Digital cognitive-behavioural therapy to reduce suicidal ideation and behaviours: a systematic review and meta-analysis of individual participant data

QUESTION

Digital interventions based on cognitive-behavioural therapy (iCBT) is associated with reductions in suicidal ideation. However, fine-grained analyses of effects and potential effect-moderating variables are missing. This study aimed to investigate the effectiveness of iCBT on suicidal ideation, effect moderators, effects on suicide attempts and predictors of adherence.

STUDY SELECTION AND ANALYSIS

We systematically searched CENTRAL, PsycINFO, Embase and PubMed for randomised controlled trials that investigated iCBT for suicidal ideation or behaviours. Participants reporting baseline suicidal ideation were eligible. We conducted a one-stage individual participant data (IPD) meta-analysis. Suicidal ideation was the primary outcome, analysed as three indices: severity of suicidal ideation, reliable changes and treatment response.

FINDINGS

We included IPD from nine out of ten eligible trials (2037 participants). iCBT showed significant reductions of suicidal ideation compared with control conditions across all indices (severity: b=-0.247, 95% CI -0.322 to -0.173; reliable changes: b=0.633, 95% CI 0.408 to 0.859; treatment response: b=0.606, 95% CI 0.410 to 0.801). In iCBT, the rate of reliable improvement was 40.5% (controls: 27.3%); the deterioration rate was 2.8% (controls: 5.1%). No participant-level moderator effects were identified. The effects on treatment response were higher for trials with waitlist-controls compared with active controls. There were insufficient data on suicide attempts. Human support and female gender predicted treatment adherence. The main source of potential bias was missing outcome data.

CONCLUSIONS

The current evidence indicates that iCBT is effective in reducing suicidal ideation irrespective of age, gender and previous suicide attempts. Future studies should rigorously assess suicidal behaviour and drop-out reasons.

Self-reported disability and quality of life in an online Australian community sample with suicidal thoughts

BACKGROUND

Limited research has been conducted to quantify the level of disability and health related quality of life (HRQoL) associated with suicidal thoughts and behaviour. The aims of the current study were to (1) describe levels of disability and HRQoL in an Australian sample of adults with suicidal ideation, (2) examine the effect of zero, one, or more than one previous suicide attempt on disability and HRQoL, and (3) describe the demographic and clinical characteristics associated with disability and HRQoL.

METHOD

Data for the current study is drawn from the baseline assessment of the Healthy Thinking trial that evaluated the effectiveness of an online self-help program for suicidal thoughts in an Australian adult community sample (n = 418). Measures of disability, quality of life, clinical symptoms, suicidality and demographic variables were included.

RESULTS

The mean disability score for the overall sample was 19.2 (SD = =8.9), while the mean perceived physical health score was 40.7 (SD = =6.5) and the mean perceived mental health score was 36.1 (SD = =5.9). Higher levels of disability and lower levels of perceived physical health were associated with multiple suicide attempts compared to one or no history of suicide attempt.

LIMITATIONS

Limitations included the limited generalisability of results, the use of self-report to assess suicide attempts, and the use of cross-sectional data.

CONCLUSION

Suicidal thoughts and behaviours are associated with high levels disability and low levels of perceived physical and mental health. Early intervention programs are needed to reduce the high levels of burden associated with suicidality.

The online treatment of suicidal ideation: A randomised controlled trial of an unguided web-based intervention

Suicide is a major public health issue, and treatment of suicidal thoughts may contribute to its prevention. Provision of online treatment of suicidal ideation may reduce barriers that suicidal individuals experience in face-to-face treatment. We therefore aimed at evaluating the effectiveness of a web-based intervention targeting a reduction of suicidal ideation. We carried out a two-arm, parallel-design, randomised controlled trial in the general population in Flanders (Belgium) (registered as NCT03209544). Participants who were 18 years or older and experienced suicidal ideation were included. The intervention group (n = 365) received access to the unguided web-based intervention, and the control group (n = 359) was placed on a waitlist. Assessments were carried out at baseline and at 6 and 12 weeks. Participants reported high levels of suicidal ideation, depression, hopelessness, worrying, and anxiety at baseline. Compared to the control group, participants in the intervention group experienced a significant decline in suicidal ideation, depression, hopelessness, worrying, and anxiety both at post-test and at follow-up. An important limitation of the study was a high dropout rate, in particular in the intervention group. Our findings suggest that the online self-help intervention was more effective in reducing suicidal ideation and suicide-related symptoms than a waitlist control in a severely affected population. It can help in filling the gap between crisis help and face-to-face treatment.

Consistency of trajectories of suicidal ideation and depression symptoms: Evidence from a randomized controlled trial

BACKGROUND

Depression is a risk factor for suicidal ideation. However, suicidal ideation can occur in the absence of depression and treating depression may not reduce suicidal thinking. This study tested whether trajectories of suicidal thinking are concordant with trajectories of depressive symptoms and sought to identify factors associated with these trajectories.

METHODS

Participants were community-based Australian adults (N = 418, 77% female) enrolled in a randomized controlled trial evaluating the effectiveness of an online cognitive-behavioral intervention for suicidal ideation. Separate linear growth mixture models were estimated across 12 months of follow-up to identify longitudinal trajectories of suicidal ideation and depression symptoms. Predictors of latent class membership were tested using logistic regression models.

RESULTS

Two-class models were found to have optimal fit for both suicidal thinking and depressive symptoms. Trajectory classes of suicidal ideation were: (1) moderate severity decreasing over time; and (2) high severity remaining stable over time. Depression trajectories were: (1) moderate severity with a small decrease over time; and (2) high severity that decreased moderately over time. Lower perceived burdensomeness was associated with having a greater decrease in both suicidal thinking and depression. More severe mental health symptoms were associated with less decrease in depression symptoms but not with suicidal ideation trajectory.

CONCLUSION

Class membership across the two outcomes and predictors of class membership were found to be largely independent. The lack of coupling in trajectories and predictors suggests that changes in suicidal thinking may occur independently of changes in depression.

Translation and validation of the Chinese versions of the Suicidal Ideation Attributes Scale, Stigma of Suicide Scale, and Literacy of Suicide Scale

This article reports the validation of the Chinese versions of the Suicidal Ideation Attributes Scale (SIDAS), the short form of Stigma of Suicide Scale (SOSS), and the short form of Literacy of Suicide Scale (LOSS) among 57 Chinese and English bilinguals and 224 Chinese university students. All the translated scales showed high correlations with the original versions. The translated SIDAS and refined SOSS demonstrated robust factor structures, good internal consistency, and convergent validity. Chinese students with self-reported depression symptoms tended to have higher glorification of suicide and lower suicide literacy. These brief scales fill an important gap in evaluating suicide outcomes in Chinese-speaking societies.

The Specificity of the Interpersonal-Psychological Theory of Suicidal Behavior for Identifying Suicidal Ideation in an Online Sample

The interpersonal-psychological theory of suicidal behavior suggests that the combination of perceived burdensomeness and thwarted belongingness predicts suicidal ideation. However, the specificity of this prediction to suicidal ideation has not been tested. This study examined whether these constructs were consistently associated with different characteristics of suicidal ideation, and whether they were associated with mental health problems more broadly, in an online sample of 1,352 Australian adults. Findings indicated that the interaction between perceived burdensomeness and thwarted belongingness was associated only with suicidal ideation and consistent across multiple characteristics of ideation. The study broadly supported the specificity of the IPTS.

Reducing suicidal thoughts in the Australian general population through web-based self-help: study protocol for a randomized controlled trial

Background

Suicidal thoughts are common in the general population, causing significant disability. However, a substantial number of people struggling with suicidality do not access appropriate services. Online self-help may help overcome barriers to help-seeking. This study aims to examine the effectiveness of an online self-help program targeted at reducing suicidal thoughts compared with an attention-matched control condition in the Australian adult population. This trial is based on a Dutch self-help program, which was found to be effective in reducing suicidal thoughts.

Methods/Design

A total of 570 community-dwelling adults (18 to 65 years old) with suicidal thoughts will be recruited via various media and randomly assigned to the 6-week online program aimed at reducing suicidal thoughts or a 6-week attention-matched control program. Primary outcome measure is the severity of suicidal thoughts. Secondary outcome measures include suicide plans, capacity to cope with suicidal thoughts, reasons for living, symptoms of depression, hopelessness, anxiety/worry, rumination, panic, perceived burdensomeness and thwarted belongingness, acquired capability, alcohol consumption, insomnia, and various cost-effectiveness measures.

Discussion

Although the original Dutch trial found web-based self-help to be effective in reducing suicidal thoughts, randomized controlled trials (RCT) of online programs for suicidal thoughts are rare. The present study extends previous research by running the first English language RCT of this sort. As a result of the original study, the current RCT includes refinements to the design, including greater levels of participant anonymity and longer follow-up periods. Limitations of this trial include the potential for high drop-out and the inability to ascertain whether any suicides occur during the study.

Trial registration

Australian New Zealand Clinical Trials Registry (ANZCTR) Registration number: ACTRN12613000410752 (15 April 2013). Universal Trial Number (UTN): U1111-1141-6595 (15 April 2013).

Electronic supplementary material

The online version of this article (doi:10.1186/s13063-015-0589-1) contains supplementary material, which is available to authorized users.

The suicidal ideation attributes scale (SIDAS): Community-based validation study of a new scale for the measurement of suicidal ideation

While suicide prevention efforts are increasingly being delivered using technology, no scales have been developed specifically for web-based use. The Suicidal Ideation Attributes Scale (SIDAS) was developed and validated as a brief, web-based measure for severity of suicidal ideation, using an online survey of Australian adults (n = 1,352). The SIDAS demonstrated high internal consistency and good convergent validity. Frequency and controllability of thoughts were more strongly associated with suicide plans and attempts than other attributes assessed. Scores ≥ 21 indicated high risk of suicide behavior. The SIDAS appears to be a valid web-based measure for severity of suicidal ideation.

Effectiveness of online self-help for suicidal thoughts: results of a randomised controlled trial

Background

Many people with suicidal thoughts do not receive treatment. The Internet can be used to reach more people in need of support.

Objective

To test the effectiveness of unguided online self-help to reduce suicidal thoughts.

Method

236 adults with mild to moderate suicidal thoughts were randomised to the intervention (n = 116) or a waitlist control group (n = 120). Assessments took place at baseline, and 2, 4 and 6 weeks later. Primary outcome was suicidal thoughts. Secondary outcomes were depressive symptoms, anxiety, hopelessness, worry, and health status.

Results

The intervention group showed a small significant effect in reducing suicidal thoughts (d = 0.28). Effects were more pronounced for those with a history of repeated suicide attempts. There was also a significant reduction in worry (d = 0.33). All other secondary outcomes showed small but non-significant improvements.

Conclusions

Although effect sizes were small, the reach of the internet could enable this intervention to help many people reduce their suicidal thoughts.

Trial Registration

Netherlands Trial Register NTR1689

The effects of psychotherapy for adult depression on suicidality and hopelessness: a systematic review and meta-analysis

BACKGROUND

Although treatment guidelines suggest that suicidal patients with depression should be treated for depression with psychotherapy, it is not clear whether these psychological treatments actually reduce suicidal ideation or suicide risk.

METHODS

We conducted a systematic review and meta-analysis of studies on psychotherapy for depression in which outcomes on suicidality were reported. We also focused on outcomes on hopelessness because this is strongly associated with suicidal behavior in depression.

RESULTS

Thirteen studies (with 616 patients) were included, three of which examined the effects of psychotherapy for depression on suicidal ideation and suicide risk, and eleven on hopelessness. No studies were found with suicide attempts or completed suicides as the outcome variables. The effects on suicidal ideation and suicide risk were small (g=0.12; 95% CI: -0.20-0.44) and not statistically significant. A power calculation showed that these studies only had sufficient power to find an effect size of g=0.47. The effects on hopelessness were large (g=1.10; 95% CI: 0.72-1.48) and significant, although heterogeneity was very high. Furthermore, significant publication bias was found. After adjustment of publication bias the effect size was reduced to g=0.60.

DISCUSSION

At this point, there is insufficient evidence for the assumption that suicidality in depressed patients can be reduced with psychotherapy for depression. Although psychotherapy of depression may have small positive effects on suicidality, available data suggest that psychotherapy for depression cannot be considered to be a sufficient treatment. The effects on hopelessness are probably higher.

Reducing suicidal ideation: cost-effectiveness analysis of a randomized controlled trial of unguided web-based self-help

Background

Suicidal ideation is highly prevalent, but often remains untreated. The Internet can be used to provide accessible interventions.

Objective

To evaluate the cost-effectiveness of an online, unguided, self-help intervention for reducing suicidal ideation.

Methods

A total of 236 adults with mild to moderate suicidal thoughts, defined as scores between 1-26 on the Beck Scale for Suicide Ideation (BSS), were recruited in the general population and randomized to the intervention (n = 116) or to a waitlist, information-only, control group (n = 120). The intervention aimed to decrease the frequency and intensity of suicidal ideation and consisted of 6 modules based on cognitive behavioral techniques. Participants in both groups had unrestricted access to care as usual. Assessments took place at baseline and 6 weeks later (post-test). All questionnaires were self-report and administered via the Internet. Treatment response was defined as a clinically significant decrease in suicidal ideation on the BSS. Total per-participant costs encompassed costs of health service uptake, participants’ out-of-pocket expenses, costs stemming from production losses, and intervention costs. These were expressed in Euros (€) for the reference year 2009.

Results

At post-test, treatment response was 35.3% and 20.8% in the experimental and control conditions, respectively. The incremental effectiveness was 0.35 − 0.21 = 0.15 (SE 0.06, P = .01). The annualized incremental costs were −€5039 per participant. Therefore, the mean incremental cost-effectiveness ratio (ICER) was estimated to be −€5039/0.15 = −€34,727 after rounding (US −$41,325) for an additional treatment response, indicating annual cost savings per treatment responder.

Conclusions

This is the first trial to indicate that online self-help to reduce suicidal ideation is feasible, effective, and cost saving. Limitations included reliance on self-report and a short timeframe (6 weeks). Therefore, replication with a longer follow-up period is recommended.

Disability weights for suicidal thoughts and non-fatal suicide attempts

BACKGROUND

Although there are disability weights available for a wide range of health states, these do not include suicidality. This makes it difficult to evaluate the severity of suicidality in comparison with other health states. The aim of this study therefore is to estimate disability weights for suicidal thoughts and for mental distress involved in non-fatal suicide attempts.

METHODS

A Dutch expert panel of sixteen medical practitioners who were knowledgeable about suicidality estimated disability weights (DWs) for twelve health states by interpolating them on a calibrated Visual Analogue Scale. The DWs for ten of these health states had been estimated in previous studies and were used to determine the external consistency of the panel. The other two concerned health states for suicidal thoughts and non-fatal suicide attempts. The resulting DWs could vary between 0 (best imaginable health state) and 1 (worst imaginable health state).

RESULTS

Both internal (Cronbach's α = 0.98) and external consistency of the panel were satisfactory. The DWs for suicidal thoughts and non-fatal suicide attempts were estimated to be 0.36 and 0.46 respectively.

LIMITATIONS

The panel was relatively small, which resulted in broad confidence intervals.

CONCLUSIONS

Suicidal thoughts are considered to be as disabling as alcohol dependence and severe asthma. The mental distress involved in non-fatal suicide attempts is thought to be comparable in disability to heroin dependence and initial stage Parkinson's. These results demonstrate the severity of suicidality.

The effectiveness of a web-based self-help intervention to reduce suicidal thoughts: a randomized controlled trial

Background

Suicide, attempted suicide and suicidal thoughts are major public health problems worldwide. Effective face-to-face treatments are Cognitive Behavioural Therapy (CBT), Dialectical Behavioural Therapy (DBT) and Problem Solving Treatment (PST). However, about two-thirds of persons who die by suicide have not been in contact with mental health care services in the preceding year, and many have never been treated. Furthermore, many patients do not disclose their suicidal thoughts to their care provider. This may be out of shame, due to fear of stigma or due to lack of trust in (mental) health care. Since many suicidal individuals seek information online, the internet provides an opportunity to reach suicidal individuals who would not be contacted otherwise. By providing a self-help intervention online, persons can anonymously learn to gain control over their suicidal thoughts. There is convincing evidence that self-help is effective for a number of mental disorders. In this study the effectiveness for suicidal thoughts is examined.

Methods/Design

In this study, a recently developed self-help intervention will be evaluated in a Randomized Controlled Trial. The intervention is based on Cognitive Behavioural Therapy and is aimed at subjects who experience mild to moderate suicidal thoughts. This is defined as a score between 1 and 26 on the Beck Scale for Suicidal Ideation (BSS). Higher and lower scores are excluded. In addition, severely depressed subjects are excluded. In total, 260 subjects will be randomly allocated to the intervention-condition (N = 130) or to the information-control condition (N = 130). Self-report questionnaires will be filled out at baseline, 6 weeks after baseline and 18 weeks after baseline. Primary outcome measure is the reduction in frequency and intensity of suicidal thoughts. Secondary outcome measures are the reduction of hopelessness, anxiety and depression, sleeplessness, worry and quality of life measures.

Discussion

This study is the first to evaluate the effectiveness of a web-based self-help intervention for suicidal thoughts. Several limitations and strengths of the design are discussed.

Trial Registration

Netherlands Trial Register, NTR1689