School of
SOCIAL AND COMMUNITY MEDICINEUniversity of
BRISTOL
Exploring the use of the internet in
relation to suicidal behaviour:
identifying priorities for prevention
Dr Lucy Biddle, Dr Jane Derges, Dr Carlie Goldsmith
School of
SOCIAL AND COMMUNITY MEDICINEUniversity of
BRISTOL
Study team/ steering
group
Bristol University: Lucy Biddle, Jane
Derges, Jenny Donovan, David Gunnell,
Jon Heron, Becky Mars, Prianka
Padmanathan, John Potokar
Samaritans: Carlie Goldsmith,
Stephanie Stace
PAPYRUS: Martyn Piper
Advisers: Rachel Holley, Chris
O’Sullivan
Acknowledgements
All material presented is drawn from
independent research commissioned
and funded by the Department of Health
Policy Research Programme (“Exploring
the Use of the Internet In Relation To
Suicidal Behaviour: Identifying Priorities
for Prevention”, PRP023/0163). The
views expressed in this talk are those of
the authors and not necessarily those of
the Department of Health.
All study participants
Bristol Liaison Psychiatry teams
Bristol Self-Harm Surveillance Register
ALSPAC
School of
SOCIAL AND COMMUNITY MEDICINEUniversity of
BRISTOL
Minimising the risks of the internet while harnessing
its potential for good is one of the most significant
emerging challenges for suicide prevention
School of
SOCIAL AND COMMUNITY MEDICINEUniversity of
BRISTOL
Study aim and objectives
“To provide detailed empirical evidence about the use of the internet
for suicide-related purposes and how this influences suicidal feelings
and behaviour”
Estimate the prevalence and patterning of suicide-related use
Examine how, for what purpose and with what impact internet is used
Describe content that is commonly accessed and how this is interpreted
Obtain evaluations of online help provision
Explore utility of asking patients about internet use during assessment
School of
SOCIAL AND COMMUNITY MEDICINEUniversity of
BRISTOL
Overview of study design
1. Surveys of use
• Young adults
(ALSPAC cohort)
• Hospital presenting
patients (following
suicide attempt)
2. In-depth interviews
with users
Conducted with multiple
samples
3. Internet search
study
Content analysis of hits:
• 12 suicide-related
search terms
• 4 search engines
4. Clinician focus
groups
Psychiatric liaison
team staff
School of
SOCIAL AND COMMUNITY MEDICINEUniversity of
BRISTOL
Survey of young adults
Survey of 3946 young adults, aged 21yrs
All young adults
22.5% reported some suicide-related use
9.1% discussed suicidal feelings on social media
7.5% used a search engine to access suicide content
8.2% viewed sites offering help/ support
3.1% viewed information about how to kill
yourself
Mars et al, JAD 2015
School of
SOCIAL AND COMMUNITY MEDICINEUniversity of
BRISTOL7 03 March 2017
0
10
20
30
40
50
60
70
80
No self-harm Self-harm Suicidal thoughts Suicidal plans Suicide attempts
Perc
enta
ge o
f sa
mp
le
S/Sh related Internet use Sites offering help, advice or support Sites offering information on how to hurt/kill yourself
Key points
• Suicide-related internet use
is a marker of severity and
potential risk
• Young people commonly turn
to the internet for information
and dialogue about suicide.
Suicide attempters:
• 1 in 2 used search engine to
find suicide information
• 1 in 3 discussed feelings
online
• 1 in 5 viewed information
about how to kill yourself
• Distressed young people
access more helpful than
harmful sites
School of
SOCIAL AND COMMUNITY MEDICINEUniversity of
BRISTOL
Patients presenting after a suicide attempt
Data on suicide-related internet use collected by clinicians from
1198 patients during psychosocial assessment
Use: reported by 8.4%;
Purpose of use:
Padmanathan et al, 2016 - forthcoming
associated with: • Age: 11.8% amongst <25yrs;
children’s hospital data showed
prevalence of 26% (age 8-17yrs)
• Intent: 24% in group with high
suicidal intent
Research suicide methods: 74.3%
Buy poison/ drugs for overdose: 8.1%
Search for help/ support: 5.4%
School of
SOCIAL AND COMMUNITY MEDICINEUniversity of
BRISTOL
In-depth interviews
4 samples:
Young adults (community-based); n=13
Patients who have attempted suicide (hospital-based); n=20
Adults recruited via Samaritans’ online survey (community-based); n=20
Bereaved informants of suicides with internet involvement recruited via
PAPYRUS (community-based); n=10
Total n=63
School of
SOCIAL AND COMMUNITY MEDICINEUniversity of
BRISTOL
Distressed. Ambivalent/
uncertain about suicide
Highly distressed
Decision to
pursue suicide
Lower severity: ‘Pessimistic browsing
communicating’
• Purpose: mixed - understand and
manage feelings & explore suicide
• Gathering: broad and unstructured
• Processing: browsing stalled by
emotional responses
• ‘Put off’ of suicide by emotional
response to content but low mood not
resolved.
Higher severity: ‘Purposeful researching’
• Purpose: specific – find/ research methods
• Gathering: deliberate, structured and
specific
• Processing: ‘mining’ of details, used to
evaluate and ‘shop’ between methods
• Quest to develop expertise/ perfect method
• Information suggests undesirable details
leading to ‘ruling out’ some methods.
• Implementation/ ‘trying out’ methods
• Emotionality
• Sociability (desire to connect)
• Interest in Help Avoidance of
help
Detachment
School of
SOCIAL AND COMMUNITY MEDICINEUniversity of
BRISTOL
Increasing physical accessibility
1. Internet informed attempts
Examples
‘Trying’ methods learnt or ideas formulated via searching/ browsing
Discovering how to use everyday items
Using to inform planning and ‘effective’ implementation
Obtaining physical means online
School of
SOCIAL AND COMMUNITY MEDICINEUniversity of
BRISTOL
Increasing cognitive accessibility2. Internet-based encouragement/ validation
Examples
Identifying ‘good’ methods
Normalising suicidal feelings
Legitimising suicide as a course of action
School of
SOCIAL AND COMMUNITY MEDICINEUniversity of
BRISTOL
But… can also reduce accessibility
‘Too hard’ (physical) ‘Too terrible’ (cognitive)
Suicide revealed to be:
School of
SOCIAL AND COMMUNITY MEDICINEUniversity of
BRISTOL
Internet as a help resource
Sub-group of participants reported positive impact of:
Peer support / interaction as part of an online community
Expressing feelings (incl. via blog writing)
Use for distraction
Web-based apps (eg. MoodScope)
Several thought online activity had ‘stopped’ them making an
attempt.
School of
SOCIAL AND COMMUNITY MEDICINEUniversity of
BRISTOL
Criticisms of formal help provision
Impersonal, unemotional: like a ‘shop window’; a ‘face’; ‘corporate’; ‘the train
leaves at…’; ‘not my safe space’; “You can find information but that’s all you
can find”
Lacking immediacy and uniqueness:
Suggesting unobtainable solutions
Not age sensitive
School of
SOCIAL AND COMMUNITY MEDICINEUniversity of
BRISTOL
Clinician focus groups
2 psychiatric liaison teams
Groups exploring:
1. Acceptability
2. Clinical usefulness
Padmanathan et al. 2016, forthcoming
School of
SOCIAL AND COMMUNITY MEDICINEUniversity of
BRISTOL
Mostly acceptable, but:
clinicians tended to ‘build in’ or ‘ask in a roundabout way’
some feared asking could be ‘risky’: ‘could be alerting somebody to
possibility they hadn’t considered’
some did not always ask if patient acutely distressed
Knowing about use seen as ‘part of a jigsaw’ that could:
enhance perceptions of risk and intent
identify those actively planning
Most clinicians unaware of use of specific sites to obtain methods
information
School of
SOCIAL AND COMMUNITY MEDICINEUniversity of
BRISTOL
Implications…
School of
SOCIAL AND COMMUNITY MEDICINEUniversity of
BRISTOL
Implications for internet industry
Maintain ongoing prevention strategies
to reduce risk (e.g. based on search
algorithms, predictive searching,
structuring search data) and
partnerships (e.g. with Samaritans)
Develop and promote safe internet use
and digital citizenship
School of
SOCIAL AND COMMUNITY MEDICINEUniversity of
BRISTOL
internet industry cont’d.
Continue to explore ways to restrict access to sites/
chatrooms primarily existing to promote suicide or
self-harm
Wikipedia to review its policies/ guidelines to cover
regulation of suicide-related content
Hosts and moderators of blog sites and discussion
forums to ensure policies and guidelines in place to
cover suicide-related content
School of
SOCIAL AND COMMUNITY MEDICINEUniversity of
BRISTOL
Implications for providers of online help
Review and redesign formal help provision to:
Focus on providing immediate responses within the online environment (rather than signposting)
Provide age-appropriate material for young people
Develop novel approaches to engage individuals in active suicidal crisis
Ensure site moderation is in place to safeguard ‘peer support’ and ‘safe spaces’
Moderators of all online community forums to be aware of National Suicide Prevention
Alliance guidance for online moderators
School of
SOCIAL AND COMMUNITY MEDICINEUniversity of
BRISTOL
Implications for clinicians/ clinical resources Training to increase clinicians’ understanding of the
online environment and suicide-related use
Consider exploring internet use as part of suicide risk
assessment
Clinicians could support patients to:
recognize how and when their use is harmful
devise personalized online safety practices as part of crisis
planning
Strategies to reduce risks associated with medical
sites and open access research:
publication guidelines for researchers
School of
SOCIAL AND COMMUNITY MEDICINEUniversity of
BRISTOL
Samaritans
1. Provided additional evidence to support established and ongoing
dialogue, relationship and joint working with social media companies and
search engines.
2. Identified new and important areas of work, for example developing
guidance for clinicians that Samaritans plans to take forward, in
partnership.
3. Made an important contribution to Samaritans understanding of suicide,
which will be embedded in its longer term strategic and service
development.
