Review articleSuicide risk management in research on internet-based interventions for depression: A synthesis of the current state and recommendations for future research
Introduction
Depression is highly prevalent, affecting approximately 350 million people worldwide at any given moment and is associated with a range of negative outcomes, including suicide (Ferrari et al., 2013). Indeed, individuals with depression are at 25 times increased risk of suicide compared to the general population (American Association of Suicidology, 2014). The assessment and management of suicidality, suicidal ideation and behavior (Silverman, 2006), is therefore a major consideration in treating individuals suffering from depression, and best-practice guidelines for the treatment of depression regularly provide information on the management of suicidal ideation and behavior (American Psychiatric Association, 2003; DGPPN, 2015; National Institute for Health and Care (NICE), 2009).
Over the past two decades, the use of the internet in health care has continuously evolved (Ebert et al., 2018; Wicks et al., 2014), and in recent years there has been an increasing number of randomized controlled trials (RCTs) showing good evidence for the efficacy of internet-based interventions (IBIs) for the treatment and prevention of depression (Karyotaki et al., 2018, 2017; Königbauer et al., 2017; Sander et al., 2016). IBIs can either be provided with human support and guidance via e-mail, chat, webcam or telephone or as strictly self-help interventions without human support (Barak et al., 2009). Human guidance has repeatedly been shown to improve the effectiveness of IBIs (Baumeister et al., 2014; Domhardt et al., 2019).
Given that IBIs differ in many aspects from face-to-face interventions, for example in the amount and nature of contact with therapists (Baumeister et al., 2014; Ebert et al., 2018), recommendations for the management of suicidality in face-to-face practice might not be applicable to the online setting. This can lead to uncertainties in the application of correct management of suicide risk in IBIs in clinical practice, but also in research in this area. In intervention research, issues like concerns for participant safety, methodological complications, resistance from review boards and burden on researchers are well known and have led to the exclusion of participants who experience suicidal ideation (Fisher et al., 2002; Hom et al., 2017; Lakeman and FitzGerald, 2009; Oquendo et al., 2004; Pearson et al., 2001; Raison et al., 2007; Sisti and Joffe, 2018). Regarding IBI for depression, the exclusion of such individuals, however, can lead to the creation of an evidence base that is not representative of individuals who experience depression (Sisti and Joffe, 2018; Zimmerman et al., 2005). To the best of our knowledge, there is to date no systematic research on how to manage suicidality in the novel field of internet-based therapy. A better understanding of how to best manage participants with suicide thoughts may help researchers, clinicians and review boards as well as depressed individuals with suicide thoughts that seek help from IBIs.
Thus, this study aimed to: (a) examine current inclusion and exclusion practices pertaining to individuals at risk of suicide in IBIs for depression; (b) consult researchers in the field on their experiences and recommendations regarding the management of suicidality in their studies; and (c) provide recommendations for future research on internet interventions for depression.
Section snippets
Methods
This study is based on a review of current literature, an online questionnaire, and subsequent telephone interviews. We used a mixed methods approach including a qualitative content analysis and descriptive statistics.
Results
Literature review. Table 1 provides an overview of the suicidality-related information of the 24 included studies. Seven studies did not exclude individuals at risk of suicide. With regard to the assessment of suicide risk, five studies exclusively used single items of self-report rating scales of the Patient Health Questionnaire (PHQ-9) (Kroenke et al., 2001) or the Beck Depression Inventory (BDI) (Beck et al., 1961), four studies exclusively used structured clinical interviews (e.g.
Discussion
This paper presents a comprehensive overview of current practices concerning the management of suicidality in trials of IBIs for depression by employing multiple methods including a review of literature, an online survey and follow-up interviews. Our sample consisted of researchers from eight different countries and three continents, representative to a broad range of international perspectives.
The identified studies differed concerning frequency of assessments, inclusion and exclusion
Conclusion
In conclusion, to the best of our knowledge, this is the first study to examine procedures to manage suicidality in research trials on IBIs for depression. The results show that the management procedures for participants with suicidal thoughts differ between studies and that the majority of studies exclude participants at risk of suicide. To exclude participants with suicide thoughts in IBI trials will limit the studies' external validity (Sisti and Joffe, 2018). However, concerns for the
CRediT authorship contribution statement
Lasse Sander: Conceptualization, Data curation, Formal analysis, Methodology, Project administration, Writing - original draft, Writing - review & editing. Katharina Gerhardinger: Data curation, Formal analysis, Methodology, Writing - original draft, Writing - review & editing. Eleanor Bailey: Methodology, Writing - review & editing. Jo Robinson: Methodology, Writing - review & editing. Jiaxi Lin: Data curation, Methodology, Writing - review & editing. Pim Cuijpers: Data curation, Supervision,
Declaration of Competing Interest
The authors have no conflicts of interest to disclose.
Acknowledgments
The article processing charge was funded by the German Research Foundation (DFG) and the University of Freiburg in the funding program Open Access Publishing.
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