, "lower distress," had the lowest prevalence of all issues. The second largest class, "anxious distress," had the highest prevalence of anxiety or stress and elevated depression. The smallest class, "relational distress," had the highest prevalence of depression and self-harm and higher probability of endorsing relational indicators.

CONCLUSIONS

Psychological and relational issues mostly distinguished the three classes. Despite differing frequency of hotline usage, most texters who reported suicidal ideation and behaviors endorsed similar issues, and these issues did not seem to vary across conversations. Yet there appeared to be distinct subgroups of texters with different presenting issues, which may inform how crisis counselors tailor strategies for both low- and high-volume texters.

[Are suicidal young people reached by online-counselling? Evaluation of the target group outreach of [U25] online suicide prevention]

Are suicidal young people reached by online-counselling? Evaluation of the target group outreach of [U25] online suicide prevention Abstract. Objective: "[U25] Germany" is an online-counselling platform designed to help adolescents and young adults suffering from suicidal ideation or emotional crisis. The online approach and anonymous counselling by peers (young voluntary workers) instead of professionals were initiated to lower the threshold for those seeking help. This study examines characteristics of people seeking help from [U25] and estimates the outreach of the program. Method: Data from n = 1062 counselling protocols dating from 2017 were obtained. In addition, we conducted n = 13 problem-focused interviews with peer counsellors. Results: Our data indicate a good target group outreach concerning age, suicidality, and psychological burden of the clients. However, young men seek counselling by [U25] less frequently than young women. Additionally, preliminary data indicate that young people with lower educational background consult [U25] less often. Conclusions: [U25] offers a promising approach to helping young people suffering from suicidal ideation or a personal crisis. New approaches should be developed and evaluated to better reach young men and persons with a lower education background.

The Effectiveness of Crisis Line Services: A Systematic Review

Background: Crisis lines are a standard component of a public health approach to suicide prevention. Clinical aims include reducing individuals' crisis states, psychological distress, and risk of suicide. Efforts may also include enhancing access and facilitating connections to behavioral health care. This review examines models of crisis line services for demonstrated effectiveness. Methods: Literature searches of Medline, EMBASE, PsycINFO, Web of Science, CINAHL, Cochrane Library, and Google Scholar were conducted from January 1, 1990, to May 7, 2018. Experts were contacted, and references were mined for additional studies. Eligible studies provided health- or utilization-related effectiveness outcome(s). Results were graded according to the Oxford Centre for Evidence-Based Medicine and evaluated for risk of bias using the Effective Public Health Practice Project quality assessment tool for quantitative studies. Results: Thirty-three studies yielded effectiveness outcomes. In most cases findings regarding crisis calls vs. other modalities were presented. Evaluation approaches included user- and helper-reported data, silent monitoring, and analyses of administrative records. About half of studies reported immediate proximal outcomes (during the crisis service), and the remaining reported distal outcomes (up to four years post-contact). Most studies were rated at Oxford level four evidence and 80% were assessed at high risk of bias. Conclusions: High quality evidence demonstrating crisis line effectiveness is lacking. Moreover, most approaches to demonstrating impact only measured proximal outcomes. Research should focus on innovative strategies to assess proximal and distal outcomes, with a specific focus on behavioral health treatment engagement and future self-directed violence.

Chat-based hotlines for health promotion: a systematic review

BACKGROUND

Chat-based hotlines use online messaging services or popular chat applications such as WhatsApp, Facebook Messenger, and WeChat, to connect users to trained health providers or staff. Chat-based hotlines can provide real-time communication between health providers and patients.

METHODS

The evidence for chat-based hotlines for health promotion has not been reviewed systematically. Electronic databases (PubMed, Cochrane Database, Google Scholar) were searched to identify English-language studies describing original research published from 2009 to 2020. This review was registered with Prospero Register of Systematic Reviews (ID: CRD42020156670).

RESULTS

Twelve publications met our criteria. Ten studies reported on user characteristics, eight on comparing use of chat-based hotlines with different modes of support, six on health outcomes and six on user satisfaction. Included studies report that chat-based hotlines have been used primarily for crisis and emotional support in high-income countries. Chat-based hotlines using instant messenger applications were preferred over other modes of services such as email, text messaging, voice calls, and face-to-face counselling. Evaluations of health outcomes, although limited in rigor due to mostly observational study designs, indicate mostly positive and statistically significant effects on mental health outcomes such as anxiety, depression, well-being and suicidality. User satisfaction with chat-based hotlines were moderately high.

CONCLUSIONS

Chat-based hotlines may be effective ways to deliver crisis support services in high income settings. They may have the potential to be effective in low- and middle-income countries to expand the reach of mental health and crisis support services although such services have not yet been publicly evaluated.

Texting for Help: Processes and Impact of Text Counseling with Children and Youth with Suicide Ideation

OBJECTIVE

To explore: (1) how children contacting a child helpline with suicide ideation differ from children discussing other topics, (2) whether text messaging effectively helps, and (3) which counselor behaviors are most effective.

METHOD

Of 6,060 text sessions at the Danish national child helpline, 444 concerned suicidality, of which the 102 sessions that included self-rated, end Session ratings were selected for content analysis.

RESULTS

Twenty-six percentage of suicidal children had severe suicidality. The suicide sample had significantly more girls, was older than the nonsuicide sample, and more often recontacted the helpline in the 2 weeks prior to follow-up. 35.9% of suicidal children felt better immediately and over half ended the session with a plan of action. At follow-up, 23.9% of suicidal children reported feeling better; however, 37.0% reported feeling worse. Talking about emotions, expressing empathy, and encouraging the child to talk to someone were associated with positive impacts. Setting boundaries was associated with negative impacts.

CONCLUSIONS

Texting with suicidal children can be helpful, but should be considered a first step toward obtaining more sustainable help. Research is needed to determine how to better help children who felt worse or did not improve in the 2 weeks after contacting the helpline. Suggestions to further training of counselors are discussed.

Use of Telepsychiatry in Emergency and Crisis Intervention: Current Evidence

PURPOSE OF REVIEW

The aim of this review is to evaluate recent literature on the use of telepsychiatry in mental crises or emergency situations.

RECENT FINDINGS

Results from recent studies which evaluated the implementation of a telepsychiatric consultation model in emergency departments point at a reduction of length of stay and a drop in admissions, increased cost-effectiveness, and improved satisfaction of patients and staff. There was almost no empirical evidence on videoconferencing in crisis intervention within the context of crisis resolution teams or online therapies. No study reporting on telepsychiatry videoconferencing in the context of disasters was found. There is still very little but increasing empirical evidence supporting the implementation of telepsychiatry in emergencies. Other mental crisis-related implementation settings remain to be researched. The implications and future research potential are discussed.

College Students' Experiences with, and Willingness to Use, Different Types of Telemental Health Resources: Do Gender, Depression/Anxiety, or Stress Levels Matter?

Objective:Telemental health (TMH) resources are plentiful; however, we know little about college students' opinions about such resources. We aimed to examine students' previous use of and willingness to use several types of TMH resources.Participants:Students (N = 662) from two U.S. Midwestern colleges participated.Methods:Using an online survey in spring 2017, we measured students' depression, anxiety, stress, and suicidal thoughts, preferences for care options during distress, and use and interest in anonymous chats with trained nonprofessionals, online therapy, and self-help resources.Results:Overall, 10.1-13.8% had experience with these TMH resources; however, 24.6-40.1% expressed willingness to try them. At-risk students, especially those higher in depression/anxiety scores, showed greater use of and willingness to use some applications.Conclusions:Counseling centers might consider endorsing TMH resources as potential pathways to care. TMH resources might help broaden reach with minimal cost, reduce mental health help-seeking barriers, and provide support to at-risk populations.

Leveraging the Web and Social Media to Promote Access to Care Among Suicidal Individuals

After two decades of exponential development, the Internet has become an inseparable component of suicide prevention matters. More specifically, social media has turned out to be a privileged space for suicidal individuals to express their distress and seek support. Although this tendency carries with it specific risks and challenges, it creates unprecedented opportunities to face the challenges of help seeking and access to care. In this paper, we present the empirical, technological, and theoretical evidence supporting the implementation of a digitally augmented prevention policy that would increase its reach. Congruent to the clinical observations and theories on the help-seeking process, we argue that social media can help undertake three main functions of increasing proactivity to bring suffering Web users to care. The gateway function relates to the properties of social media interactions to leverage help-seeking barriers and enable ambivalent individuals to access the mental healthcare system. The communication outreach function aims to broadcast pro-help-seeking messages, while drawing on the functional structure of the social media network to increase its audience. The intervention outreach function consists in using machine learning algorithms to detect social media users with the highest risk of suicidal behaviors and give them a chance to overcome their dysfunctional reluctance to access help. We propose to combine these three functions into a single coherent operational model. This would involve the joint actions of a communication and intervention team on social networks, working in close collaboration with conventional mental health professionals, emergency service, and community resources.

Effectiveness of a transdiagnostic individually tailored Internet-based and mobile-supported intervention for the indicated prevention of depression and anxiety (ICare Prevent) in Dutch college students: study protocol for a randomised controlled trial

Background

Depression and anxiety are common and co-morbid disorders that affect a significant proportion of students. Innovative prevention strategies targeting both conditions are needed to reduce their health burden and costs. ICare Prevent is such an innovative strategy and contains a transdiagnostic individually tailored Internet-based and mobile-supported intervention. It addresses common risk factors of depression and anxiety as part of a large EU-funded multi-country project* (ICare). Little is known about the clinical and cost-effectiveness of this type of intervention compared to care as usual (CAU) for college students. We hypothesize that ICare Prevent will be more (cost-)effective than CAU in the reduction of symptoms of depression and anxiety.

Methods

A three-arm, parallel, randomized controlled superiority trial will be conducted comparing a guided and an unguided version of ICare Prevent with a control group receiving CAU. The trial will be open-label but outcome assessors will be blinded. A total of 252 college students (age ≥ 16 years) with subclinical symptoms of depression defined as a score ≥ 16 on the Center for Epidemiological Studies Depression Scale (CES-D), and/or anxiety, defined as a score ≥ 5 on the Generalized Anxiety Disorder scale (GAD-7), will be included. Those meeting diagnostic criteria for a depressive or anxiety disorder will be excluded. The primary outcome is change in disorder specific symptom severity from baseline to post-intervention. Secondary endpoints include self-reported depression and anxiety symptoms as well as time to onset of a mood or anxiety disorder until 12-month follow-up. Societal costs and quality of life will be assessed to estimate the intervention’s cost-effectiveness compared to CAU.

Discussion

Transdiagnostic individually tailored Internet-based prevention could be a (cost-)effective approach to tackle the disease burden of depression and anxiety among college students.

Trial registration

Dutch trial register, NTR 6562. Registered on 6 July 2017.

Electronic supplementary material

The online version of this article (10.1186/s13063-018-2477-y) contains supplementary material, which is available to authorized users.