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

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Many suicidal patients do worry a lot about their reasons for contemplating suicide, about the meaning of life, about their failures, about their losses and disappointments, and they worry about their …

Many suicidal patients do worry a lot about their reasons for contemplating suicide, about the meaning of life, about their failures, about their losses and disappointments, and they worry about their suicidal thoughts. Part of the suicidal urges are caused by the wish to stop this endless worrying and rumination. It is hypothesized that anti – worry exercises may help suicidal patients to decrease the amount of time a day that they are thinking of suicide, and therewith decrease the intensity of the reasons for contemplating suicides. In the workshop CBT techniques for worrying and rumination will be explained and applied to suicidal worrying. In the workshop participants are requested to present actual cases and engage in role playing, therewith train their skills in addressing persistent repetitive thoughts of suicide in patients.

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  • 1. Reducing suicidal thoughts:Effectiveness of a web-basedself-help intervention: RCTAd KerkhofBregje van SpijkerSelf-help course in 113OnlineJan MokkenstormCRISE - SUMMER INSTITUTE 2012 - MONTRÉAL
  • 2. 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 effectiveCRISE - SUMMER INSTITUTE 2012 - MONTRÉAL
  • 3. Barriers to help-seeking• Shame• Fear of loosing autonomy• Fear for rejection• Past negative experiences• Current negative experiences• Limited facilities• Too many chatsCRISE - SUMMER INSTITUTE 2012 - MONTRÉAL
  • 4. Internet• Providing anonymous help online may addresssome of these barriers (Sahar, 113Online)• Online self-help may help suicidal people tovisit GP or mental health care center• People who receive treatment could benefitfrom additional online self-help intervention?CRISE - SUMMER INSTITUTE 2012 - MONTRÉAL
  • 5. Effective web-based interventions:guided and unguided• Depression (Andersson et al, 2009)• Anxiety (Cuijpers et al, 2009)• Problem drinking (Riper, 2008)CRISE - SUMMER INSTITUTE 2012 - MONTRÉAL
  • 6. RCT study• Comparing unguided web-based self-help forsuicidal thoughts with a waitlist control groupCRISE - SUMMER INSTITUTE 2012 - MONTRÉAL
  • 7. Intervention• Six modules• Unguided• CBT (PST / DBT /Mindfulness)Module Aimed at:1 Reducing suicidal worrying2 Regulating intense emotions3 Identifying automatic thoughts4 Recognizing cognitive distortions5 Cognitive restructuring6 Relapse preventionCRISE - SUMMER INSTITUTE 2012 - MONTRÉAL
  • 8. Intervention website - homepageCRISE - SUMMER INSTITUTE 2012 - MONTRÉAL
  • 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 planCRISE - SUMMER INSTITUTE 2012 - MONTRÉAL
  • 10. Intervention websiteCRISE - SUMMER INSTITUTE 2012 - MONTRÉAL
  • 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 treatmentCRISE - SUMMER INSTITUTE 2012 - MONTRÉAL
  • 12. Intervention websiteCRISE - SUMMER INSTITUTE 2012 - MONTRÉAL
  • 13. 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 careCRISE - SUMMER INSTITUTE 2012 - MONTRÉAL
  • 14. Intervention websiteCRISE - SUMMER INSTITUTE 2012 - MONTRÉAL
  • 15. Intervention• Week 5: Changing thoughts– Challenging cognitive distortions– Evaluating evidence for and against validity– Reformulate thoughts– If needed contact GP / Mental health careCRISE - SUMMER INSTITUTE 2012 - MONTRÉAL
  • 16. Intervention• Week 6: Relapse prevention– Picture of the future– Possible future setbacks– Relapse prevention plan– Self–help is no substitute for treatmentCRISE - SUMMER INSTITUTE 2012 - MONTRÉAL
  • 17. Design• RCT• 2 arms• Sample size: 236• Recruitment through newspapers, 113Online, google• Exclusion criteria:– Age < 18– BSS < 1 or BSS > 26– BDI > 39Condition Base-line2weeks2 weeks 2 weeks Post-test3 months Follow-upControl T0 T1 T2 T3 (Intervention) T4Intervention T0 T1 T2 T3 T4CRISE - SUMMER INSTITUTE 2012 - MONTRÉAL
  • 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 designCRISE - SUMMER INSTITUTE 2012 - MONTRÉAL
  • 19. Medical-ethical considerations• Suicidal people are a vulnerable group• Unethical to experiment with anonymoussuicidal people• Safety protocol: participants in acute risk• Involvement GP• Respondents not anonymous• Approval Medical Ethical Committee VUCRISE - SUMMER INSTITUTE 2012 - MONTRÉAL
  • 20. 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 GPCRISE - SUMMER INSTITUTE 2012 - MONTRÉAL
  • 21. 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 registrationsAssessed for eligibility (n=1268)Visits to registration website(n=2484)Flow of participants through the RCTRandomized (n=236)CRISE - SUMMER INSTITUTE 2012 - MONTRÉAL
  • 22. Characteristics of RegistrationsCharacteristicParticipants(n=236)Declined participation(n=417) pFemale 65.3% 67.9% 0.417Age (m, sd) 40.9 (13.7) 37.2 (13.9) 0.001Education:•Low•Middle•High•Other2.5%50.4%39.8%5.1%4.8%57.6%30.0%5.8%0.050Anonymity important 39.8% 61.9% 0.000No care 44.5% 57.4% 0.006Living with partner 39.4% 36.7% 0.508Suicidal thoughts (M, SD) 15.7 (5.6) 16.1 (6.0) 0.135Depressive symptoms (M, SD) 27.7 (7.6) 27.3 (7.9) 0.243CRISE - SUMMER INSTITUTE 2012 - MONTRÉAL
  • 23. 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 interventionAssessments• 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 RCTAssessments• 116 completed T0 (baseline)• 106 completed T1• 105 completed T2• 105 completed T3 (posttest)•102 completed T4 (follow-up)Analysed: n=120 Analysed: n=116CRISE - SUMMER INSTITUTE 2012 - MONTRÉAL
  • 24. 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 hospitalCRISE - SUMMER INSTITUTE 2012 - MONTRÉAL
  • 25. Characteristics of participantsCharacteristic Control (n=120) Intervention (n=116) pFemale 66.7% 65.5% 0.852Age (m, sd) 41.4 (13.4) 40.5 (14.1) 0.602Education:•Low•Middle•High•Other6.7%43.3%42.5%7.5%9.5%51.7%33.6%5.2%0.365Living with a partner 45.0% 35.3% 0.131Born in Netherlands 93.3% 94.7% 0.651Paid employment 49.6% 50.4% 0.895Suicidal thoughts (m, sd) 14.5 (7.3) 15.2 (6.8) 0.444Depressive symptoms (m, sd) 26.5 (9.0) 27.6 (9.3) 0.364Hopelessness (m, sd) 14.1 (3.9) 14.7 (3.5) 0.204Worrying (m, sd) 56.9 (11.3) 58.8 (11.0) 0.199Anxiety (m, sd) 10.1 (3.9) 10.6 (3.5) 0.346Health status (m, sd) 62.6 (18.2) 60.0 (17.8) 0.289CRISE - SUMMER INSTITUTE 2012 - MONTRÉAL
  • 26. Linear Mixed Model: suicidal thoughts (ITT)• Controlcondition:b=0.74• Interventioncondition:b=1.58• Time*groupInteraction:F(1,656)=8.83,p=0.004)CRISE - SUMMER INSTITUTE 2012 - MONTRÉAL
  • 27. Mean change (t-tests: pre-posttest) &between group effect sizes. ITT sampleControl(n=120)¹Intervention(n=116)¹p dSuicidal thoughts (m, sd) 2.30 (6.6) 4.47 (8.7) 0.036 0.28Depressive symptoms (m, sd) 1.82 (8.8) 3.93 (10.1) 0.086 0.22Hopelessness (m, sd) 0.68 (3.6) 1.91 (4.9) 0.029 0.28Worrying (m, sd) 2.12 (10.1) 5.48 (10.1) 0.010 0.34Anxiety (m, sd) 0.51 (3.3) 1.03 (3.9) 0.270 0.14Health status (m, sd) -3.00 (18.3) 1.96 (19.7) 0.045 0.26¹Multiple imputation was used to replace missing valuesCRISE - SUMMER INSTITUTE 2012 - MONTRÉAL
  • 28. Linear Mixed Model: suicidal thoughts• Control condition:b=0.73• Interventioncondition 1 / 2module: b=1.18• Interventioncondition, 3 +modules: b=1.81• Time*groupinteraction:F(2,597)=5.52,p=0.005.CRISE - SUMMER INSTITUTE 2012 - MONTRÉAL
  • 29. Mean change (pre-posttest) & between groupeffect sizes (adherent sample 3+ modules)Control(n=120)¹Intervention(n=65)¹p dSuicidal thoughts (m, sd) 2.30 (6.6) 5.45 (8.3) 0.005 0.44Depressive symptoms (m, sd) 1.82 (8.8) 4.85 (9.2) 0.027 0.34Hopelessness (m, sd) 0.68 (3.6) 2.68 (5.1) 0.002 0.48Worrying (m, sd) 2.12 (10.1) 6.40 (10.5) 0.006 0.43Anxiety (m, sd) 0.51 (3.3) 1.60 (3.7) 0.039 0.32Health status (m, sd) -3.00 (18.3) -2.36 (21.2) 0.125 0.27¹Multiple imputation was used to replace missing values. Control group comparedwith participants from intervention group who completed at least 3 modulesCRISE - SUMMER INSTITUTE 2012 - MONTRÉAL
  • 30. Follow-up: within group effects(intervention group)Posttest(m, sd)¹Follow-up(m, sd)¹ΔM (sd) dSuicidal thoughts (m, sd) 10.6 (9.2) 10.3 (9.8) -0.3 (8.1) 0.04Depressive symptoms (m, sd) 23.5 (13.1) 20.6 (14.3) -2.9 (11.2)* 0.26Hopelessness (m, sd) 12.6 (5.6) 11.9 (6.0) -0.7 (5.4) 0.12Worrying (m, sd) 53.2 (13.9) 53.7 (14.8) 0.5 (14.5) 0.03Anxiety (m, sd) 9.6 (4.3) 9.0 (4.0) -0.6 (3.4) 0.16Health status (m, sd) 62.7 (21.2) 62.0 (19.8) -0.7 (20.8) 0.03¹ Multiple imputation was used to replace missing values.* p<0.01CRISE - SUMMER INSTITUTE 2012 - MONTRÉAL
  • 31. 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=0CRISE - SUMMER INSTITUTE 2012 - MONTRÉAL
  • 32. 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 severedepression but moderate suicidal thinking• Attrition as expected with self-help• Greater hopelessness at baseline is associated with attrition• No formal psychiatric diagnosis obtainedCRISE - SUMMER INSTITUTE 2012 - MONTRÉAL
  • 33. Strong points• Participants with mild to moderate depressionand mild to moderate suicidal thoughts:probably fairly representative of targetpopulationCRISE - SUMMER INSTITUTE 2012 - MONTRÉAL
  • 34. Conclusions• Significant reduction in suicidal thoughts inintervention group compared with controlgroup• Results intervention group maintained atthree months follow-up• Studying online self-help for suicidal thoughtsis feasibleCRISE - SUMMER INSTITUTE 2012 - MONTRÉAL
  • 35. Implications:• Online self help available for people withsuicidal thoughts, irrespective of diagnosed ordiagnosable disorder• Implementation through the internet worldwide possible: small effects but huge numbers• Implementation possible in LAMIC countries• If possible guided self help preferred• New trial being initiated in AustraliaCRISE - SUMMER INSTITUTE 2012 - MONTRÉAL
  • 36. • Kerkhof, AJFM, & Van Spijker, BAJ (2011). Worrying andrumination as proximal risk factors for suicidal behaviour. In:R.C. O’Connor, S. Platt, & J. Gordon (Eds.). InternationalHandbook of Suicide Prevention. Wiley Blackwell,• Ad Kerkhof en Bregje van Spijker (2012). Piekeren overZelfdoding. Boom Hulpboek, Amsterdam• BAJ van Spijker (2012). Reducing the burden of suicidalthoughts through online self-help. Ph D Dissertation VUAmsterdam, June 13CRISE - SUMMER INSTITUTE 2012 - MONTRÉAL
  • 37. Cost-Effectiveness• BAJ van Spijker, CM Majo, F. Smit, A vanStraten, AJFM Kerkhof (2012). Reducingsuicidal ideation via the internet: Cost –effectiveness analysis alongside a randomizedtrial into unguided self-help.Journal of Medical Internet Research, accepted,CRISE - SUMMER INSTITUTE 2012 - MONTRÉAL
  • 38. 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 savingCRISE - SUMMER INSTITUTE 2012 - MONTRÉAL