CRISE - INSTITUT 2012 - Ad Kerkhof - Reducing suicidal thoughts: Effectiveness of a web-based self-help intervention: RCT

Reducing suicidal thoughts:

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

Ad Kerkhof

Bregje van Spijker

Self-help course in 113Online

Jan Mokkenstorm

CRISE - SUMMER INSTITUTE 2012 - MONTRÉAL

Treatment of suicidal people

• Bruffaerts (2011): 21 nat. samples, n=55.302

• 44% - 83% do not receive treatment

• Attitudinal (54% of suicidal respondents)

– 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 of loosing autonomy

• Fear for rejection

• Past negative experiences

• Current negative experiences

• Limited facilities

• Too many chats


Internet

• Providing anonymous help online may address some of these barriers (Sahar, 113Online)

• 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)

Module 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 website - homepage CRISE - SUMMER INSTITUTE 2012 - MONTRÉAL

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 CRISE - SUMMER INSTITUTE 2012 - MONTRÉAL

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

• Week 4: Dysfunctional thinking

– Cognitive distortions

• All-or-nothing thinking

• Overgeneralization

• Mind reading

• Disqualifying the positive

• Emotional reasoning

• Fortune telling

• If needed, contact your GP / Mental health care



Intervention

• Week 5: Changing thoughts

– Challenging cognitive distortions

– Evaluating evidence for and against validity

– Reformulate thoughts

– If needed contact GP / Mental health care


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 T1 T2 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

• 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)


Characteristics of Registrations Characteristic

Participants (n=236)

Declined participation (n=417)

p

Female 65.3% 67.9% 0.417

Age (m, sd) 40.9 (13.7) 37.2 (13.9) 0.001

Education: •Low •Middle •High •Other

2.5%

50.4% 39.8% 5.1%

4.8%

57.6% 30.0% 5.8%

0.050

Anonymity important 39.8% 61.9% 0.000

No care 44.5% 57.4% 0.006

Living with partner 39.4% 36.7% 0.508

Suicidal thoughts (M, SD) 15.7 (5.6) 16.1 (6.0) 0.135

Depressive symptoms (M, SD) 27.7 (7.6) 27.3 (7.9) 0.243


Randomized (n=236)

Allocated to control group (n=120)

Allocated to intervention (n=116) • 90 completed at least 1 module • 65 completed at least 3 modules • 21 completed whole intervention

Assessments • 120 completed T0 (baseline) •114 completed T1 • 106 completed T2 • 110 completed T3 (post-test) •98 completed T4 (follow-up)

Flow of participants through the RCT

Assessments • 116 completed T0 (baseline) • 106 completed T1 • 105 completed T2 • 105 completed T3 (posttest) •102 completed T4 (follow-up)

Analysed: n=120 Analysed: n=116


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


Characteristics of participants Characteristic Control (n=120) Intervention (n=116) p

Female 66.7% 65.5% 0.852

Age (m, sd) 41.4 (13.4) 40.5 (14.1) 0.602

Education: •Low •Middle •High •Other

6.7%

43.3% 42.5% 7.5%

9.5%

51.7% 33.6% 5.2%

0.365

Living with a partner 45.0% 35.3% 0.131

Born in Netherlands 93.3% 94.7% 0.651

Paid employment 49.6% 50.4% 0.895

Suicidal thoughts (m, sd) 14.5 (7.3) 15.2 (6.8) 0.444

Depressive symptoms (m, sd) 26.5 (9.0) 27.6 (9.3) 0.364

Hopelessness (m, sd) 14.1 (3.9) 14.7 (3.5) 0.204

Worrying (m, sd) 56.9 (11.3) 58.8 (11.0) 0.199

Anxiety (m, sd) 10.1 (3.9) 10.6 (3.5) 0.346

Health status (m, sd) 62.6 (18.2) 60.0 (17.8) 0.289


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 trial being initiated in Australia


• 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, accepted,


Cost Effectiveness:

• Economical evaluation in Euro’s (TIC-P)

• Costs of:

– health service uptake,

– Production losses

– Intervention costs

– Incremental savings: € 5.000 per participant.

– Feasible, effective and cost saving


Health & Medicine

CRISE - INSTITUT 2012 - Ad Kerkhof - Reducing suicidal thoughts: Effectiveness of a web-based self-help intervention: RCT