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Suicidal Worrying : Online and Telephone

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

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Suicidal Worrying : Online and Telephone

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

  4. 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

  5. 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?

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

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

  8. Intervention • Six modules • Unguided • CBT (PST / DBT / Mindfulness)

  9. 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

  10. Interventionwebsite

  11. 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

  12. Interventionwebsite

  13. 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

  14. Interventionwebsite

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

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

  17. Design • RCT • 2 arms • Sample size: 236 • Recruitment throughnewspapers, 113Online, google • Exclusion criteria: • Age < 18 • BSS < 1 or BSS > 26 • BDI > 39

  18. 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

  19. 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

  20. Safety protocol • At T1, T2, T3 and T4: • BSS > 26 and / or BDI > 39  safety protocol: • Call participant • Risk assessment • High risk = call GP • Notbeingable to contact participant = call GP

  21. Flow of participants through the RCT Visits to registration website (n=2484) • Excluded (n=1216) • Incomplete registrations Assessedforeligibility (n=1268) • Excluded (n=1032) • Not meeting inclusion criteria (n=562) • BSS <1 (n=15) • BSS >26 (n=48) • BDI >39 (n=468) • Tooyoung (n=31) • Declined to participate (n=417) • No valid e-mail (n=53) Randomized (n=236)

  22. Dropoutattrition • 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

  23. Linear Mixed Model: suicidal thoughts (ITT) • Control condition: b=0.74 • Interventioncondition: b=1.58 • Time*groupInteraction: F(1,656)=8.83, p=0.004)

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

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

  26. Mean change (pre-posttest) & betweengroup effect sizes (adherent sample 3+ modules)

  27. Follow-up: withingroupeffects (interventiongroup)

  28. 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

  29. 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

  30. Strong points 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 interventiongroupcompared with control group Resultsinterventiongroupmaintained at threemonths follow-up 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 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

  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, Ad Kerkhof en Bregje van Spijker (2012). Piekeren over Zelfdoding. Boom Hulpboek, Amsterdam BAJ van Spijker (2012). Reducing the burden of suicidalthoughtsthrough 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 intounguidedself-help. Journal of Medical Internet Research, 2012, 14, 5, e14, 1-141 doi:10.2196/jmir.1966

  35. Thankyou for your attention

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