Research roundup: Treating suicidality through technology

Throughout the COVID-19 pandemic, there has been an increase in suicidal ideations as well as use of substances. Recent data from the Centers for Disease Control show that 27% of Americans reported an increase in substance use and 11% reported seriously considering suicide.

In this installment of “Research Roundup,” we explore research on adjunctive interventions that could help bridge the gap in accessing necessary services for individuals who are experiencing suicidal ideation alone or in addition to heavy drinking. We also explore research on ways to reduce access to firearms and other lethal means through a web-based decision aid.

Note: In addition to reviewing the research summaries, psychologists are encouraged to further explore the literature to determine what may be useful to them in practice, particularly as it relates to patients’ values, culture, and preferences.

De Jaegere, E., van Landschoot, R., van Heeringen, K., van Spijker, B. A. J., Kerkhof, A. J. F. M., Mokkenstorm, J. K., and Portzky, G. (2019). The online treatment of suicidal ideation: A randomised controlled trial of an unguided web-based intervention. Behaviour Research and Therapy, 119, Article 103406.

Individuals experiencing suicidal ideation may not know where to seek help and may also be reluctant toward seeking help, as there is still significant stigma around seeking mental health treatment. Several online interventions address suicide in the context of targeting psychological disorders but these interventions do not target suicidal behaviors. Researchers in Belgium tested the efficacy of a self-help online intervention for reducing suicidal ideation and behavior, regardless of whether the individual has an existing psychiatric diagnosis.

Of the 1,688 adults who expressed interest in participating in the online self-help intervention, 724 met criteria and were randomly assigned to either receive a link to the intervention website “Think Life” or a link to the Flemish government operated suicide resources webpage “1813 Zelfmoord.” Both groups completed self-report ratings that assessed the severity of suicidality as well as depression, worry, hopelessness, and anxiety. The “Think Life” unguided self-help website consists of six modules that combine principles of cognitive-behavior therapy, problem-solving therapy, and other third-wave approaches, with the goal of recognizing the signs and symptoms of suicidal ideation and then applying the skills gained through completing the online exercises. The exercises range from identifying and modifying maladaptive thinking patterns to preparing for future crises.

Participants who were randomly assigned to receive the link to the “Think Life” website reported a decrease in suicidal ideation and anxiety as well as an improvement in mood. The improvement in symptoms also lasted three months after the experiment, which further demonstrates that the modules within the “Think Life” website were effective in reducing suicidal ideation and mood/anxiety symptoms.

Wilks, C. R., Lungu, A., Ang, S. Y., Matsumiya, B., Yin, Q., and Linehan, M. M. (2018). A randomized controlled trial of an Internet delivered dialectical behavior therapy skills training for suicidal and heavy episodic drinkers. Journal of Affective Disorders, 232, 219–228.

Not only has there been a slight increase in suicidal ideations during the COVID-19 pandemic, but there has also been an increase in alcohol consumption. This pilot study examined the usefulness and efficacy of a Dialectical Behavior Therapy skills training delivered over the internet (iDBT) for individuals who drink heavily and report having suicidal ideations. The online training program consisted of eight sections, each lasting around 30 minutes, that trained individuals how to regulate their emotions and reduce their alcohol use with topics ranging from mindfulness to distress tolerance. At the end of each session, individuals were given homework assignments to practice their skills offline and received daily encouragement via email or text message.

Fifty-nine adults with heavy episodic drinking and suicidal ideation were randomized to receive either a link to the iDBT program or were asked to complete self-report assessments of suicidality and alcohol consumption over the course of eight weeks (participants in the control group then received a link to the iDBT program at the end of the experiment). Participants in the iDBT group also completed questionnaires on the accessibility and usefulness of the iDBT program. Individuals in both groups received a call from the clinic staff if their self-reported levels of suicidality exceeded a determined safety point on weekly self-report measures.

Individuals who were assigned to the iDBT group reported a significant reduction in alcohol consumption as well as suicidal ideation. The positive effects of the treatment continued four months after the study and individuals who started the iDBT program immediately showed significant reduction in drinking, suicidality, and improved emotion regulation. While the results are promising and individuals found the skills helpful and useful, the study authors noted that about 50% of the study participants reported having issues with accessing the iDBT program materials, with reasons ranging from poor internet connectivity to website malfunction. Despite this limitation, with improvement in technology the online intervention could have significant reach to individuals from rural or underserved areas who are experiencing suicidal ideation and excessive alcohol consumption.

Betz, M. E., Knoepke, C. E., Simpson, S., Siry, B. J., Clement, A., Saunders, T., Johnson, R., Azrael, D., Boudreaux, E. D., Omeragic, F., Adams, L. M., Almond, S., Juarez-Colunga, E., and Matlock, D. D. (2020). An interactive web-based lethal means safety decision aid for suicidal adults (Lock to Live): Pilot randomized controlled trial. Journal of Medical Internet Research, 22(1), Article e16253.

Throughout the pandemic, there has been an increase in firearm sales, which poses a greater risk to individuals experiencing suicidal ideation. At the same time, not all staff working in emergency rooms are comfortable assessing risk of suicide with patients. The researchers examined the usefulness of an online decision aid to reduce firearm access to individuals who present to the emergency room with suicidal ideation. The online interactive decision aid “Lock to Live” was developed by researchers from the University of Colorado with input from suicide prevention experts and individuals with lived experiences. The tool includes graphics and brief videos depicting steps to safely storing firearms and medications.

Forty-nine adult patients in an emergency room setting were randomized to receive a link to the “Lock to Live” site or information on preventing suicide without steps to locking away firearms and medications. All 39 patients who were randomized to receive the “Lock to Live” link completed the online decision aid intervention and even reported that the decision aid was user-friendly and relatable to their current situation. The patients also reported that they would recommend the online decision aid to friends and family who owned a firearm or medication and were struggling with suicidal ideations. Among the 14 patients who responded to follow-up and reported having firearms at both the beginning and end of the study, roughly half of the group reported moving their firearms to a safe location, which shows that the online decision aid is useful for individuals who are struggling with suicidality and have access to firearms.

While the authors only examined the usefulness of the application and noted that future research is warranted on whether it influences suicidal outcomes, they overall confirmed that the “Lock to Live” online decision aid is feasible and applicable in various settings. The online decision aid could serve as a gateway to more intensive, evidence-based interventions for suicidality.

Given the rise in suicidal ideations, the consumption of alcohol, and rates of firearm access during the COVID-19 pandemic, it is critical to bridge the gap between individuals who may be struggling with suicidality to effective services. The three studies above illustrate how technology can be used to reduce suicidality and prevent suicide as well as serve as a gateway to more intensive interventions. Clinicians may be able to use these or similar technology programs as an adjunctive modality to treat individuals with suicidal ideations.