The use of the internet is a promising approach in preventing suicide on the individual as well as the population level. However, this promise remains to be proven in trials and in practice. The national Dutch suicide prevention platform113Online offers a 24/7 online anonymous mental health care programme. This includes crisis resolution, guided self help, and online psychotherapy. This programme is provided by professionals in close cooperation with volunteers staffing chat- and telephone helplines. In this presentation philosophy, structure, methods, cost, and preliminary results of the first two years of 113Online are presented.

1. Jan. K. Mokkenstorm M.D.,
psychiatrist
Director 113 Online
j.mokkenstorm@113online.nl
mokkenstorm@gmail.com
info@113online.nl
www.113online.nl 01-09-12

2. 113Online
First two year results
• Background: why online help may benefit suicide
prevention
• Outline of the online services
• Preliminary results: help seeker characteristics, site
use, service use, application of railway suicide
prevention
• Conclusion
Presentatie titel 2 01-09-12

3. The problem
• Netherlands: 16 million inhabitants
• 1600 suicides per year
• 96.000 attempts registered
• > 500.000 individuals
with death wish or suicidal ideation> 2 weeks
• 40 % of attempters no treatment sought <1 year
• 33% of attempters no treatment sought ever
(Ten Have et al 2011 NEMESIS 2 Results of the Netherlands Mental Health
Survey and Incidence Study)
www.113online.nl 3 01-09-12

4. Help seeking barriers
(Pagura et al 2009, Bruffaerts et al 2011)
• Low perceived need
• Wish for autonomy, control
• Stigma
• Structural & financial barriers
• Negative experiences with regular care?
Presentatie titel 4 01-09-12

5. Unmet needs and
expectations in regular care
(Pirkis et al 2001, Taylor et al 2009)
– Specific competence & knowledge
– Empathy and respect
– Shared decision making
– Open communication
Presentatie titel 5 01-09-12

6. Why online help may
benefit suicide prevention
• Reach: large scale dissemination
• Low treshold and easy acces
• Autonomy and control of the help seeker
• Online disinhibition effects enhance therapeutic
processes
• Online interventions are effective
www.113online.nl
6 01-09-12

7. Stage 1
Website +telephone hotline
Education
Hotline Advice
Presentatie titel 7 01-09-12

8. Pioneer online interactive
SAHAR
Acute Peer
chat support
Hotline
Presentatie titel 8 01-09-12

9. Stage 2:
online interactive Education
Advice
Acute
chat
Peer
support
Hotline
Presentatie titel 9 01-09-12

10. Presentatie titel 10 01-09-12

11. Stage 3 Multi level
online platform
Education
Direct Self Test
Referral
Advice
Brief
Online
Therapy
Acute Peer
chat support
Hotline Self Help
Course
Presentatie titel 11 01-09-12

12. Site stats
Site usage 5 / 10 / 09-20 / 03 /12 Average per day
Sitevisits 730
Unique visitors 367
Pageviews 6,2
Visit Duration 00:03:053
Visitors Yough<18 yr Adult 18+ Total
Suicidal 14,8% 53,8% 68,6%
Concerned 5,8% 17,6% 23,4%
Bereaved 1,4% 6,7% 8,0%
Total 21,9% 78.1% 100%
www.113online.n 12 01-09-12

13. Selftests & Autoreplies
Selftest Age< 23 SIQ J Age 23+: BSI
(0-72) (0-39)
Average tests per day 6 10
Age 19,2 (sd 6,7) 36,6 (sd 11,8)
% Female 72% 60%
Average Score 40,7 (sd 20,7) 20,5 (sd 8,5)
Autoreply Advice Age<23 Age 23+
Absent-Low 10% 5%
Mild 5% 2%
Suicidal 8% 38%
Severely Suicidal 78% 55%
www.113online.n 13 01-09-12

14. Acute chat calls:
use and satisfaction
• DEMAND>> Supply
• Av. duration: 61 min (sd 39 min).
• 48% female, 15 % male, 37% ?. Av. 25,6
• 46% of callers in a form of mental health treatment
• Content: 41% psychiatric symptoms and treatment
• 63 % of callers thanked the helper spontaneously
• 15 % dissatisfied
www.113online.n 14 01-09-12

15. Comparison Mishara silent monitoring study
1-800-SUICIDE Telephone vs 113Online Chat
Suicide and Life-Threatening Behavior 37(3) June 2007
1-800: n=1431 tel.calls
113: n=396 chats Worse No change Better
1-800 113 1-800 113 1-800 113
Apprehensive/ Confident 11% 7% 49% 52% 38% 43%
Sad / Happy 9% 5% 67% 51% 22% 44%
Helpless / Resourcefull 10% 15% 41% 44% 49% 41%
Hopeless / Hopefull 11% 8% 47% 46% 40% 46%
Confused/Decided 10% 8% 36% 54% 52% 39%
Depressive mood 7% 8% 74% 56% 18% 36%
Desperate 6% 7% 77% 55% 16% 38%
Sustain thoughts 8% 56% 37%
Suicide ambivalence 2% 8% 84% 69% 14% 23%
(n=121)
Presentatie titel 15 01-09-12

16. Online Psychotherapy by
chat or e-mail
• Anonymous, free
• Solution Focused; CBT/DBT/ACT elements
• Treatment manual
• Trained & supervised psychologists
• Brief: max 8 sessions/exchanges
• Average number sessions = 5
• Av. number of completed therapies = 25/week
www.113online.nl 16 01-09-12

17. Routine Outcome Monitor
Effect studies (RCT)
T2:
BSS/SIQ
CES-D
T2 FOLLOW-UP
T1:
BSS/SIQ
T1 END CES-D
Gould& Therapy
THERAPY PROCESS SRS
ORS Session or
Exchange
T0:
T0 START BSS/SIQ
CES-D
www.113online.nl 17 01-09-12

18. Presentatie titel 18 01-09-12

19. Railway related
content acute chats
• 260 of 2443 unique acute chat callers (10,6%) refer to
the railways as a means of suicide. In 16 cases this
related to someone else. There were 3 direct and
positive references tot the “ I Listen” signs
Situation Number % of 260
On the railway now 10 3,8%
Today-yesterday 19 7,3%
This week 10 3,8%
Ever 27 10,3%
Urge or a plan now 64 24,6%
Decided against rail suicide 32 12,3%
Ambivalent on rail suicide 23 8,8%
Presentatie titel 19 01-09-12

20. Adverse events
• We know of 3 suicides, in 2 cases the client was
in regular treatment as well.
• Suicide attempts occur during calls or sessions
and have been dealt with by emergency services
if caller/client revealed location.
• Management received 3 formal complaints
regarding unmet expectations.
www.113online.nl 20 01-09-12

21. Conclusion
• 113Online reaches a large number of (very)
suicidal, concerned or bereaved individuals.
• A substantial number did not seek help otherwise.
• 113Online meets needs and expectations
(partially) unmet in regular care.
• Effectivity remains to be proven
• Less than expected adverse events.
Presentatie titel 21 01-09-12

22. Acknowledgments and thanks
• Professionals and Volunteers of 113Online and Ex6
• Management and volunteers of Sensoor Helpline
• Mady Samuels; Netherlands Ministry of Health Care (VWS)
• ProRail
• Prof. Ad Kerkhof
• Prof. Brian Mishara
• Prof. Jan Smit
• Dr. Annemiek Huisman
• Lucy Stut
• Anouk Romers
• Merijn Eikelenboom
• Dr. Bregje van Spijker
• Leo Wijnbelt
• Ed Claasens
• Age Nils Holstein
Presentatie titel 22 01-09-12

23. References
• Bruffaerts,R., Demyttenaere, K., Hwang, I., Chiu, W.T. Sampson, N. ,Kessler, R.C.,
Alonso, J., Borges, G., Girolamo, G de , Graaf, R. de, Florescu, S, Gureye, O., Hu,
C., Karam, E.G., Kawakami, N., Kostyuchenko, S., Kovess-Mastety, V., Lee, S.,
Levingson, D., Matschinger, H., Posada-Villa, J., Sagar, R., Scott, K.M., Stein, D.J.,
Tomov, T., Viana, M.C., Nock, M.K. Treatment of suicidal people around the world
BJP 2011; 199(1): 64–70.
• Krysinska, K.E. and D. De Leo, Telecommunication and suicide prevention: hopes
and challenges for the new century. Omega - Journal of Death & Dying, 2007. (3): p.
237-53.
• Mishara BL, Chagnon F, Daigle M, Balan B, Raymond S, Marcoux I, et al. Which
helper behaviors and intervention styles are related to better short-term outcomes in
telephone crisis intervention? Results from a silent monitoring study of calls to the
U.S. 1-800- SUICIDE network. Suicide Life Threat Behav 2007a; 37: 291-307.
• Pagura J, Fotti S, Katz LY, Sareen J. Help seeking and percieved need for mental
health care among individuals in Canada with suicidal behaviors. Psychiatr Serv
2009; 60: 943-49.
• Pirkis J, Burgess P, Meadows G, Dunt D. Self-reported needs for care among
persons who have suicidal ideation or who have attempted suicide. Psychiatr Serv
2001; 52: 381-83.
• Taylor, T.L., Hawton,K., Fortune, S., Kapur, N. Attitudes towards clinical services
among people who self-harm: systematic review Br.J.Psych (2009) 194, 104–110.

24. Thank You
www.113online.nl
www.113online.nl 24 01-09-12