Development and evaluation of e-mental health interventions to reduce stigmatization of suicidality - a study protocol

Evaluation of an online suicide prevention program to improve suicide literacy and to reduce suicide stigma: A mixed methods study

Low-threshold e-health approaches in prevention to reduce suicide stigma are scarce. We developed an online program containing video reports on lived experience of suicide and evidence-based information on suicidality. We evaluated the program by a mixed methods design. We examined pre-post-changes of program completers (n = 268) in suicide literacy, suicide stigma (self and perceived), and self-efficacy expectation of being able to seek support in psychologically difficult situations using linear mixed models. To examine reported changes and helpful program elements 12-26 weeks after program completion, we content analyzed transcripts of telephone interviews (n = 16). Program completers showed more suicide literacy (Cohen's d = .74; p < .001), higher self-efficacy expectations to seek support (d = .09; p < .01), lower self-stigma (subscales glorification/normalization: d = -.13, p = .04; isolation/depression: d = -.14; p = .04; stigma: d = -.10; p = .07; n = 168) compared to baseline. We found no significant differences in perceived suicide stigma. We identified lived experience reports, the possibility of sharing own narrative on stigma and suicidality, and information on support as helpful elements. The current online program can increase suicide literacy and self-efficacy expectations to seek support and reduce self-stigma. We recommend a larger randomized controlled trial with longer follow-up to confirm these findings.

Suicide in China: Community Attitudes and Stigma

China accounts for an estimated third of the world's suicides, yet individuals experiencing suicidality typically do not seek out or receive treatment. This study examines community perceptions and public stigma toward suicide. In Shanghai, China 186 adults were recruited to participate in a survey with an experimental vignette describing a suicidal individual, manipulated on gender and age, followed by questions eliciting attitudes toward suicide. Most participants agreed that the suicidal subject had a serious problem, with seriousness of the problem decreasing with participant's age. Participants reported moderate levels of public stigma. More stigma was found toward adolescent subjects rather than adult. Male subjects were perceived as being more likely to change than females. The public's accurate view of suicide without biases could help prevent suicide from getting worse. Public perceptions regarding a suicidal individual's likelihood to change could lead to stigma reduction, which can subsequently help with effective crisis intervention.

Entwicklung und psychometrische Überprüfung eines Kurzfragebogens zur Selbstwirksamkeitserwartung im Umgang mit psychisch belastenden Situationen (SWEP)

Ziel der Studie Entwicklung und psychometrische Überprüfung eines 6-Item-Instruments zur Erfassung von Selbstwirksamkeitserwartung, sich in psychisch belastenden Situationen Unterstützung suchen zu können (SWEP).

Methodik Entwicklung von Items, Ermittlung von Verteilungscharakteristika, Faktorenstruktur und interner Konsistenz der Skala anhand einer Paper-Pencil-Befragung (N=269) und einer Untersuchung einer Online-Intervention zur Suizidprävention (N=802). Bestimmung der Retest-Reliabilität und diskriminanten Validität zu Skalen, die suizidspezifisches Wissen und einen Aspekt von Suizidstigma erfassten.

Ergebnisse Die Hauptkomponentenanalyse ergab für die SWEP-Skala ein eindimensionales Konstrukt mit hoher interner Konsistenz (Cronbachs α=0,83 bzw. α=0,89). Es zeigten sich inhaltlich plausible Korrelationen zu anderen Konstrukten und erste Hinweise auf eine hohe Retest-Reliabilität.

Schlussfolgerung Die SWEP-Skala ist ein reliables, augenscheinlich valides, kurzes Instrument zur Erfassung von Selbstwirksamkeitserwartung, sich in psychisch belastenden Situationen Unterstützung suchen zu können.

Digital interventions to enhance readiness for psychological therapy: A scoping review (Preprint)

Background

Psychological therapy is an effective treatment method for mental illness; however, many people with mental illness do not seek treatment or drop out of treatment early. Increasing client uptake and engagement in therapy is key to addressing the escalating global problem of mental illness. Attitudinal barriers, such as a lack of motivation, are a leading cause of low engagement in therapy. Digital interventions to increase motivation and readiness for change hold promise as accessible and scalable solutions; however, little is known about the range of interventions being used and their feasibility as a means to increase engagement with therapy.

Objective

This review aimed to define the emerging field of digital interventions to enhance readiness for psychological therapy and detect gaps in the literature.

Methods

A literature search was conducted in PubMed, PsycINFO, PsycARTICLES, Scopus, Embase, ACM Guide to Computing Literature, and IEEE Xplore Digital Library from January 1, 2006, to November 30, 2021. The PRISMA-ScR (Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews) methodology was applied. Publications were included when they concerned a digitally delivered intervention, a specific target of which was enhancing engagement with further psychological treatment, and when this intervention occurred before the target psychological treatment.

Results

A total of 45 publications met the inclusion criteria. The conditions included depression, unspecified general mental health, comorbid anxiety and depression, smoking, eating disorders, suicide, social anxiety, substance use, gambling, and psychosis. Almost half of the interventions (22/48, 46%) were web-based programs; the other formats included screening tools, videos, apps, and websites. The components of the interventions included psychoeducation, symptom assessment and feedback, information on treatment options and referrals, client testimonials, expectation management, and pro-con lists. Regarding feasibility, of the 16 controlled studies, 7 (44%) measuring actual behavior or action showed evidence of intervention effectiveness compared with controls, 7 (44%) found no differences, and 2 (12%) indicated worse behavioral outcomes. In general, the outcomes were mixed and inconclusive owing to variations in trial designs, control types, and outcome measures.

Conclusions

Digital interventions to enhance readiness for psychological therapy are broad and varied. Although these easily accessible digital approaches show potential as a means of preparing people for therapy, they are not without risks. The complex nature of stigma, motivation, and individual emotional responses toward engaging in treatment for mental health difficulties suggests that a careful approach is needed when developing and evaluating digital readiness interventions. Further qualitative, naturalistic, and longitudinal research is needed to deepen our knowledge in this area.

Feasibility and Preliminary Efficacy of a New Online Self-Help Intervention for Depression among Korean College Students' Families

Applying innovative online approaches to interventions for preventing depression is necessary. Since depressive emotions are typically shared within the family, the development of interventions involving family members is critical. This study thus aimed to examine the feasibility, acceptability, and preliminary outcomes of a new online self-help intervention, MindGuide, among Korean college students’ families. We developed MindGuide, which integrates cognitive behavioral therapy with mindfulness and an emotional regulation approach. A one-group pretest–posttest design was used to measure the changes in the Center for Epidemiological Studies Depression Scale, the Attitude Toward Suicide scale, and the Satisfaction With Life Scale before and after the intervention. Of the 34 families that began the program, completion rates were 88.2%, 85.3%, and 91.2% for fathers, mothers, and children, respectively. The findings indicated that the MindGuide program is feasible and acceptable for families of Korean college students. The results support the potential effect of MindGuide on reducing depression, improving positive attitudes toward suicide prevention, and enhancing family relationships in participants at risk of depression. However, future research is needed to thoroughly explore and evaluate the efficacy of the MindGuide program.

[Development of an online intervention on suicidality-providing knowledge and reducing suicide stigma]

Bei Suizidalität können die Angst, von anderen stigmatisiert zu werden, sowie Selbststigmatisierung und unzureichende Informationen dazu führen, dass Hilfsangebote weniger oder gar nicht in Anspruch genommen werden. E‑Mental-Health-Interventionen sind eine Möglichkeit, niederschwellig viele Betroffene über die Thematik zu informieren und auf persönliche Hilfsangebote vorzubereiten. Am Universitätsklinikum Hamburg-Eppendorf wurde eine komplexe Intervention entwickelt, gefördert im Rahmen des Förderschwerpunkts „Suizidprävention (A: Entstigmatisierung)“ des Bundesministeriums für Gesundheit. Entwicklung und Inhalte dieser Onlineintervention sollen im vorliegenden Beitrag beschrieben werden.

Nach einer repräsentativen Telefonbefragung der deutschen Allgemeinbevölkerung, mit der Wissenslücken und Stigmatisierungstendenzen zum Thema Suizid untersucht wurden, entstand auf Basis eines australischen Suizidpräventionsprojekts und in Zusammenarbeit mit Betroffenen und Angehörigen die Onlineintervention „8 Leben – Erfahrungsberichte und Wissenswertes zum Thema Suizid“. Darin wurden sowohl wissenschaftlich-klinische Fakten rund um das Thema Suizidalität als auch eine gesellschaftlich-kulturelle Perspektive beleuchtet sowie auf Selbsthilfemöglichkeiten und professionelle Hilfsangebote verwiesen. Es wurden Videoerfahrungsberichte von Betroffenen und Angehörigen gezeigt. Aktuell wird das Projekt ausgewertet. Eine Weiterführung ist geplant.

In der Intervention werden verschiedene Sichtweisen gezeigt und die Personen, die die Intervention in Anspruch nehmen, werden sowohl auf kognitiver als auch auf emotionaler Ebene angesprochen. Aufgrund der Prävalenz von Suizidalität und der dennoch bestehenden Tabuisierung des Themas scheinen seriöse, evidenzbasierte und niedrigschwellige Präventions- und Informationsangebote besonders relevant.

Development of an online suicide prevention program involving people with lived experience: ideas and challenges

BACKGROUND

Fear of stigmatization, self-stigmatization, and insufficient information can lead to secrecy, reduced help-seeking, lower self-esteem, and lower self-efficacy among people affected by suicidality or suicide. Therefore, we developed an online suicide prevention program aiming to improve knowledge about suicidality and suicide stigma.

METHODS

Inspired by the Australian program The Ripple Effect, a German team comprising people with lived experience of suicide, researchers, and clinicians was established for developing an online suicide prevention program. Therefore, we oriented on guidelines for evidence-based health information, for reporting on suicide, and on dealing with suicidality. The lived experience team discussed and developed concept, structure, and content of the program. This manuscript presents summaries of protocols from 16 team meetings and 3 written text reviews to outline the program development process. A summative evaluation 3 years after program development began was qualitatively analyzed based on thematic analysis.

RESULTS

Between 2018 und 2021, the lived experience team (n = 10) discussed possibilities of support in suicidal crises, attitudes towards suicide, content, and design of the online program. In a structured process, six members of the lived experience team reviewed the content. Eight persons shared their lived experience of suicide in video reports by focusing on constructive ways of dealing with suicidality or a loss by suicide, conveying hope and encouraging people to continue living. Team members recommended greater public and patient involvement from the application stage, as well as more financial and personnel resources.

CONCLUSIONS

Through contributions to discussions and text reviews, the lived experience team shaped decisions in the program development process. While involving persons with lived experiences of suicide, it is important to consider that suicidality is 1. emotionally challenging, 2. a stigmatized issue, and 3. that the aspect of safety must be a priority. A distinction must be made between the duty of care based on actual risk and inappropriate overprotection. Hereby, transparency, autonomy, and a clear structure appeared to be helpful. For further research, we recommend a structured formative review process of the development of the program. Additionally, we recommend discussing the purpose and the specific design of the evaluation with a lived experience team in advance. Trial registration German Clinical Trial RegisterDRKS00015071 on August 6, 2018.

Suicide literacy and suicide stigma - results of a population survey from Germany

BACKGROUND

While a growing number of studies analyze the magnitude and predictors of mental health literacy, little is known about suicide-specific knowledge and beliefs ("suicide literacy").

AIMS

To examine suicide literacy among the German population and to investigate associations between suicide literacy and suicide stigma.

METHODS

Telephone interviews were conducted in Germany (N = 2002, response rate: 47.3%). The literacy of suicide scale (LOSS-SF) was used covering the knowledge domains "signs," "risk factors," "causes/nature" and "treatment/prevention." In multiple regression analyses, associations between the LOSS-SF and the three dimensions "stigma," "normalization/glorification," and "depression/isolation" of the stigma of suicide scale (SOSS-SF) were examined controlling for several covariates.

RESULTS

Respondents showed most knowledge concerning "treatment and prevention" (>80% correct answers). Lower suicide literacy was found in the domains "risk factors" (33-60% correct answers) and "signs for suicidal ideation" (45-53%). Suicide literacy was negatively associated with age, while it was positively associated with education, own affliction, and personal contact. Moreover, suicide literacy showed negative associations with all three dimensions of the SOSS-SF.

CONCLUSIONS

There are deficits in suicide literacy in the German public that may increase suicide stigma. Addressing those deficits in information-campaigns and encouraging personal contact could help decrease suicide stigma.

Connected Mental Health: Systematic Mapping Study

BACKGROUND

Although mental health issues constitute an increasing global burden affecting a large number of people, the mental health care industry is still facing several care delivery barriers such as stigma, education, and cost. Connected mental health (CMH), which refers to the use of information and communication technologies in mental health care, can assist in overcoming these barriers.

OBJECTIVE

The aim of this systematic mapping study is to provide an overview and a structured understanding of CMH literature available in the Scopus database.

METHODS

A total of 289 selected publications were analyzed based on 8 classification criteria: publication year, publication source, research type, contribution type, empirical type, mental health issues, targeted cohort groups, and countries where the empirically evaluated studies were conducted.

RESULTS

The results showed that there was an increasing interest in CMH publications; journals were the main publication channels of the selected papers; exploratory research was the dominant research type; advantages and challenges of the use of technology for mental health care were the most investigated subjects; most of the selected studies had not been evaluated empirically; depression and anxiety were the most addressed mental disorders; young people were the most targeted cohort groups in the selected publications; and Australia, followed by the United States, was the country where most empirically evaluated studies were conducted.

CONCLUSIONS

CMH is a promising research field to present novel approaches to assist in the management, treatment, and diagnosis of mental health issues that can help overcome existing mental health care delivery barriers. Future research should be shifted toward providing evidence-based studies to examine the effectiveness of CMH solutions and identify related issues.

[Suicide stigma and suicide prevention]

In many societies suicide was and is an extremely controversial topic. This review article outlines the historical background of social condemnation of suicidal thoughts and actions in the western world. It summarizes current research results about the consequences of suicide stigma for affected persons and its relevance for suicide prevention. Finally, the next steps in research and prevention are discussed. Over time and in different cultures, the societal judgement of suicide has greatly varied. During antiquity, some philosophers viewed suicide negatively and by the fifth century AD suicide was widely condemned by societies across the western world. Until today suicide remains a taboo topic in Germany and other countries. Current research showed that the social condemnation of suicidal thoughts and behavior (i.e. suicide stigma) is an additional stressor among persons who experience or have experienced suicidality and their relatives. Furthermore, suicide stigma is considered to be a central barrier to seeking help for and disclosure of suicidality. Despite its relevance for suicide prevention, only a few interventions to reduce suicide stigma among members of the general public and to support affected persons in dealing with suicide stigma exist.

[The Stigma of Suicide Scale: Psychometric Validation of the German Short Version (SOSS-SF-D)]

OBJECTIVE

The Australian Stigma of Suicide Scale (SOSS-SF) was translated and tested for applicability and psychometric properties in Germany. Further, it was investigated whether the observed factors from the Australian original could be replicated in a German sample.

METHODS

Based on a nation-wide, representative telephone survey (N = 2,002), the 16 items of the SOSS-SF-D were examined with a principal component analysis (varimax rotation). Mean values, standard deviations and medians as well as the z-standardized values for skewness and kurtosis were determined.

RESULTS

The principal component analysis revealed 3 subscales (stigma, normalization/glorification, depression/isolation), just as in the Australian sample. Internal consistency of the subscales was acceptable (Cronbachs α: 0.64-0.78).

CONCLUSION

The SOSS-SF-D is a valid and short instrument for measuring the multidimensionality of attitudes towards suicidal persons.