1. Suicidal Worrying: Online and Telephone IFOTES Göteborg July 11th 2013 Ad Kerkhof VU Vrije Universiteit Amsterdam

2. Reducing suicidal thoughts: Effectiveness of a web-based self-help intervention: RCT

3. Treatment of suicidal people 44% - 83% do not receive treatment 44% - 83% do not receive treatment Attitudinal barriers: Attitudinal barriers: Preference for self-reliancePreference for self-reliance Believing in spontaneous recoveryBelieving in spontaneous recovery Thinking problem is not that severeThinking problem is not that severe Believing treatment will not be effectiveBelieving treatment will not be effective

4. Barriers to help-seeking Shame Shame Fear for stigma and self-stigma Fear for stigma and self-stigma Fear of loosing autonomy Fear of loosing autonomy Fear for rejection Fear for rejection Past negative experiences Past negative experiences Anonymity: Helpline / online service Anonymity: Helpline / online service

5. Internet Providing anonymous help online may address some of these barriers 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 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? People who receive treatment could benefit from additional online self-help intervention?

6. Effective web-based interventions: guided and unguided Depression (Andersson et al, 2009) Depression (Andersson et al, 2009) Anxiety (Cuijpers et al, 2009) Anxiety (Cuijpers et al, 2009) Problem drinking (Riper, 2008) Problem drinking (Riper, 2008)

7. RCT study Comparing unguided web-based self- help for suicidal thoughts with a waitlist control group Comparing unguided web-based self- help for suicidal thoughts with a waitlist control group

8. Intervention Six modules Six modules Unguided Unguided CBT (PST / DBT / Mindfulness) CBT (PST / DBT / Mindfulness) Mod.Aimed at: 1Reducing suicidal worrying 2Regulating intense emotions 3Identifying automatic thoughts 4Recognizing cognitive distortions 5Cognitive restructuring 6Relapse prevention

9. Intervention Self-help is no substitute for treatment Self-help is no substitute for treatment Week 1: ‘Thinking about suicide’ Week 1: ‘Thinking about suicide’ Repetitive character of suicidal cognitionsRepetitive character of suicidal cognitions Exercises aimed at reducing suicidal worryExercises aimed at reducing suicidal worry Week 2: ‘Dealing with emotions’ Week 2: ‘Dealing with emotions’ Tolerate and regulate intense emotionsTolerate and regulate intense emotions Crisis planCrisis plan

10. Intervention website

11. Intervention Week 3: Automatic thoughts Week 3: Automatic thoughts ABC modelABC model Identifying automatic thoughtsIdentifying automatic thoughts ‘I am worthless’ ‘I am worthless’ ‘I am incapable’ ‘I am incapable’ ‘I am unlovable’ ‘I am unlovable’ Self-help is no substitute for treatment Self-help is no substitute for treatment

12. Intervention website

13. Intervention Week 4: Dysfunctional thinking Week 4: Dysfunctional thinking Cognitive distortionsCognitive distortions All-or-nothing thinking All-or-nothing thinking Overgeneralization Overgeneralization Mind reading Mind reading Disqualifying the positive Disqualifying the positive Emotional reasoning Emotional reasoning If needed, contact GP / mental health care If needed, contact GP / mental health care

14. Intervention website

15. Intervention Week 5: Changing thoughts Week 5: Changing thoughts Challenging cognitive distortionsChallenging cognitive distortions Evaluating evidence for and against validityEvaluating evidence for and against validity Reformulate thoughtsReformulate thoughts If needed contact GP / mental healthIf needed contact GP / mental health

16. Intervention Week 6: Relapse prevention Week 6: Relapse prevention Picture of the futurePicture of the future Possible future setbacksPossible future setbacks Relapse prevention planRelapse prevention plan Self–help is no substitute for treatmentSelf–help is no substitute for treatment

17. Design RCT RCT 2 arms 2 arms Sample size: 236 Sample size: 236 Recruitment through newspapers, 113Online, google Recruitment through newspapers, 113Online, google Exclusion criteria: Exclusion criteria: Age < 18Age < 18 BSS 26BSS 26 BDI > 39BDI > 39 ConditionBase- line 2 weeks 2 weeks Post- test 3 monthsFollow- up ControlT0T1T2T3 (Intervention) T4 InterventionT0intervT1intervT2intervT3T4

18. Control group Waiting list: 6 weeks Waiting list: 6 weeks Access to website constructed for this study: Access to website constructed for this study: Warning signsWarning signs General information on suicidalityGeneral information on suicidality Advice to seek help (as in experimental condition)Advice to seek help (as in experimental condition) Explanation of study designExplanation of study design

19. Medical-ethical considerations Suicidal people are a vulnerable group Suicidal people are a vulnerable group Unethical to experiment with anonymous suicidal people Unethical to experiment with anonymous suicidal people Safety protocol: participants in acute risk Safety protocol: participants in acute risk Involvement GP Involvement GP Respondents not anonymous Respondents not anonymous Approval Medical Ethical Committee VU Approval Medical Ethical Committee VU

20. Safety protocol At T1, T2, T3 and T4: At T1, T2, T3 and T4: BSS > 26 and / or BDI > 39  safety protocol:BSS > 26 and / or BDI > 39  safety protocol: Call participant Call participant Risk assessment Risk assessment High risk = call GP High risk = call GP Not being able to contact participant = call GP Not being able to contact participant = call GP

21. 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=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 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)

22. Dropout attrition Total dropout: n = 21 Total dropout: n = 21 Control condition: n = 10Control condition: n = 10 Intervention condition: n = 11Intervention condition: n = 11 χ²(1)=0.096, p=0.757χ²(1)=0.096, p=0.757 Reasons for dropoutReasons for dropout Lack of time Lack of time Recovery of symptoms Recovery of symptoms Admission to psychiatric hospital Admission to psychiatric hospital

23. Linear Mixed Model: suicidal thoughts (ITT) Control condition: b=0.74 Control condition: b=0.74 Intervention condition: b=1.58 Intervention condition: b=1.58 Time*group Interaction: F(1,656)=8. 83, p=0.004) Time*group Interaction: F(1,656)=8. 83, p=0.004)

24. Mean change (t-tests: pre-posttest) & between group effect sizes. ITT sample Control (n=120)¹ Intervention (n=116)¹ pd Suicidal thoughts (m, sd)2.30 (6.6)4.47 (8.7)0.0360.28 Depressive symptoms (m, sd)1.82 (8.8)3.93 (10.1)0.0860.22 Hopelessness (m, sd)0.68 (3.6)1.91 (4.9)0.0290.28 Worrying (m, sd)2.12 (10.1)5.48 (10.1)0.0100.34 Anxiety (m, sd)0.51 (3.3)1.03 (3.9)0.2700.14 Health status (m, sd)-3.00 (18.3)1.96 (19.7)0.0450.26 ¹Multiple imputation was used to replace missing values

25. Linear Mixed Model: suicidal thoughts Control condition: b=0.73 Control condition: b=0.73 Intervention condition 1 / 2 module: b=1.18 Intervention condition 1 / 2 module: b=1.18 Intervention condition, 3 + modules: b=1.81 Intervention condition, 3 + modules: b=1.81 Time*group interaction: F(2,597)=5.52, p=0.005. Time*group interaction: F(2,597)=5.52, p=0.005.

26. Mean change (pre-posttest) & between group effect sizes (adherent sample 3+ modules) Control (n=120)¹ Intervention (n=65)¹ pd Suicidal thoughts (m, sd)2.30 (6.6)5.45 (8.3)0.0050.44 Depressive symptoms (m, sd)1.82 (8.8)4.85 (9.2)0.0270.34 Hopelessness (m, sd)0.68 (3.6)2.68 (5.1)0.0020.48 Worrying (m, sd)2.12 (10.1)6.40 (10.5)0.0060.43 Anxiety (m, sd)0.51 (3.3)1.60 (3.7)0.0390.32 Health status (m, sd)-3.00 (18.3)-2.36 (21.2)0.1250.27 ¹Multiple imputation was used to replace missing values. Control group compared with participants from intervention group who completed at least 3 modules

27. 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

28. Use of safety protocol Total number of participants called: n = 50 Total number of participants called: n = 50 31 in control, and 19 in intervention group (p=0.076) 31 in control, and 19 in intervention group (p=0.076) GP called: n = 12 GP called: n = 12 9 in control, and 3 in intervention group (p=0.086). 9 in control, and 3 in intervention group (p=0.086). Attempted suicide: n=11 Attempted suicide: n=11 7 in control, and 3 in intervention group (p=0.351). 7 in control, and 3 in intervention group (p=0.351). Suicide: n=0 Suicide: n=0

29. Limitations In experimental group 26 persons didn’t start In experimental group 26 persons didn’t start Effect sizes perhaps underestimations of effectiveness Effect sizes perhaps underestimations of effectiveness Potential participants did not want to disclose their identity Potential participants did not want to disclose their identity Substantial interest Substantial interest Generisability to target audience? Generisability to target audience? Guided self help probably more effective and appreciated Guided self help probably more effective and appreciated Perhaps too many respondents excluded with severe depression but moderate suicidal thinking Perhaps too many respondents excluded with severe depression but moderate suicidal thinking Attrition as expected with self-help Attrition as expected with self-help Greater hopelessness at baseline is associated with attrition Greater hopelessness at baseline is associated with attrition No formal psychiatric diagnosis obtained No formal psychiatric diagnosis obtained

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

31. Conclusions Significant reduction in suicidal thoughts in intervention group compared with control group Significant reduction in suicidal thoughts in intervention group compared with control group Results intervention group maintained at three months follow- up Results intervention group maintained at three months follow- up Studying online self-help for suicidal thoughts is feasible Studying online self-help for suicidal thoughts is feasible

32. Implications: Online self help available for people with suicidal thoughts, irrespective of diagnosed or diagnosable disorder 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 through the internet world wide possible: small effects but huge numbers Implementation possible in LAMIC countries Implementation possible in LAMIC countries If possible guided self help preferred If possible guided self help preferred New trials being initiated in Australia, Spain, Denmark, Turkye New trials being initiated in Australia, Spain, Denmark, Turkye

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

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

35. Thank you for your attention