Can digital interventions help young people with suicidal thoughts?
SUICIDE is the leading cause of death among young Australians between the ages of 15 and 24, and rates of hospital visits for self-harm in this age group have steadily increased over the past decade.
Suicide and self-harm are very complex and rare events, which has created significant challenges in identifying appropriate and optimal targets for effective intervention. The fight against suicidal thoughts emerged as a potentially useful indirect target for their prevention, given that a third of adolescents with suicidal thoughts develop a suicide plan and that 60% with a plan will attempt suicide.
Understanding how to better support and treat young people who are having suicidal ideation is receiving increasing attention, driven by research showing young people aged 12-18 are very reluctant to seek help from mental health services. face to face in suicidal distress. Figuring out how best to meet young people where they are in terms of how they want to receive information and engage with support is at the forefront of youth suicide prevention, and one of the greatest innovations resulting from this change was consideration of the role digital smart phone applications (apps) could play a role in suicide prevention.
Certainly, the touted benefits of smartphone-delivered therapy are numerous and include the ability to deliver proven treatment approaches with high fidelity, on demand, at low cost, and with great scalability. It is also believed that smartphone apps may be particularly appropriate models of care for young people given the high rates of smartphone ownership (>90%) and with many (>40%) young people now accessing apps for good. – to be mental.
While current evidence indicates that adults in suicidal distress can readily access and benefit from digital interventions that directly target suicidal ideation and/or behavior (here and here), unfortunately, there have been few published studies involving young people to establish their acceptability and effectiveness for young people. suicidal ideators.
To advance the field, there is a question that is increasingly important to answer: can smartphone interventions help to effectively reduce the severity of suicidal ideation among young people in suicidal distress?
In our recent randomized controlled trial of a co-designed brief, self-guided smartphone app (known as LifeBuoy), we found that community-based young adults (ages 18-25) who received the app from treatment reported greater improvements in their ideation compared to an attention-matched control group (effect size, 0.45 post intervention). These significant effects, although slightly diminished, were maintained at 3 months after the active intervention period (effect size, 0.32).
This finding represents an important contribution to the existing literature. This study provides evidence that a self-guided smartphone intervention targeting suicidal ideation can work for young adults. Prior to this study, there were only two published studies of comparable smartphone apps – and neither app demonstrated an intervention effect for suicidal ideation (here and here).
One of the potential reasons why the LifeBuoy app seems to have worked while others have not may be due to differences in the treatment delivered. Treatment patterns have been shown elsewhere to be an important moderator of efficacy (here and here). While our app primarily offered dialectical behavior therapy (DBT), which is a modified form of cognitive-behavioral therapy designed to treat persistent emotional dysregulation, previous apps used acceptance and commitment therapy (ACT) or a therapeutic evaluative conditioning (TEC). In DBT, individuals learn adaptive strategies to improve emotional regulation and tolerate distress, so that self-injurious behavior is not viewed as a coping solution. DBT is considered one of the most effective therapeutic approaches for reducing distress and suicidal behavior in young people. In comparison, ACT helps individuals behave in ways that are consistent with their values by teaching mindfulness strategies and acceptance skills, and TEC seeks to condition an aversion to suicide and self-harm. Trials of digital smartphone therapies using ACT and TEC treatment models have yet to be associated with significant reductions in suicidal ideation (here and here). In contrast, our results suggest that elements of DBT can be effectively digitized to treat suicidal ideation, and when done well, digital DBT appears to be comparable in effectiveness to the more intensive face-to-face modality for ideation. suicidal.
Interestingly, we did not find an effect of the intervention on common mental health symptoms (depression, anxiety, psychological distress). While both groups improved over time, the LifeBuoy group did not outperform the control group. This finding seems somewhat unexpected; however, this supports evidence from previous meta-analytic studies that DBT does not appear to significantly reduce depressive symptoms in adolescents. What we can infer from this is that effective treatment approaches for treating suicidal ideation may not be the same as those used to successfully treat common mental health conditions (e.g., depression, anxiety disorder generalized). Certainly, although cognitive behavioral therapy has been successfully translated into digital interventions for depression and anxiety, it appears to have little impact on ideation or other suicidal outcomes when delivered digitally. This is remarkable, given that suicidal ideation and mental health often coexist, potentially creating an expectation that these health issues can be effectively treated using a single approach. The literature seems to suggest that without carefully tailoring the digital intervention to a specific health outcome, we might find that these self-guided therapies are used “out in the wild” with little effect.
Needless to say, this study is only the beginning of the era of digital processing for suicide prevention. We need to replicate rigorous trials to confirm initial efficacy results to ensure that when apps are made public, they are effective and safe. There is also much work to be done to prepare for the effective use of these tools at scale, including understanding who self-guided digital interventions work best for, what strategies are needed to support delivery and engagement, developing sustainable funding schemes to support access at low or no cost to users, and establish their cost-effectiveness compared to face-to-face treatment and services.
Dr Michelle Torok is a senior researcher at the Black Dog Institute at UNSW Sydney and a researcher at the National Health and Medical Research Council.
Dr. Lauren McGillivray is a postdoctoral researcher at the Black Dog Institute and a clinical psychologist with experience in the research environment.
Dr Jin Han is a researcher at the Black Dog Institute, UNSW Sydney.
Statements or opinions expressed in this article reflect the views of the authors and do not necessarily represent the official policy of WADA, the MJA Where Preview+ unless otherwise stated.
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