SUICIDE is the leading cause of death in young Australians aged 15–24 years, and rates of hospital presentations for self-harm in this age group have steadily been rising over the past decade.
Suicide and self-harm are highly complex and rare events, and this has created significant challenges in identifying appropriate and optimal targets for effective intervention. Addressing suicidal ideation has emerged as a potentially useful proxy target for their prevention, given evidence that one-third of adolescents with suicidal ideation go on to develop a suicide plan, and 60% with a plan will make a suicide attempt.
Understanding how to best support and treat young people experiencing suicidal ideation is receiving increasing attention, prompted by research showing that young people aged 12–18 years are highly reluctant to seek help from face-to-face mental health services for suicide distress. Solving how to best meet young people where they are at in terms of how they want to receive information and engage with support is at the forefront of youth suicide prevention, and one of the biggest innovations resulting from this shift has been the consideration of what role digital smartphone applications (apps) might play in suicide prevention.
Certainly, the touted benefits of smartphone-delivered treatment are many and include the ability to deliver proven treatment approaches with high fidelity, on demand, at low cost, and with high scalability. It is also thought that smartphone apps may be particularly appropriate models of care for young people given high rates of smartphone ownership (> 90%) and with many (> 40%) young people now accessing apps for mental wellbeing.
While current evidence indicates that adults experiencing suicidal distress can readily access and benefit from digital interventions that directly target suicidal ideation and/or behaviours (here and here), unfortunately there have been few published studies involving young people to establish their acceptability and effectiveness for young suicidal ideators.
To move the field forward, there is a question that is increasingly important to answer: can smartphone interventions help to effectively reduce the severity of suicidal ideation among young people experiencing suicide distress?
In our recent randomised controlled trial of a co-designed brief, self-guided smartphone app (known as LifeBuoy), we found that the community-based young adults (aged 18–25 years) who received the treatment app reported superior improvements in their ideation relative to an attention-matched control group (effect size, 0.45 at post-intervention). These significant effects, although slightly diminished, were maintained at 3 months following the active intervention period (effect size, 0.32).
This finding represents an important contribution to the existing literature. This study provides evidence that a self-guided smartphone intervention targeting suicidal ideation can work for young adults. Before this study, there were only two published studies of comparable smartphone apps – and neither app demonstrated an intervention effect for suicidal ideation (here and here).
One potential reason why the LifeBuoy app appears to have worked when others have not may be due to differences in the treatment delivered. Treatment models have been shown elsewhere to be an important moderator of efficacy (here and here). While our app primarily delivered dialectical behaviour therapy (DBT), which is a modified form of cognitive behaviour therapy designed to treat persistent emotional dysregulation, prior apps have used acceptance and commitment therapy (ACT) or therapeutic evaluative conditioning (TEC). In DBT, individuals are taught adaptive strategies to improve emotional regulation and tolerate distress, so that self-injurious behaviour is not seen as a coping solution. DBT is considered one of the most effective therapeutic approaches for reducing suicidal distress and behaviour in young people. In comparison, ACT helps individuals behave in ways that are consistent with their values by teaching mindfulness strategies and acceptance skills, and TEC seeks to condition an aversion to suicide and self-injury. Trials of digital smartphone therapeutics using ACT and TEC treatment models have not yet been associated with significant reductions in suicidal ideation (here and here). In contrast, our findings suggest that elements of DBT can be effectively digitised to treat suicidal ideation, and when done well, digital DBT appears to be comparably effective to the more intensive face-to-face modality for suicidal ideation.
Interestingly, we did not find an intervention effect on common mental health symptoms (depression, anxiety, psychological distress). While both groups improved over time, the LifeBuoy group did not outperform the control group. This finding seems somewhat unexpected; however, it does corroborate evidence from prior meta-analytic studies that DBT does not appear to significantly reduce depressive symptoms among adolescents. What we can infer from this is that effective therapeutic approaches for the treatment of suicidal ideation may not be the same as those used to successfully treat common mental health conditions (eg, depression, generalised anxiety disorder). Certainly, while cognitive behavioural therapy has been successfully translated into digital interventions for depression and anxiety, it appears to have little impact on ideation or other suicidal outcomes when delivered digitally. This is notable, given that suicidal ideation and mental health often commonly co-occur, potentially creating an expectation that these health issues may be able to be effectively treated using a single approach. The literature seems to suggest that, without carefully tailoring digital intervention to a specific health outcome, we might find these self-guided therapeutics being used “in the wild” to little effect.
Needless to say, this study is just the beginning of the digital treatment age for suicide prevention. We need replication of rigorous trials to confirm initial efficacy findings to ensure that when apps are made publicly available they are effective and safe. There is also much work to do to prepare for these tools to be used effectively at scale, including understanding for whom self-guided digital interventions work best, what strategies are needed to support delivery and engagement, developing sustainable funding models to support access at low or no cost to users, and establishing their cost-effectiveness compared with face-to-face treatments and services.
Dr Michelle Torok is a Senior Research Fellow at the Black Dog Institute at UNSW Sydney, and a National Health and Medical Research Council Investigator.
Dr Lauren McGillivray is a Postdoctoral Research Fellow at the Black Dog Institute, and a clinical psychologist with experience working in the research setting.
Dr Jin Han is a Research Fellow at the Black Dog Institute, UNSW Sydney.
The statements or opinions expressed in this article reflect the views of the authors and do not necessarily represent the official policy of the AMA, the MJA or InSight+ unless so stated.
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