Abstract
Suicidal ideation is a widespread phenomenon. However, many individuals at risk for suicide do not seek treatment, which might be addressed by providing low-threshold, internet-based self-help interventions. To investigate whether internet-based self-help interventions directly targeting suicidal ideation or behavior are associated with reductions in suicidal ideation. A systematic search of PsycINFO, MEDLINE, Cochrane Central Register of Controlled Trials (CENTRAL), and the Centre for Research Excellence of Suicide Prevention (CRESP) databases for trials from inception to April 6, 2019, was performed, supplemented by reference searches. Search strings consisted of various search terms related to the concepts of internet, suicide, and randomized clinical trials. Two independent researchers reviewed titles, abstracts, and full texts. Randomized clinical trials evaluating the effectiveness of internet-based self-help interventions to reduce suicidal ideation were included. Interventions were eligible if they were based on psychotherapeutic elements. Trials had to report a quantitative measure of a suicide-specific outcome. Mobile-based and gatekeeper interventions were excluded; no further restrictions were placed on participant characteristics or date of publication. This study followed the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) reporting guidelines. Risk of bias was evaluated using the Cochrane Risk of Bias Tool. Standardized mean differences were calculated using a random-effects model. Suicidal ideation was the a priori primary outcome. Six unique eligible trials (1567 unique participants; 1046 [66.8%] female; pooled mean [SD] age, 36.2 [12.5] years) were included in the systematic review and meta-analysis. All identified interventions were internet-based cognitive behavioral therapy (iCBT). Participants assigned to the iCBT condition experienced a significantly reduced suicidal ideation compared with controls following intervention in all 6 trials (standardized mean difference, -0.29; 95% CI, -0.40 to -0.19; P < .001). Heterogeneity was low (I2 = 0%). The effect appeared to be maintained at follow-up in 4 trials (standardized mean difference, -0.18; 95% CI, -0.34 to -0.02; P = .03; I2 = 36%). Studies did not report sufficient data on completed suicides and suicide attempts to assess potential associations. These results show that iCBT interventions are associated with significant reductions in suicidal ideation compared with control conditions. Considering their high scalability, iCBT interventions have the potential to reduce suicide mortality. Future research should assess the effect of these digital health interventions on suicidal behavior and identify moderators and mediators to advance understanding of the mechanisms of effectiveness of these interventions.
Highlights
Suicidal ideation is a common phenomenon[1,2,3,4,5] that often precedes suicide attempts and suicide deaths.[1]
Participants assigned to the internet-based cognitive behavioral therapy (iCBT) condition experienced a significantly reduced suicidal ideation compared with controls following intervention in all 6 trials
Studies did not report sufficient data on completed suicides and suicide attempts to assess potential associations. These results show that iCBT interventions are associated with significant reductions in suicidal ideation compared with control conditions
Summary
Suicidal ideation is a common phenomenon[1,2,3,4,5] that often precedes suicide attempts and suicide deaths.[1] suicidal ideation may be an important target for suicide prevention efforts, as an indicator for early detection and intervention to avoid or reduce nonfatal and fatal outcomes.[6,7] Cognitive behavioral therapy (CBT), including dialectical behavioral therapy, has been shown to be effective in the reduction of suicidal ideation and behaviors.[8] Cognitive behavioral therapy is based on the assumption that cognitions play a central role in the development and maintenance of mental health issues and that emotional and behavioral problems can be resolved by modifying dysfunctional thoughts.[9] effective treatments are available,[8,10,11] many individuals at risk of suicide do not receive professional help.[12] Barriers to treatment seeking in suicidal individuals include the wish to solve the problem by oneself, the belief that the problem is not that severe, stigma, limited access to treatment, and financial issues.[12]
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