Suicidal Worrying:Online and Telephone

IFOTES Göteborg July 11th 2013

Ad Kerkhof

VU Vrije Universiteit Amsterdam

Reducing suicidal thoughts:

Effectiveness of a web-based self-help intervention: RCT

Treatment of suicidal people

44% - 83% do not receive treatment

Attitudinal barriers:• Preference for self-reliance • Believing in spontaneous recovery• Thinking problem is not that severe• Believing treatment will not be effective

Barriers to help-seeking

Shame Fear for stigma and self-stigma Fear of loosing autonomy Fear for rejection Past negative experiences Anonymity: Helpline / online service

Internet

Providing anonymous help online may address some of these barriers

Online self-help may help suicidal people to visit GP or mental health care center

People who receive treatment could benefit from additional online self-help intervention?

Effective web-based interventions:

guided and unguided

Depression (Andersson et al, 2009)

Anxiety (Cuijpers et al, 2009)

Problem drinking (Riper, 2008)

RCT study

Comparing unguided web-based self-help for suicidal thoughts with a waitlist control group

Intervention

Six modules Unguided CBT (PST / DBT /

Mindfulness)

Mod. Aimed at:

1 Reducing suicidal worrying

2 Regulating intense emotions

3 Identifying automatic thoughts

4 Recognizing cognitive distortions

5 Cognitive restructuring

6 Relapse prevention

Intervention

Self-help is no substitute for treatment

Week 1: ‘Thinking about suicide’• Repetitive character of suicidal cognitions• Exercises aimed at reducing suicidal worry

Week 2: ‘Dealing with emotions’• Tolerate and regulate intense emotions• Crisis plan

Intervention website

Intervention

Week 3: Automatic thoughts

• ABC model• Identifying automatic thoughts

‘I am worthless’ ‘I am incapable’ ‘I am unlovable’

Self-help is no substitute for treatment

Intervention website

Intervention

Week 4: Dysfunctional thinking• Cognitive distortions

All-or-nothing thinking Overgeneralization Mind reading Disqualifying the positive Emotional reasoning

If needed, contact GP / mental health care

Intervention website

Intervention

Week 5: Changing thoughts• Challenging cognitive distortions• Evaluating evidence for and against

validity• Reformulate thoughts

• If needed contact GP / mental health

Intervention

Week 6: Relapse prevention

• Picture of the future• Possible future setbacks• Relapse prevention plan

• Self–help is no substitute for treatment

Design RCT 2 arms

Sample size: 236 Recruitment through newspapers, 113Online,

google Exclusion criteria:

• Age < 18• BSS < 1 or BSS > 26• BDI > 39

Condition Base-line

2 weeks

2 weeks 2 weeks Post-test

3 months Follow-up

Control T0 T1 T2 T3 (Intervention) T4

Intervention T0 interv T1 interv T2 interv T3 T4

Control group

Waiting list: 6 weeks Access to website constructed for

this study:• Warning signs• General information on suicidality• Advice to seek help (as in experimental

condition)• Explanation of study design

Medical-ethical considerations

Suicidal people are a vulnerable group Unethical to experiment with anonymous

suicidal people Safety protocol: participants in acute risk Involvement GP Respondents not anonymous Approval Medical Ethical Committee VU

Safety protocol

At T1, T2, T3 and T4:

• BSS > 26 and / or BDI > 39 safety protocol:

Call participant Risk assessment High risk = call GP Not being able to contact participant = call GP

Excluded (n=1032)• Not meeting inclusion

criteria (n=562)• BSS <1 (n=15)• BSS >26 (n=48)• BDI >39 (n=468)• Too young (n=31)• Declined to participate

(n=417)• No valid e-mail (n=53)

Excluded (n=1216)•Incomplete registrations

Assessed for eligibility (n=1268)

Visits to registration website (n=2484)

Flow of participants through the RCT

Randomized (n=236)

Dropout attrition

Total dropout: n = 21• Control condition: n = 10• Intervention condition: n = 11• χ²(1)=0.096, p=0.757 • Reasons for dropout

Lack of time Recovery of symptoms Admission to psychiatric hospital

Linear Mixed Model: suicidal thoughts (ITT)

Control condition: b=0.74

Intervention condition: b=1.58

Time*group Interaction: F(1,656)=8.83, p=0.004)

Mean change (t-tests: pre-posttest) & between group effect sizes. ITT sample

Control (n=120)¹

Intervention (n=116)¹

p d

Suicidal thoughts (m, sd) 2.30 (6.6) 4.47 (8.7) 0.036 0.28

Depressive symptoms (m, sd) 1.82 (8.8) 3.93 (10.1) 0.086 0.22

Hopelessness (m, sd) 0.68 (3.6) 1.91 (4.9) 0.029 0.28

Worrying (m, sd) 2.12 (10.1) 5.48 (10.1) 0.010 0.34

Anxiety (m, sd) 0.51 (3.3) 1.03 (3.9) 0.270 0.14

Health status (m, sd) -3.00 (18.3) 1.96 (19.7) 0.045 0.26

¹Multiple imputation was used to replace missing values

Linear Mixed Model: suicidal thoughts

Control condition: b=0.73

Intervention condition 1 / 2 module: b=1.18

Intervention condition, 3 + modules: b=1.81

Time*group interaction: F(2,597)=5.52, p=0.005.

Mean change (pre-posttest) & between group effect sizes (adherent sample 3+

modules) Control (n=120)¹

Intervention (n=65)¹

p d

Suicidal thoughts (m, sd) 2.30 (6.6) 5.45 (8.3) 0.005 0.44

Depressive symptoms (m, sd) 1.82 (8.8) 4.85 (9.2) 0.027 0.34

Hopelessness (m, sd) 0.68 (3.6) 2.68 (5.1) 0.002 0.48

Worrying (m, sd) 2.12 (10.1) 6.40 (10.5) 0.006 0.43

Anxiety (m, sd) 0.51 (3.3) 1.60 (3.7) 0.039 0.32

Health status (m, sd) -3.00 (18.3) -2.36 (21.2) 0.125 0.27

¹Multiple imputation was used to replace missing values. Control group compared with participants from intervention group who completed at least 3 modules

Follow-up: within group effects (intervention group)

Posttest (m, sd)¹

Follow-up (m, sd)¹

ΔM (sd) d

Suicidal thoughts (m, sd) 10.6 (9.2) 10.3 (9.8) -0.3 (8.1) 0.04

Depressive symptoms (m, sd) 23.5 (13.1) 20.6 (14.3) -2.9 (11.2)* 0.26

Hopelessness (m, sd) 12.6 (5.6) 11.9 (6.0) -0.7 (5.4) 0.12

Worrying (m, sd) 53.2 (13.9) 53.7 (14.8) 0.5 (14.5) 0.03

Anxiety (m, sd) 9.6 (4.3) 9.0 (4.0) -0.6 (3.4) 0.16

Health status (m, sd) 62.7 (21.2) 62.0 (19.8) -0.7 (20.8) 0.03

¹ Multiple imputation was used to replace missing values. * p<0.01

Use of safety protocol

Total number of participants called: n = 50• 31 in control, and 19 in intervention group

(p=0.076)

• GP called: n = 12 9 in control, and 3 in intervention group (p=0.086).

• Attempted suicide: n=11 7 in control, and 3 in intervention group

(p=0.351).

• Suicide: n=0

Limitations In experimental group 26 persons didn’t start Effect sizes perhaps underestimations of effectiveness Potential participants did not want to disclose their identity Substantial interest Generisability to target audience? Guided self help probably more effective and appreciated Perhaps too many respondents excluded with severe

depression but moderate suicidal thinking Attrition as expected with self-help Greater hopelessness at baseline is associated with attrition No formal psychiatric diagnosis obtained

Strong points

Participants with mild to moderate depression and mild to moderate suicidal thoughts: probably fairly representative of target population

Conclusions

Significant reduction in suicidal thoughts in intervention group compared with control group

Results intervention group maintained at three months follow-up

Studying online self-help for suicidal thoughts is feasible

Implications:

Online self help available for people with suicidal thoughts, irrespective of diagnosed or diagnosable disorder

Implementation through the internet world wide possible: small effects but huge numbers

Implementation possible in LAMIC countries If possible guided self help preferred New trials being initiated in Australia, Spain,

Denmark, Turkye

Kerkhof, AJFM, & Van Spijker, BAJ (2011). Worrying and rumination as proximal risk factors for suicidal behaviour. In: R.C. O’Connor, S. Platt, & J. Gordon (Eds.). International Handbook of Suicide Prevention. Wiley Blackwell,

Ad Kerkhof en Bregje van Spijker (2012). Piekeren over Zelfdoding. Boom Hulpboek, Amsterdam

BAJ van Spijker (2012). Reducing the burden of suicidal thoughts through online self-help. Ph D Dissertation VU Amsterdam, June 13

Cost-Effectiveness

BAJ van Spijker, CM Majo, F. Smit, A van Straten, AJFM Kerkhof (2012).

Reducing suicidal ideation via the internet: Cost – effectiveness analysis alongside a randomized trial into unguided self-help.

Journal of Medical Internet Research, 2012, 14, 5, e14, 1-141 doi:10.2196/jmir.1966

Thank you for your attention