Using my Demons to Make Good: The Short- and Long-Term Impact of Participating in Suicide-Related Research

Examining missingness at the momentary level in clinical research using ecological momentary assessment: Implications for suicide research

The use of intensive time sampling methods, such as ecological momentary assessment (EMA), has increased in clinical, and specifically suicide, research during the past decade. While EMA can capture dynamic intraindividual processes, repeated assessments increase participant burden, potentially resulting in low compliance. This study aimed to shed light on study-level and psychological variables, including suicidal ideation (SI), that may predict momentary prompt (i.e., prompt-to-prompt) completion. We combined data from three EMA studies examining mental health difficulties (N = 103; 10,656 prompts; 7144 completed), using multilevel models and machine learning to determine how well we can predict prompt-to-prompt completion and which variables are most important. The two most important variables in prompt-to-prompt completion were hours since the last prompt and time in study. Psychological variables added little predictive validity; similarly, trait-level SI demonstrated a small effect on prompt-to-prompt completion. Our study showed how study-level characteristics can be used to explain prompt-to-prompt compliance rates in EMA research, highlighting the potential for developing adaptive assessment schedules to improve compliance.

Examining the effects of response monitoring instructions on endorsements of suicidal ideation in an online study

INTRODUCTION

It is common practice for researchers to monitor responses to items assessing suicidal ideation and follow-up with high-risk participants, when their identities are known. However, it is becoming increasingly common for researchers to administer fully anonymous online surveys that do not allow for follow-ups with participants at higher risk. The aim of the current study was to investigate whether these two different approaches-monitoring and follow-up versus no monitoring or follow-up-affect the willingness of participants to endorse suicidal ideation.

METHODS

The sample included N = 555 undergraduate students, who were randomly assigned to the monitoring (n = 275) or anonymous (n = 280) instruction conditions, with the monitoring condition shifting to anonymous, non-monitored responses at Time 2.

RESULTS

There were no significant differences in self-reported suicidal ideation between those in the monitoring and anonymous condition at Time 1. At Time 2, no significant interaction was identified between condition and time, suggesting that the change in instructions across timepoints for the monitoring condition had no impact on endorsement of suicidal ideation.

CONCLUSION

Findings indicate that both monitoring and anonymous instruction methods should elicit the same pattern of endorsements of suicidal ideation.

Trauma-Informed Approach to Qualitative Interviewing in Non-Suicidal Self-Injury Research

Non-suicidal self-injury (NSSI) is recognized as a public health concern owing to its chronic nature, association with suicide risk, and its growing prevalence rates across the globe. Including individuals living with NSSI in research is crucial as it offers opportunities to give primacy to participant voices and insights, further guiding therapeutic interventions. Research has established an association between history of traumatic events and adverse childhood experiences with subsequent risk of NSSI. When planning a qualitative research study with individuals with potential trauma history, researchers need to be aware of and sensitive to potential re-traumatization and distressing emotions that participants may experience during interviews, as well as complex trauma reactions that may affect individuals after study participation. The article emphasizes that researchers be cognizant of the multifaceted nature of trauma and how it can impact individuals and communities and be sensitive in their approach to interviewing vulnerable groups such as individuals with experiences of NSSI. The authors propose adopting a trauma-informed approach to ethically plan and conduct qualitative interviews exploring NSSI experiences. Trauma-informed recommendations for preparing and carrying out specific steps during different stages of NSSI interviews are detailed.

The interplay between suicidal experiences, psychotic experiences and interpersonal relationships: a qualitative study

BACKGROUND

Suicidal thoughts, acts, plans and deaths are considerably more prevalent in people with non-affective psychosis, including schizophrenia, compared to the general population. Social isolation and interpersonal difficulties have been implicated in pathways which underpin suicidal experiences in people with severe mental health problems. However, the interactions between psychotic experiences, such as hallucinations and paranoia, suicidal experiences, and the presence, and indeed, absence of interpersonal relationships is poorly understood and insufficiently explored. The current study sought to contribute to this understanding.

METHODS

An inductive thematic analysis was conducted on transcripts of 22, individual, semi-structured interviews with adult participants who had both non-affective psychosis and recent suicidal experiences. A purposive sampling strategy was used. Trustworthiness of the analysis was assured with researcher triangulation.

RESULTS

Participants relayed both positive and negative experiences of interpersonal relationships. A novel conceptual model is presented reflecting a highly complex interplay between a range of different suicidal experiences, psychosis, and aspects of interpersonal relationships. Three themes fed into this interplay, depicting dynamics between perceptions of i. not mattering and mattering, ii. becoming disconnected from other people, and iii. constraints versus freedom associated with sharing suicidal and psychotic experiences with others.

CONCLUSION

This study revealed a detailed insight into ways in which interpersonal relationships are perceived to interact with psychotic and suicidal experiences in ways that can be both beneficial and challenging. This is important from scientific and clinical perspectives for understanding the complex pathways involved in suicidal experiences.

TRIAL REGISTRATION

ClinicalTrials.gov (NCT03114917), 14th April 2017. ISRCTN (reference ISRCTN17776666 .); 5th June 2017). Registration was recorded prior to participant recruitment commencing.

Acceptability of a novel suicide prevention psychological therapy for people who experience non-affective psychosis

OBJECTIVES

Suicide is a leading cause of death worldwide. People experiencing psychosis are at increased risk of death by suicide. Talking therapies can alleviate suicidal thoughts, plans, and attempts. Therapies need to also be acceptable to recipients. The aim of this study was to investigate the views on psychological therapy for people experiencing psychosis and suicidality using the Theoretical Framework of Acceptability.

DESIGN

Qualitative interview study.

METHODS

Participants were recruited from a randomised controlled trial comparing suicide prevention psychological therapy with treatment as usual. Individuals had a diagnosis of non-affective psychosis and experience of suicidal thoughts, plans and/or attempts. To assess the acceptability of the therapy, semi-structured interviews were conducted with 20 participants randomised to receive therapy. Data were deductively analysed using an adaptation of the Theoretical Framework of Acceptability.

RESULTS

Interviews (Mean = 45 min) were conducted and audio recorded with 21 participants. Data were organised into six themes: 1. Affective attitude, 2. Burden, 3. Alliance, 4. Intervention coherence, 5. Perceived effectiveness, and 6. Self-efficacy. There was no evidence of issues relating to domains of ethicality and opportunity costs associated with receiving therapy.

CONCLUSIONS

Talking about suicide was difficult and, at times, distressing, but it was perceived to be useful for understanding experiences. To be acceptable, it is important for therapists to ensure that clients' understanding of therapy aligns with expectations of effectiveness and to invest in building strong therapeutic alliances. Future research will benefit from examining therapists' experiences of delivering therapy through different modes (e.g. online, telephone).

What is important to service users and staff when implementing suicide-focused psychological therapies for people with psychosis into mental health services?

Introduction

Suicide is a leading cause of death globally. People with psychosis are at increased risk of suicide death and up to half experience suicidal thoughts and/or engage in suicidal behaviors in their lifetime. Talking therapies can be effective in alleviating suicidal experiences. However, research is yet to be translated into practice, demonstrating a gap in service provision. The barriers and facilitators in therapy implementation require a thorough investigation including the perspectives of different stakeholders such as service users and mental health professionals. This study aimed to investigate stakeholders' (health professionals and service users) perspectives of implementing a suicide-focused psychological therapy for people experiencing psychosis in mental health services.

Methods

Face-to-face, semi-structured interviews with 20 healthcare professionals and 18 service users were conducted. Interviews were audio recorded and transcribed verbatim. Data were analyzed and managed using reflexive thematic analysis and NVivo software.

Results

For suicide-focused therapy to be successfully implemented in services for people with psychosis, there are four key aspects that need to be considered: (i) Creating safe spaces to be understood; (ii) Gaining a voice; (iii) Accessing therapy at the right time; and (iv) Ensuring a straightforward pathway to accessing therapy.

Discussion

Whilst all stakeholders viewed a suicide-focused therapy as valuable for people experiencing psychosis, they also recognize that enabling successful implementation of such interventions will require additional training, flexibility, and resources to existing services.

Preventing male suicide through a psychosocial intervention that provides psychological support and tackles financial difficulties: a mixed method evaluation

BACKGROUND

To help resolve high suicide rates in Bristol, North Somerset and South Gloucestershire, the charity Second Step was commissioned to roll-out the Hope service offering a psychosocial intervention for men, supporting them through acute distress and addressing financial difficulties. This study evaluated the impact of the Hope service on men at risk of suicide experiencing financial and other difficulties.

METHODS

Mixed methods study using: (i) a prospective cohort study design to compare depression, suicidal ideation and financial self-efficacy scores of men aged 30-64, referred to the service between October 2018 and July 2020, at baseline and 6 months follow-up and between low and moderate to high-intensity service users; and (ii) a qualitative interview study to evaluate the acceptability and impact of the Hope service to Hope service users.

RESULTS

There was a 49% reduction in depression score (mean reduction - 10.0, 95% CI - 11.7 to - 8.3) and in the proportion of service users with suicidal ideation (percent reduction - 52.5, 95% CI - 64.1% to - 40.9%) at 6 months follow-up compared to baseline. Financial self-efficacy scores increased by 26% (mean increase 2.9, 95% CI 1.8 to 3.9). Qualitative accounts illustrated how 'Hope saved my life' for several men interviewed; most respondents described being able to move forward and tackle challenges with more confidence following the Hope intervention. Professional advice to tackle financial and other difficulties such as housing helped to relieve anxiety and stress and enable practical issues to be resolved.

CONCLUSIONS

The Hope service offered practical and emotional support to men who have experienced suicidal feelings, redundancy, homelessness and poverty and occupies an important space between mental health and social care provision. Hope demonstrates the value of an intervention which cuts across traditional boundaries between psychiatric care and social advice agencies to provide, what is, in effect, an integrated care service.

Challenges and adaptations to public involvement with marginalised groups during the COVID-19 pandemic: commentary with illustrative case studies in the context of patient safety research

Patient and public involvement (PPI) is integral to research on patient safety in the NIHR Greater Manchester Patient Safety Translational Research Centre (NIHR GMPSTRC), and is central to our patient safety research within our theme focusing on people in marginalised groups. Due to the impact of COVID-19, researchers had to adapt how they do PPI. For marginalised groups, remote working and digital adaptations (the key adaptations made in accessing and utilising health services in the United Kingdom during COVID-19) can potentially lead to further marginalisation of people already marginalised and provide new barriers to others. This editorial showcases three case examples of PPI with marginalised groups during COVID-19, these are with: (1) adults with vision impairments, (2) adults and carers with lived experience of self-harm and/ or suicide and (3) adults with lived experience of homelessness. In these case examples, we focus on challenges relating to key aspects of PPI during the pandemic. First, setting up a PPI advisory group and secondly maintaining relationships and effective PPI with a pre-existing advisory group. We contrast these examples using more traditional ways of 'doing PPI' i.e. involving public contributors in various stages of the research cycle, with a more fully 'co-produced' approach to research when developing a new patient safety intervention. Important considerations for PPI with marginalised groups during COVID-19 include: how to avoid exacerbating the digital divide when using video conferencing for PPI, the need for enhanced awareness around flexibility and resources, and the value of working closely with specialist charities to enable adaptations that are sensitive to the changed circumstances and needs of PPI contributors.

The Reactions of Adolescents, Parents and Clinicians to Participating in Qualitative Research Interviews Regarding Adolescents Bereaved by Suicide and Other Traumatic Death

There are concerns that involving adolescents bereaved by suicide and other traumatic death in research may cause distress and harm. However, no study has investigated such bereaved adolescents’ research experiences. In addition, no study has looked at the experiences of parents and clinicians as participants in adolescent suicide and traumatic death bereavement research. This study aimed to explore the short-term impact of research participation experienced by adolescents, parents, and clinicians. A total of 61 participants (adolescents, n = 17; parents, n = 12; clinicians, n = 32) filled out a short survey within two weeks of having taken part in a qualitative interview study. Data were analyzed descriptively. Most participants had experienced no distress while participating and no negative effects of participating; rather, participation was experienced as helpful for them and they would highly recommend participating in a study like this to others. A few adolescents and parents reported some distress, related to anxiety about participation and the unpleasantness of grief memories. The study clearly indicates that bereaved adolescents, parents and clinicians can safely participate in research interviews regarding their experiences of grief and help after suicide, generally valuing the opportunity to share their experience. To prevent and mitigate potential distress, training of research staff and implementation of appropriate participant distress protocols are imperative. Future studies could include longitudinal follow-up of participants to assess any longer-term consequences.

Feasibility of a serious game coupled with a contact-based session led by lived experience workers for depression prevention in high-school students

BACKGROUND

Stigma and limited mental health literacy impede adolescents getting the help they need for depressive symptoms. A serious game coupled with a classroom session led by lived experience workers (LEWs) might help to overcome these barriers. The school-based Strong Teens and Resilient Minds (STORM) preventive program employed this strategy and offered a serious game, Moving Stories. The current study was carried out to assess inhibiting and promoting factors for scaling up Moving Stories once its effectiveness has been ascertained.

METHODS

Moving Stories was offered in three steps: (1) introductory classroom session, (2) students playing the game for five days, (3) debriefing classroom session led by lived experience worker. Data was collected on the number of participating students, costs of offering Moving Stories, and was further based on the notes of the debriefing sessions to check if mental health first aid (MHFA) strategies were addressed.

RESULTS

Moving Stories was offered in seven high-schools. Coverage was moderate with 982 participating students out of 1880 (52%). Most participating students (83%) played the Moving Stories app three out of the five days. Qualitative data showed that the MHFAs were discussed in all debriefing sessions. Students showed great interest in lived experience workers' stories and shared their own experiences with depression.

CONCLUSIONS

Bringing Moving Stories to scale in the high-school setting appears feasible, but will remain logistically somewhat challenging. Future implementation and scale-up of Moving Stories could benefit from improved selection and training of LEWs that played such an important role in grabbing the full attention of students and were able to launch frank discussions about depressive disorder and stigma in classrooms.

TRIAL REGISTRATION

The study is registered in the Dutch Trial Register: Trial NL6444 (NTR6622: https://www.trialregister.nl/trial/6444).

Opening the Black Box of Daily Life in Nonsuicidal Self-injury Research: With Great Opportunity Comes Great Responsibility

Although nonsuicidal self-injury (NSSI)-deliberate damaging of body tissue without suicidal intent-is a behavior that occurs in interaction with real-world contexts, studying NSSI in the natural environment has historically been impossible. Recent advances in real-time monitoring technologies have revolutionized our ability to do exactly that, providing myriad research and clinical practice opportunities. In this viewpoint paper, we review new research pathways to improve our ability to understand, predict, and prevent NSSI, and provide critical perspectives on the responsibilities inherent to conducting real-time monitoring studies on NSSI. Real-time monitoring brings unique opportunities to advance scientific understanding about (1) the dynamic course of NSSI, (2) the real-time predictors thereof and ability to detect acute risk, (3) the ecological validity of theoretical models, (4) the functional mechanisms and outcomes of NSSI, and (5) the promotion of person-centered care and novel technology-based interventions. By considering the opportunities of real-time monitoring research in the context of the accompanying responsibilities (eg, inclusive recruitment, sound and transparent research practices, participant safety and engagement, measurement reactivity, researcher well-being and training), we provide novel insights and resources to open the black box of daily life in the next decade(s) of NSSI research.

Developing Suicide Safety Protocols for Qualitative Research as a Universal Equity Practice

Qualitative research offers a range of approaches to elucidate the health and social experiences of populations and communities that are historically oppressed and repressed, yet is not without ethical and practical challenges that may have unintended consequences and added risks for certain individuals and communities. As a result of experiences of trauma and environmental factors, many oppressed and repressed populations have disproportionately high rates of suicide, but there are no widely accepted standards or best practices for addressing suicidality while conducting qualitative research. We describe an example of a qualitative interview during which a participant reported thoughts of suicide, even though the study topic was not directly related to mental health or suicide. We describe how the research team responded and present a framework for developing suicide safety protocols when conducing qualitative research with oppressed and repressed populations.

Evaluating the impact of patient and carer involvement in suicide and self-harm research: A mixed-methods, longitudinal study protocol

BACKGROUND

Patient and public involvement (PPI) is becoming more commonplace in mental health research. There are strong moral and ethical arguments for good quality PPI. Few studies have documented and evaluated PPI in self-harm and suicide research. Inconsistent reporting of PPI makes it difficult to discern practices that deliver quality, effective and meaningful involvement. It is important to understand and address emotional support needs of PPI members contributing to sensitive topics such as suicide and self-harm. Therefore, this study will examine the effect of PPI on self-harm and suicide research and explore patients', carers' and researchers' experiences and views in relation to the quality of PPI practice and provision of appropriate support for PPI members.

METHODS

This protocol outlines the longitudinal, mixed methodological approach that will be taken. Qualitative and quantitative data will be collected via baseline and repeated questionnaires, document review and semi-structured interviews. Both PPI members and researchers will be invited to participate in this study. The two-year data collection period will enable evaluation of PPI throughout the entire research cycle. An integrated approach will be taken to data analysis, using inductive thematic analysis and descriptive and repeated measures analyses, to address specified study aims.

DISSEMINATION

Findings from this study will inform practical guidance to support self-harm and suicide researchers in effectively involving people with experiential knowledge in their research. Analyses will offer insight into the effect of PPI throughout the research process and assess changes in PPI members' and researchers' experiences of involvement across a two-year period.

Contact between patients with suicidal ideation and nurses in mental health wards: Development and psychometric evaluation of a questionnaire

Suicide prevention and treatment opportunities often depend on interpersonal contact between patients and professionals. Presently, there is a lack of valid and reliable instruments to obtain the perspective of patients with suicidal ideation regarding their contact with professionals in mental health wards. This was a three-stage study to develop and psychometrically evaluate a questionnaire: the Contact with Nurses from the perspective of Patients with Suicidal ideation (CoNuPaS). First, the construct was defined by a systematic review, qualitative study, and face validity among experts. Second, the content was validated through a Delphi procedure with professional experts (n = 14) and cognitive interviews with hospitalized patients (n = 12). Third, using a sample of adult patients with suicidal ideation in the past year (n = 405), the psychometric properties were assessed by an exploratory factor analysis, a test-retest procedure, and the internal consistency. The CoNuPaS comprises 23 items and two subsections, to examine patients' perceptions of contact experiences with nurses (CoNuPaS-experience) and what they find important in that contact (CoNuPaS-importance). The subsections comprise four components: encountering a space to express suicidal thoughts and explore needs, being recognized as a unique and self-determining individual, encountering nurses' availability/information-sharing/transparency on expectations, and trusting nurses in communication about suicidality. Content validity scores were excellent (0.78-1.00); test-retest intraclass correlation coefficient and internal consistency were >0.90. Thus, the CoNuPaS demonstrated good psychometric properties. The availability of a valid questionnaire to examine patient-nurse contact in mental health wards is central to improving understanding of nurses' contributions to suicide prevention and suicidal ideation treatment.

How is Participating in Suicide Prevention Activities Experienced by Those with Lived and Living Experiences of Suicide in Australia? A Qualitative Study

People with a lived experience of suicide are commonly included within suicide prevention research. This includes participation in conferences, policy development, research and other activities. Yet little is known about the impact on the person in the long term of regularly sharing one’s experience to different audiences and, in some cases, to a schedule not of your choosing. This qualitative study asked twenty people to share their reflections of being lived experience representatives within suicide prevention. Participants varied in the length of time they had been sharing their stories, and how they shared with different audiences. These narratives were thematically analysed within a reflective framework, including field notes. Four broad themes were noted that highlighted participants’ recommendations as to how the lived experience speaker training could grow alongside suicide prevention activities to facilitate safe activities that include a shared understanding of the expected outcome from participation. The environment for people with lived experience of suicide to tell their stories already exists, meaning that the suicide prevention sector needs to move quickly to ensure people understand the variety of spaces where lived experience needs to be incorporated, evaluated and better supported. When lived experience is a valued inclusion in the creation of effective and appropriate suicide prevention research and interventions, those who share their experience must be valued and supported in a way that reflects this. This study recommends strategies to practically and emotionally support speakers, including ways to ensure debriefing and support, which can enhance the longevity of the speakers in the suicide prevention space by valuing the practical and emotional labour required to be suicide prevention representatives, with an outcome recommendation for best practice guidelines for those who engage people with lived experience in suicide prevention activities.