BackUp: Development and evaluation of a smart-phone application for coping with suicidal crises

Translating Suicide Safety Planning Components Into the Design of mHealth App Features: Systematic Review

BACKGROUND

Suicide safety planning is an evidence-based approach used to help individuals identify strategies to keep themselves safe during a mental health crisis. This study systematically reviewed the literature focused on mobile health (mHealth) suicide safety planning apps.

OBJECTIVE

This study aims to evaluate the extent to which apps integrated components of the safety planning intervention (SPI), and if so, how these safety planning components were integrated into the design-based features of the apps.

METHODS

Following the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines, we systematically analyzed 14 peer-reviewed studies specific to mHealth apps for suicide safety planning. We conducted an analysis of the literature to evaluate how the apps incorporated SPI components and examined similarities and differences among the apps by conducting a comparative analysis of app features. An independent review of SPI components and app features was conducted by downloading the available apps.

RESULTS

Most of the mHealth apps (5/7, 71%) integrated SPI components and provided customizable features that expanded upon traditional paper-based safety planning processes. App design features were categorized into 5 themes, including interactive features, individualized user experiences, interface design, guidance and training, and privacy and sharing. All apps included access to community supports and revisable safety plans. Fewer mHealth apps (3/7, 43%) included interactive features, such as associating coping strategies with specific stressors. Most studies (10/14, 71%) examined the usability, feasibility, and acceptability of the safety planning mHealth apps. Usability findings were generally positive, as users often found these apps easy to use and visually appealing. In terms of feasibility, users preferred using mHealth apps during times of crisis, but the continuous use of the apps outside of crisis situations received less support. Few studies (4/14, 29%) examined the effectiveness of mHealth apps for suicide-related outcomes. Positive shifts in attitudes and desire to live, improved coping strategies, enhanced emotional stability, and a decrease in suicidal thoughts or self-harm behaviors were examined in these studies.

CONCLUSIONS

Our study highlights the need for researchers, clinicians, and app designers to continue to work together to align evidence-based research on mHealth suicide safety planning apps with lessons learned for how to best deliver these technologies to end users. Our review brings to light mHealth suicide safety planning strategies needing further development and testing, such as lethal means guidance, collaborative safety planning, and the opportunity to embed more interactive features that leverage the advanced capabilities of technology to improve client outcomes as well as foster sustained user engagement beyond a crisis. Although preliminary evidence shows that these apps may help to mitigate suicide risk, clinical trials with larger sample sizes and more robust research designs are needed to validate their efficacy before the widespread adoption and use.

Mobile phone addiction and suicide behaviors among Chinese adolescents: The mediation of poor sleep quality

Background and aims

Mobile phone addiction (MPA) is emerging among adolescents, especially during the COVID-19 pandemic. Nevertheless, there is a dearth of knowledge regarding the correlation between MPA and suicide behaviors and its mechanism. The objective of the current study is exploring the direct effect of MPA on suicide behaviors and the indirect effect through poor sleep quality.

Methods

A total of 18,900 Chinese adolescents aged 12 to 18 were recruited via a multi-stage cluster sampling method.

Results

The prevalence of MPA and poor sleep quality was 26.2 and 23.1%, respectively. During the past year, 24.4% participants were involved in suicide behaviors. Specifically, suicide ideators, suicide planners, and suicide attempters were 10.7, 8.4, and 5.3%, respectively. Particularly, rural females had the highest prevalence of suicide behaviors, MPA, and poor sleep quality. Logistic regression analysis showed that MPA was significantly associated with suicide ideators (OR = 1.22, 95% CI: 1.09-1.37, p < 0.001) and planners (OR = 1.18, 95% CI: 1.04-1.34, p < 0.05), but not for suicide attempters (p > 0.05). Structural equation modelling demonstrated that MPA had direct effect on suicide behaviors (β = 0.145, 95% CI = 0.127-0.160), and poor sleep quality partially mediated the relationship (the mediating ratio was 46.7%). The mediating ratio of poor sleep quality was the highest in urban males.

Conclusions

MPA has both direct and indirect effects on suicide behaviors. For suicide prevention, limited mobile phone use and improvement sleep quality may be practical for adolescents. Additionally, more efforts of intervention could give priority to rural girls.

Digital safety plan effectiveness and use: Findings from a three-month longitudinal study

Few studies have examined the effectiveness of self-guided smartphone apps for suicide safety planning, despite their increasing use. Participants (n = 610) were self-selected users of the Beyond Now suicide prevention safety planning app with a history of suicidal thoughts and behaviours. Surveys were completed (baseline, one and three months), safety plan content and app usage data was shared. Repeated-measures ANOVAs examined changes in suicidal ideation and suicide-related coping over three months. Multiple regression models were used to predict suicidal ideation and suicide-related coping at one- and three-month follow-ups with plan-related variables: perceived usefulness, personalised content, app use time and co-authoring of the plan with a third party. Significant reductions in suicidal ideation and increases in suicide-related coping were found over three months. Higher suicide-related coping at three months predicted lower suicidal ideation. Higher perceived usefulness and personalised content at three months were associated with higher suicide-related coping, but not suicidal ideation. App use time and co-authoring were not significantly related to suicidal ideation or suicide-related coping. Practitioners should empower clients to create safety plans with personalised (not generic) strategies that a client perceives to be useful. Such plans may strengthen beliefs about coping with suicidal ideation, which in turn reduces suicidal ideation over time.

Perceived Usefulness of Self-Guided Versus Collaborative Suicide Safety Plans in Online Help-Seekers

Background: Suicide safety plans were originally devised to be paper-based and clinician-guided, but digital self-guided plans are now common. Aim: This study explored whether plan format (paper vs. digital), assistance (self-authored vs. collaboration), and suicide attempt history were associated with differences in suicidal ideation, suicide-related coping, and perceived usefulness. Method: An online sample of safety plan users (N = 131) completed a survey assessing suicidal ideation, suicide-related coping, and perceived usefulness of their plan. t tests compared outcomes by plan format, collaboration, and suicide attempt history. Pearson correlations explored associations between reasons for plan use, suicidal ideation, and suicide-related coping. Results: Suicidal ideation was significantly higher, and perceived usefulness significantly lower in participants with a past suicide attempt (vs. none) and in those who had collaborated to make their safety plan (vs. self-authored). Collaborators were largely health professionals. No significant differences were found between plan formats. Suicide-related coping was associated with higher perceived usefulness overall. Limitations: Our study design was cross-sectional, utilizing a largely young, female, English-speaking, online help-seeking sample. Conclusions: For clients with prior suicide attempts and higher levels of suicidal ideation, meaningful collaboration may be needed to find safety plan coping strategies that are perceived as useful.

Smartphone-based safety plan for suicidal crisis: The SmartCrisis 2.0 pilot study

Here we present the findings of the pilot phase of the SmartCrisis 2.0 Randomized Clinical Trial. This pilot study aimed to explore the feasibility and acceptability of a safety plan contained in a smartphone app. Our sample consisted patients with a history of recent suicidal behaviour who installed a smartphone-based safety plan. To explore the satisfaction with of the safety plan, two patient satisfaction surveys were conducted: one qualitative and one quantitative. To explore the objective use of the safety plan, we gained access to texts contained in the safety plans completed by the patients. Participation rate was 77%, while 48.9% patients completed both satisfaction surveys at the end of the pilot phase. N = 105 successfully installed the safety plan. In a scale from 1 to 10, users rated the usefulness of the security plan at 7.4, the usability at 8.9, the degree to which they would recommend it to others at 8.6 and the overall satisfaction with the project including evaluations at 9.6. The most widely completed tab was warning signs. Feeling sad or lonely was the warning sign most commonly reported by patients. The second most completed tab was internal coping strategies. Walking or practicing any other exercise was the strategy most commonly resorted to. Our smartphone-based safety plan appears to be a feasible intervention. Data obtained from this pilot study showed high participation rates and high acceptability by patients. This, together with the general satisfaction with the project, supports its implementation in the clinical practice.

Crisis plans in mental health: A scoping review

Crisis situations are frequent among people with mental health disorders. Several interventions have been developed to act in prevention, including crisis plans recognized as particularly effective in reducing coercive measures. In the literature, several models of crisis plans are proposed with similar aims and contents. Based on the methodology proposed by the Joanna Briggs Institute, a scoping review was conducted to map the state of knowledge on crisis plans in adult mental health settings. The literature search conducted on six databases (CINAHL, PubMed, Medline, EMBASE, PsychINFO and Cochrane) yielded 2435 articles. Of these, 122 full-text articles were assessed for eligibility, and 78 met the inclusion criteria. Studies were critically appraised using the Joanna Briggs Institute appraisal tools, and data were extracted by two independent reviewers. Content analysis identified a typology of crisis plans: (1) the legal crisis plan and (2) the formal crisis plan. Five modalities were identified for its completion: the sections, the moment, the completion steps, the people involved and the training of key actors. Most identified outcomes are consistent with the main purpose of the intervention, which is crisis prevention. However, the most identified outcomes focused on the service user's recovery and indicated that crisis plans could provide an opportunity to operationalize recovery in mental healthcare, thus suggesting an evolution in the aim of the intervention. Future research should further focus on the modalities of crisis plans to guide the implementation in clinical practice.

A randomized 3-month, parallel-group, controlled trial of CALMA m-health app as an adjunct to therapy to reduce suicidal and non-suicidal self-injurious behaviors in adolescents: study protocol

Background

Suicidal and non-suicidal self-injurious behaviors are among the leading causes of death and injury in adolescents and youth worldwide. Mobile app development could help people at risk and provide resources to deliver evidence-based interventions. There is no specific application for adolescents and young people available in Spanish. Our group developed CALMA, the first interactive mobile application with the user in Spanish, which provides tools based on Dialectical Behavioral Therapy to manage a crisis of suicidal or non-suicidal self-directed violence with the aim of preventing suicide in adolescents and youth.

Methods

To test the effectiveness, safety and level of engagement of the CALMA app in people aged 10 to 19 who are treated in mental health services of two public hospitals, we will conduct a parallel-group, two-arm randomized controlled trial. Participants will be assessed face-to-face and via video call at four timepoints: day-0 (baseline), day-30, day-60, and day-90. A total of 29 participants per group will be included. Change in the frequency of suicidal and non-suicidal self-injurious behaviors will be compared between groups, as well as the level of emotional dysregulation, level of app engagement and time of psychiatric admission during the follow-up period.

Discussion

This study is particularly relevant to young people given their widespread use of mobile technology, while there are currently no available smartphone app-based self-guided psychological strategies in Spanish that attempt to reduce suicidal behavior in adolescents who are assisted in the public health sector from low and middle-income countries in Latin America.

Clinical trial registration

https://clinicaltrials.gov/, NCT05453370.

Defining the Characteristics of an e-Health Tool for Suicide Primary Prevention in the General Population: The StopBlues Case in France

With over one million deaths per year in the world, suicide is a major public health problem that could be significantly reduced by effective prevention programs. E-health tools are of particular interest for primary prevention as they can address a broad population including people unaware of their own risk and provide information and help without the fear of stigma. Our main objective was to define the overall characteristics of an e-health tool for suicide primary prevention in the French general population by defining the characteristics of the IT features; the content of the information delivered; the best way to structure it; and how it should be relayed and by whom. The research was carried out through a literature review and a co-construction phase with stakeholders. Four types of strategies may guide the construction of e-health tools for suicide primary prevention: education and awareness, (self-)screening, accessing support, and mental health coping. They should be accessible on different devices to reach the most users, and language and content should be adapted to the target population and to the issue being addressed. Finally, the tool should be consistent with ethical and quality best practices. The e-health tool StopBlues was developed following those recommendations.

Identification of Risk Factors for Suicide and Insights for Developing Suicide Prevention Technologies: A Systematic Review and Meta-Analysis

Suicide is a termite that engulfs close to seven hundred thousand people worldwide each year. Existing work on risk factors that predict suicide lacks statistical associations, does not consider most countries, and has a wide range of risk factor domains. The goal of this systematic review and meta-analysis is to enhance our current understanding of suicidality by identifying risk factors that are most strongly associated with suicide and their impact on developing technological interventions for suicide prevention. A search strategy was carried out on four databases: (1) PsycINFO, (2) IEEE Xplore, (3) the ACM Digital Library, and (4) PubMed, and twenty-five studies were included based on the inclusion criteria. Factors statistically associated with suicide are any diagnosed mental disorder, adverse life events, past suicide attempts, low education level, loneliness or high levels of isolation, bipolar disorder, depression, multiple chronic health conditions, family history of suicide, sexual trauma, and being female. Domain-wise, comorbid disorders, and behavior-related risk factors are most strongly associated with suicide. We present a new hierarchical model of risk factors for suicide that advances our understanding of suicide and its causes. Finally, we present open research directions and considerations for developing suicide prevention technologies.

Health Needs for Suicide Prevention and Acceptance of e-Mental Health Interventions in Adolescents and Young Adults: Qualitative Study

BACKGROUND

Adolescence is a phase of higher vulnerability for suicidal behavior. In Germany, almost 500 adolescents and young adults aged 15-25 years commit suicide each year. Youths in rural areas are characterized by a higher likelihood of poorer mental health. In rural areas, appropriate support for adolescents and young adults in mental health crises is difficult to access. The general acceptability of digital communication in youths can make the provision of an eHealth tool a promising strategy.

OBJECTIVE

The aim of this study was to explore the health needs regarding suicide prevention for adolescents and young adults in rural areas of Germany and Switzerland and to identify characteristics of suitable e-mental health interventions.

METHODS

This study reports on a qualitative secondary analysis of archived data, which had been collected through formative participatory research. Using 32 semistructured interviews (individually or in groups of 2) with 13 adolescents and young adults (aged 18-25 years) and 23 experts from relevant fields, we applied a deductive-inductive methodological approach and used qualitative content analyses according to Kuckartz (2016).

RESULTS

Experts as well as adolescents and young adults have reported health needs in digital suicide prevention. The health needs for rural adolescents and young adults in crises were characterized by several categories. First, the need for suicide prevention in general was highlighted. Additionally, the need for a peer concept and web-based suicide prevention were stressed. The factors influencing the acceptability of a peer-driven, web-based support were related to low-threshold access, lifelike intervention, anonymity, and trustworthiness.

CONCLUSIONS

The results suggest a need for suicide prevention services for adolescents and young adults in this rural setting. Peer-driven and web-based suicide prevention services may add an important element of support during crises. By establishing such a service, an improvement in mental health support and well-being could be enabled. These services should be developed with the participation of the target group, taking anonymity, trustworthiness, and low-threshold access into account.

The feasibility of using smartphone apps as treatment components for depressed suicidal outpatients

Mental health smartphone apps could increase the safety and self-management of patients at risk of suicide, but it is still unclear whether it is feasible to integrate such apps into routine mental healthcare. This study reports on the feasibility of using a safety planning app (BackUp) and a self-monitoring app (mEMA) as components of the routine treatment of depressed outpatients with suicidal ideation. Clinicians were trained in working with both of the apps, and they invited their eligible patients with suicidal ideation for study participation. Patients used the apps for 3 months and discussed these with their clinician during treatment. Patients completed assessments at baseline (T0), 4 weeks (T1) and post-test (T2, 12 weeks after baseline). Both patients and clinicians also participated in telephone interviews. Feasibility was assessed in terms of usability (score > 70 on System Usability Scale, SUS), acceptability (score > 20 on Client Satisfaction Questionnaire-8, CSQ-8), and uptake (sufficient rates of component completion and app usage in treatment). The sample included 17 adult outpatients (52.9% male, age range 20-50 years) diagnosed with a depressive disorder and suicidal ideation at baseline. BackUp was rated by patients at above the cut-off scores for usability (SUS mean score at T1 75.63 and at T2 77.71) and acceptability (CSQ-8 mean score at T1 23.42 and at T2 23.50). mEMA was similarly rated (SUS mean score at T1 75.83 and at T2 76.25; CSQ-8 mean score at T1 23.92 and at T2 22.75). Telephone interviews with patients and clinicians confirmed the usability and acceptability. The uptake criteria were not met. Our findings suggest that mobile safety planning and mobile self-monitoring can be considered acceptable and usable as treatment components for depressed suicidal outpatients, but the integration of apps into routine treatment needs to be further explored.

The Effectiveness of Mobile Apps for Monitoring and Management of Suicide Crisis: A Systematic Review of the Literature

Suicide risk is a multifaceted phenomenon, and many risk factors are involved in its complexity. In the last few decades, mental health apps have spread, providing economic and affordable strategies to prevent suicide. Therefore, the aim of this review is to identify original studies on mobile apps that target suicidal crises. The review follows PRISMA guidelines, searching through four major electronic databases (PubMed/MEDLINE, Scopus, PsycInfo and Web of Science) for relevant titles/abstracts published from January 2010 to May 2022. It includes original studies that explicitly analyze mobile apps for suicide prevention. A total of 32 studies met the inclusion criteria. Sixteen studies assessed the feasibility and acceptability of mobile apps, ten studies assessed the efficacy of mobile apps in preventing suicide, and six studies described randomized control trial protocols not yet implemented. Generally, the apps were judged by participants to be acceptable and helpful, and several improvements to enhance the functionality of apps were suggested. The efficacy of mobile apps, although limited and assessed with very heterogenous methods, was confirmed by most of the studies. Mobile apps could represent a helpful supplement to traditional prevention tactics, providing real-time monitoring of at-risk persons, personalized tools to cope with suicidal crises, and immediate access to specific support.

The Effectiveness of the Safety Planning Intervention for Adults Experiencing Suicide-Related Distress: A Systematic Review

The safety planning intervention (SPI) is gaining momentum in suicide prevention practice and research. This systematic review sought to determine the effectiveness of the SPI for adults experiencing suicide-related distress. Systematic searches of international, peer-reviewed literature were conducted in six databases (Cochrane Trials, Embase, Emcare, Medline, PsycINFO and Web of Science), including terms for safety planning, suicide, and suicide-related outcomes. A total of 565 results were included for screening. Result screening (title/abstract and full-text), data extraction and critical appraisal were conducted in duplicate. Twenty-six studies met the inclusion criteria. Studies were primarily quantitative (n = 20), largely with general adult or veteran samples; a small number of studies explored the perspectives of staff and significant others. Half of the studies included the SPI as a standalone intervention, while the other half examined the SPI in combination with other interventions. Most interventions were delivered in-person, with a hard-copy safety plan created, while a smaller number explored internet-based interventions. Primary measures included: suicidality (ideation, behavior, deaths; 10 studies), suicide-related outcomes (depression, hopelessness; 5 studies) and treatment outcomes (hospitalizations, treatment engagement; 7 studies). The evidence supports improvements in each of these domains, with complementary findings from the remaining quantitative and qualitative studies suggesting that the SPI is a feasible and acceptable intervention. While positive, these findings are limited by the heterogeneity of interventions and study designs, making the specific impact of the SPI difficult to both determine and generalize. Conversely, this also points to the flexibility of the SPI.HighlightsThe Safety Planning Intervention (SPI) is a valuable indicated intervention for general adult and veteran populations experiencing suicide-related distress, primarily in face-to-face, clinical settings.Quantitative findings indicate associations between the SPI and improvements in suicidal ideation and behavior, decreases in depression and hopelessness, along with reductions in hospitalizations and improvements in treatment attendance.Qualitative studies suggest the SPI is acceptable and feasible, with areas for development.SPIs have been shown to be adaptable to the clinical area in its modality (digital or paper-based), delivery (face-to-face or online), facilitation (clinician or self-administered) and multiplicity (as stand-alone or combined intervention).

CALMA, a Mobile Health Application, as an Accessory to Therapy for Reduction of Suicidal and Non-Suicidal Self-Injured Behaviors: A Pilot Cluster Randomized Controlled Trial

The present study was aim to evaluate the acceptability and preliminary effectiveness of a mobile-health application, CALMA, based on dialectical behavioral therapy skills. CALMA was proposed as an adjunct to therapy for the reduction of non-suicidal and suicidal self-injury behaviors. A parallel design was used to compare the intervention group (DBT + CALMA) and the comparison group (DBT). Patients were randomized based on their groups following a randomized cluster design. After treatment, patients completed a follow-up assessment four weeks later. Each cluster was represented by a different DBT Skills Training Group offered weekly at FORO Foundation for Mental Health. Six DBT Skills Training groups were randomized to the intervention or comparison group. Twenty-one individuals met inclusion criteria and eighteen were included in the analysis. Acceptability was measured with the User Experience Questionnaire short version (UEQ-s) and preliminary efficacy with the Self-injurious thoughts and behaviors interview (SITBI). CALMA shows good acceptability to be used as an adjunct to therapy specific to the reduction of suicidal and non-suicidal self-directed violence. Evidence for preliminary efficacy included a high probability of decreased in more behaviors evaluated with the SITBI pre- and post-intervention for the group that received CALMA as compared to the comparison group. Our study provides initial evidence for the effectiveness and acceptability of CALMA. Future studies scaling up this intervention in a larger number of participants are necessary. CALMA may be especially useful in low and middle-income Latin American countries to improve access to evidence-based interventions openly available in Spanish and free to download.HighlightsCALMA is a DBT-based app aimed to reduce non-suicidal and suicidal self-directed violence.The app showed good acceptability by usersA high probability of decrease in suicidal ideation, suicidal plan, suicidal gesture, thoughts about NSSI and NSSI pre- and post-intervention was observed.

Suicide Prevention in Your Pocket: A Systematic Review of Ecological Momentary Interventions for the Management of Suicidal Thoughts and Behaviors

BACKGROUND

This study reviews the evidence on ecological momentary interventions (EMIs) for managing and preventing suicidal thoughts and behaviors.

METHODS

This review follows the Preferred Reporting Items for Systematic Reviews and Meta-analyses guidelines. Its protocol was registered in the PROSPERO database. We conducted a systematic literature search of five databases: PubMed, EMBASE, Web of Science, PsycInfo, and Cochrane library. The most recent search date was 10 September 2021.

RESULTS

After screening and full-text review, 27 studies were included, totaling 19 different interventions. Many of the available interventions have not yet been clinically tested. Those that have undergone effectiveness evaluation (10 interventions) showed good rates of effectiveness and feasibility, with some exceptions. The most widely used intervention model is the safety plan, which allows the user to implement coping and distracting strategies in case of suicidal ideation.

CONCLUSIONS

Ecological momentary interventions provide certain advantages, such as their wide availability, versatility, and potential for customization. These interventions can be useful complements to traditional care, especially in situations in which face-to-face care is not possible. Evidence on the effectiveness of such interventions is still scarce. Furthermore, barriers limiting implementation in clinical practice remain. The constant advance of technology means that these interventions have great potential for improvement in the coming years.

Suicidal Ideation Is Associated With Excessive Smartphone Use Among Chinese College Students

BACKGROUND

Suicidal ideation is the first step and a strong predictor of suicide. College students are at a considerably high risk of suicidal ideation, and smartphones are commonly used in this group. However, the relationship between suicidal ideation and smartphone use among Chinese college students is unclear. The current study aimed to investigate the prevalence of suicidal ideation among Chinese college students and its association with smartphone use and addiction factors.

METHODS

A total of 439 college students participated the survey. We collected the demographic information, physical health, psychosocial factors (depressive symptoms, social support, sleep quality), characteristics of smartphone use, and mobile phone addiction (MPA). Suicidal ideation was measured with a single question, "did you feel that life was not worth living in the past 1 year?"

RESULTS

The prevalence of suicidal ideation ("Yes" response) in the past year among Chinese college students was 7.5%. In binary logistic regression analysis, suicidal ideation was significantly correlated with less subjective social support (OR: 2.49, p = 0.049), lower utilization of social support (OR: 13.28, p = 0.012), more depressive symptoms (OR:4.96, p = 0.005), and more than 5 h of daily smartphone use (OR: 2.60, p = 0.025).

CONCLUSION

Considering the widely use of smartphones in Chinese colleges and the correlation with suicidal ideation, excessive phone use among college students should be given more attention by administrators and health workers. It is necessary to obtain more information about the intention of smartphone use, make full use of smartphones for health education, and monitor excessive use of smartphones, while improving social support and coping mechanisms for depression, to identify suicidal ideation and prevent suicidal behavior among Chinese college students.

A Systematic Evaluation of Mobile Health Applications for the Prevention of Suicidal Behavior or Non-suicidal Self-injury

People with suicidal ideation and non-suicidal self-injury (NSSI) behavior face numerous barriers to help-seeking, which worsened during the COVID-19 pandemic. Mobile health applications (MHA) are discussed as one solution to improve healthcare. However, the commercial app markets are growing unregulated and rapidly, leading to an inscrutable market. This study evaluates the quality, features, functions, and prevention strategies of MHA for people with suicidal ideation and NSSI. An automatic search engine identified MHA for suicidal behavior and NSSI in the European commercial app stores. MHA quality and general characteristics were assessed using the Mobile Application Rating Scale (MARS). MHA of high quality (top 25%) were examined in detail and checked for consistency with established suicide prevention strategies. Of 10,274 identified apps, 179 MHA met the predefined inclusion criteria. Average MHA quality was moderate (M = 3.56, SD = 0.40). Most MHA provided emergency contact, but lacked security features. High-quality MHA were broadly consistent with the best-practice guidelines. The search revealed apps containing potentially harmful and triggering content, and no randomized controlled trial of any included MHA was found. Despite a large heterogeneity in the quality of MHA, high-quality MHA for suicidal behavior and NSSI are available in European commercial app stores. However, a lack of a scientific evidence base poses potential threats to users.

A Digital Companion, the Emma App, for Ecological Momentary Assessment and Prevention of Suicide: Quantitative Case Series Study

BACKGROUND

Many suicide risk factors have been identified, but traditional clinical methods do not allow for the accurate prediction of suicide behaviors. To face this challenge, emma, an app for ecological momentary assessment (EMA), ecological momentary intervention (EMI), and prediction of suicide risk in high-risk patients, was developed.

OBJECTIVE

The aim of this case report study was to describe how subjects at high risk of suicide use the emma app in real-world conditions.

METHODS

The Ecological Mental Momentary Assessment (EMMA) study is an ongoing, longitudinal, interventional, multicenter trial in which patients at high risk for suicide are recruited to test emma, an app designed to be used as a self-help tool for suicidal crisis management. Participants undergo clinical assessment at months 0, 1, 3, and 6 after inclusion, mainly to assess and characterize the presence of mental disorders and suicidal thoughts and behaviors. Patient recruitment is still ongoing. Some data from the first 14 participants who already completed the 6-month follow-up were selected for this case report study, which evaluated the following: (1) data collected by emma (ie, responses to EMAs), (2) metadata on emma use, (3) clinical data, and (4) qualitative assessment of the participants' experiences.

RESULTS

EMA completion rates were extremely heterogeneous with a sharp decrease over time. The completion rates of the weekly EMAs (25%-87%) were higher than those of the daily EMAs (0%-53%). Most patients (10/14, 71%) answered the EMA questionnaires spontaneously. Similarly, the use of the Safety Plan Modules was very heterogeneous (2-75 times). Specifically, 11 patients out of 14 (79%) used the Call Module (1-29 times), which was designed by our team to help them get in touch with health care professionals and/or relatives during a crisis. The diversity of patient profiles and use of the EMA and EMI modules proposed by emma were highlighted by three case reports.

CONCLUSIONS

These preliminary results indicate that patients have different clinical and digital profiles and needs that require a highly scalable, interactive, and customizable app. They also suggest that it is possible and acceptable to collect longitudinal, fine-grained, contextualized data (ie, EMA) and to offer personalized intervention (ie, EMI) in real time to people at high risk of suicide. To become a complementary tool for suicide prevention, emma should be integrated into existing emergency procedures.

TRIAL REGISTRATION

ClinicalTrials.gov NCT03410381; https://clinicaltrials.gov/ct2/show/NCT03410381.

Effectiveness of self-help mobile telephone applications (apps) for suicide prevention: A systematic review

Background: According to the expansion of suicide prevention applications in recent years, the aim of this study was to review randomized controlled trials (RCTs) and pretest-posttest studies that evaluated the effectiveness of suicide prevention applications. Methods: In this systematic review, we searched online databases including Pubmed, SCOPUS, Web of Science, Chocrane Database, and Google Scholar to find randomized controlled trials and pretest-posttest studies published up to Jul 18, 2019. Randomized controlled trials and pretest-posttest of efficacy self-guided telephone applications that reported any primary and secondary outcome of suicidal thoughts and behaviors were included in the review. We evaluated the articles using the CONSORT 2010 checklist. Results: After screening articles, 7 studies were included in this review. Four studies focused on the effectiveness of applications on suicide thoughts and attempt, 2 on effectiveness of applications on self-injury, 4 on depression and anxiety, 1 on impulsivity, and 2 on adaptive strategies. Overall, mobile phone applications were associated with reductions in suicidal ideation scores at post intervention, and enhancement of adaptive skills; however, no evidence of reduction was reported in impulsivity after use of applications. Conclusion: Despite the differences in studies, this review showed that the use of mobile applications had an overall positive effect on reducing the risk of suicide and improving performance and health of patients.

Ethical issues and practical barriers in internet-based suicide prevention research: a review and investigator survey

BACKGROUND

People who are at elevated risk of suicide stand to benefit from internet-based interventions; however, research in this area is likely impacted by a range of ethical and practical challenges. The aim of this study was to examine the ethical issues and practical barriers associated with clinical studies of internet-based interventions for suicide prevention.

METHOD

This was a mixed-methods study involving two phases. First, a systematic search was conducted to identify studies evaluating internet-based interventions for people at risk of suicide, and information pertaining to safety protocols and exclusion criteria was extracted. Second, investigators on the included studies were invited to complete an online survey comprising open-ended and forced-choice responses. Quantitative and qualitative methods were used to analyse the data.

RESULTS

The literature search identified 18 eligible studies, of which three excluded participants based on severity of suicide risk. Half of the 15 suicide researchers who participated in the survey had experienced problems obtaining ethics approval, and none had encountered adverse events attributed to their intervention. Survey respondents noted the difficulty of managing risk in online environments and the limitations associated with implementing safety protocols, although some also reported increased confidence resulting from the ethical review process. Respondents recommended researchers pursue a collaborative relationship with their research ethics committees.

CONCLUSION

There is a balance to be achieved between the need to minimise the risk of adverse events whilst also ensuring interventions are being validated on populations who may be most likely to use and benefit from them (i.e., those who prefer anonymity). Further research is required to obtain the views of research ethics committees and research participants on these issues. Dialogue between researchers and ethics committees is necessary to address the need to ensure safety while also advancing the timely development of effective interventions in this critical area.

A Systematic Review of the Evidence Supporting Mobile- and Internet-Based Psychological Interventions For Self-Harm

OBJECTIVES

Internet- and mobile phone-based psychological interventions have the potential to overcome many of the barriers associated with accessing traditional face-to-face therapy. Self-injurious thoughts and behaviors (STB) are prevalent global health problems that may benefit from Internet- and mobile-based interventions. We provide a systematic review and meta-analysis of studies evaluating mobile- and Internet-based interventions for STB, including nonsuicidal self-injury (NSSI).

METHODS

Online databases (PsycINFO, Web of Science, Medline) were searched up to March 2019 for single-arm and controlled trials of Internet- or mobile-based interventions for STB. The potential for bias was assessed using the Cochrane risk of bias tool.

RESULTS

Twenty-two eligible trials were identified. The research was limited by a lack of controlled designs and small samples. Evidence supports the acceptability of interventions. There is preliminary evidence that these interventions are associated with a decline in STB. A meta-analysis suggested a positive treatment effect on suicidal ideation when compared to treatment as usual, but not when trials with active controls were also considered.

CONCLUSIONS

Overall, Internet- and mobile-based interventions show promise and further controlled trials are warranted, focusing on behavioral outcomes (NSSI, suicidal behavior). This review was preregistered with PROSPERO (CRD42017074065).

Smartphone applications targeting borderline personality disorder symptoms: a systematic review and meta-analysis

BACKGROUND

Smartphone applications could improve symptoms of borderline personality disorder (BPD) in a scalable and resource-efficient manner in the context limited access to specialized care.

OBJECTIVE

This systematic review and meta-analysis aims to evaluate the effectiveness of applications designed as treatment interventions for adults with symptoms such as anger, suicidality, or self-harm that commonly occur in BPD.

DATA SOURCES

Search terms for BPD symptoms, smartphone applications, and treatment interventions were combined on PubMed, MEDLINE, and PsycINFO from database inception to December 2019.

STUDY SELECTION

Controlled and uncontrolled studies of smartphone interventions for adult participants with symptoms such as anger, suicidality, or self-harm that commonly occur in BPD were included.

STUDY APPRAISAL AND SYNTHESIS METHODS

Comprehensive Meta-Analysis v3 was used to compute between-groups effect sizes in controlled designs. The primary outcome was BPD-related symptoms such as anger, suicidality, and impulsivity; and the secondary outcome was general psychopathology. An average dropout rate across interventions was computed. Study quality, target audiences, therapeutic approach and targets, effectiveness, intended use, usability metrics, availability on market, and downloads were assessed qualitatively from the papers and through internet search.

RESULTS

Twelve studies of 10 applications were included, reporting data from 408 participants. Between-groups meta-analyses of RCTs revealed no significant effect of smartphone applications above and beyond in-person treatments or a waitlist on BPD symptoms (Hedges' g = - 0.066, 95% CI [-.257, .125]), nor on general psychopathology (Hedges' g = 0.305, 95% CI [- 0.14, 0.75]). Across the 12 trials, dropout rates ranged from 0 to 56.7% (M = 22.5, 95% CI [0.15, 0.46]). A majority of interventions studied targeted emotion dysregulation and behavioral dyscontrol symptoms. Half of the applications are commercially available.

CONCLUSIONS

The effects of smartphone interventions on symptoms of BPD are unclear and there is currently a lack of evidence for their effectiveness. More research is needed to build on these preliminary findings in BPD to investigate both positive and adverse effects of smartphone applications and identify the role these technologies may provide in expanding mental healthcare resources.

Suicide on Facebook-the tales of unnoticed departure in Bangladesh

Facebook has transformed social communication and offers the opportunity to share personal thoughts to people including suicide ideas, plans and attempts. Suicide after Facebook posts has been reported in different parts of the world and it has become a potential area of research for suicide prevention. The analysis of Facebook posts prior to suicide or Facebook live streaming may help in understanding the etiological factors, patterns of communication and possible prevention approaches for a particular community. However, there is a dearth of evidence about suicide incidents after Facebook posts and Facebook live streaming in low and middle-income countries. This study aims to explore the trends and phenomena of suicide after Facebook posts and live streaming in Bangladesh. We conducted an online search using the Google, Facebook and five daily online newspaper archives from 15th August to 15th September 2019. Two research assistants independently conducted the initial searching to find out people who committed suicide after Facebook posts or live streamed suicide in Bangladesh and documented 21 cases. After further evaluation of each of the 21 cases we confirmed 19 cases that met the selection criteria. All of them were under 35-years of age. We observed sucide after Facebook posts were more common in male(78%) e and students. Hanging was the most frequently used method of suicide followed by poisoning. Their Facebook posts and livestream videos indicated relationship problems, academic stress and mental disorders were the common stressors for their suicide. This study lays the foundation for the future researchers to work on suicidal posts on Facebook in Bangladesh and develop culture-specific, real-time suicide preventive systems using a social media platform.

Differences in Firearm Suicides by Residential Location in Texas, 2006-2015

This study used Texas state vital statistics records, 2006-2015, to examine firearm use rates among 28,010 suicide decedents by residential location (urbanized vs. all others). Firearms were responsible for 44% of all teenage suicides and 76-90% and 50-60% of suicides of men and women aged 60 + years, respectively, and firearm use rates remained steady for both genders during the study period. Logistic regression analysis showed a significantly higher firearm use rate (AOR = 1.35, 95% CI = 1.28-1.42) among decedents who resided in nonurbanized areas. Differences in firearm use rates by residential location likely reflect higher firearm ownership in smaller communities and rural than urban areas. The findings underscore the importance of community- and individual-level suicide prevention strategies.

Creating a Theoretically Grounded, Gamified Health App: Lessons From Developing the Cigbreak Smoking Cessation Mobile Phone Game

Background

Gaming techniques are increasingly recognized as effective methods for changing behavior and increasing user engagement with mobile phone apps. The rapid uptake of mobile phone games provides an unprecedented opportunity to reach large numbers of people and to influence a wide range of health-related behaviors. However, digital interventions are still nascent in the field of health care, and optimum gamified methods of achieving health behavior change are still being investigated. There is currently a lack of worked methodologies that app developers and health care professionals can follow to facilitate theoretically informed design of gamified health apps.

Objective

This study aimed to present a series of steps undertaken during the development of Cigbreak, a gamified smoking cessation health app.

Methods

A systematic and iterative approach was adopted by (1) forming an expert multidisciplinary design team, (2) defining the problem and establishing user preferences, (3) incorporating the evidence base, (4) integrating gamification, (5) adding behavior change techniques, (6) forming a logic model, and (7) user testing. A total of 10 focus groups were conducted with 73 smokers.

Results

Users found the app an engaging and motivating way to gain smoking cessation advice and a helpful distraction from smoking; 84% (62/73) of smokers said they would play again and recommend it to a friend.

Conclusions

A dedicated gamified app to promote smoking cessation has the potential to modify smoking behavior and to deliver effective smoking cessation advice. Iterative, collaborative development using evidence-based behavior change techniques and gamification may help to make the game engaging and potentially effective. Gamified health apps developed in this way may have the potential to provide effective and low-cost health interventions in a wide range of clinical settings.

Facilitating Factors and Barriers to the Use of Emerging Technologies for Suicide Prevention in Europe: Multicountry Exploratory Study

BACKGROUND

This study provides an analysis on the use of emerging technologies for the prevention of suicide in 8 different European countries.

OBJECTIVE

The objective of this study was to analyze the potentiality of using emerging technologies in the area of suicide prevention based on the opinion of different professionals involved in suicide prevention.

METHODS

Opinions of 3 groups of stakeholders (ie, relevant professionals in suicide field) were gathered using a specifically designed questionnaire to explore dimensions underlying perceptions of facilitating factors and barriers in relation to the use of emerging technologies for suicide prevention.

RESULTS

Goal 1 involved facilitating factors for the use of emerging technologies in suicide prevention. Northern European countries, except for Belgium, attach greater relevance to those that optimize implementation and benefits. On the other hand, Southern European countries attach greater importance to professionally oriented and user-centered facilitating factors. According to different stakeholders, the analysis of these facilitating factors suggest that professionals in the field of social work attach greater relevance to those that optimize implementation and benefits. However, professionals involved in the area of mental health, policy makers, and political decision makers give greater importance to professionally oriented and user-centered facilitating factors. Goal 2 was related to barriers to the usability of emerging technologies for suicide prevention. Both countries and stakeholders attach greater importance to barriers associated with resource constraints than to those centered on personal limitations. There are no differences between countries or between stakeholders. Nevertheless, there is a certain stakeholders-countries interaction that indicates that the opinions on resource constraints expressed by different stakeholders do not follow a uniform pattern in different countries, but they differ depending on the country.

CONCLUSIONS

Although all countries and stakeholders agree in identifying resource constraints as the main barrier to the use of emerging technologies, factors facilitating their use in suicide prevention differ among countries and among stakeholders.

Youth Codesign of a Mobile Phone App to Facilitate Self-Monitoring and Management of Mood Symptoms in Young People With Major Depression, Suicidal Ideation, and Self-Harm

BACKGROUND

Effective treatment of depression in young people is critical, given its prevalence, impacts, and link to suicide. Clinical practice guidelines point to the need for regular monitoring of depression symptom severity and the emergence of suicidal ideation to track treatment progress and guide intervention delivery. Yet, this is seldom integrated in clinical practice.

OBJECTIVE

The objective of this study was to address the gap between guidelines about monitoring and real-world practice by codesigning an app with young people that allows for self-monitoring of mood and communication of this monitoring with a clinician.

METHODS

We engaged young people aged 18 to 25 years who had experienced depression, suicidal ideation including those who self-harm, as well as clinicians in a codesign process. We used a human-centered codesign design studio methodology where young people designed the features of the app first individually and then as a group. This resulted in a minimal viable product design, represented through low-fidelity hand-drawn wireframes. Clinicians were engaged throughout the process via focus groups.

RESULTS

The app incorporated a mood monitoring feature with innovative design aspects that allowed customization, and was named a "well-being tracker" in response to the need for a positive approach to this function. Brief personalized interventions designed to support young people in the intervals between face-to-face appointments were embedded in the app and were immediately available via pop-ups generated by a back-end algorithm within the well-being tracker. Issues regarding the safe incorporation of alerts generated by the app into face-to-face clinical services were raised by clinicians (ie, responding in a timely manner) and will need to be addressed during the full implementation of the app into clinical services.

CONCLUSIONS

The potential to improve outcomes for young people via technology-based enhancement to interventions is enormous. Enhancing communication between young people and their clinicians about symptoms and treatment progress and increasing access to timely and evidence-based interventions are desirable outcomes. To achieve positive outcomes for young people using technology- (app) based interventions, it is critical to understand and incorporate, in a meaningful way, the expectations and motivations of both young people and clinicians.

The relationship between entrapment and suicidal behavior through the lens of the integrated motivational-volitional model of suicidal behavior

Suicide and suicidal behavior are major public health concerns. As a result, a number of psychological models have been developed to better understand the emergence of suicidal ideation and suicide attempts. One such model is the integrated motivational-volitional model, a tri-partite model of suicidal behavior, which posits that entrapment is central to the final common pathway to suicide. In this review, we summarize the extant research evidence for the relationship between entrapment and suicidal ideation and behavior. Although there is robust evidence for the relationship between entrapment and suicidal ideation and behavior, there are gaps in our knowledge. We discuss the clinical implications and suggest key directions for future research.