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

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

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)
• 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

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