Elsevier

Journal of Affective Disorders

Volume 263, 15 February 2020, Pages 676-683
Journal of Affective Disorders

Review article
Suicide risk management in research on internet-based interventions for depression: A synthesis of the current state and recommendations for future research

https://doi.org/10.1016/j.jad.2019.11.045Get rights and content

Highlights

  • Most trials exclude individuals who report some level of suicidal ideation from participation, which limits the generalizability of results.

  • Suicidal ideation is rarely specifically addressed in internet-based treatments for depression.

  • We provide recommendations on how to increase participants´ safety in internet-based trials for depression.

Abstract

Background

The number of studies examining internet-based interventions (IBIs) for depression is increasing. Although many individuals with depression experience suicidal ideation, there is only insufficient information available on how to manage and support individuals at risk of suicide in IBI trials. Here, we examined the current practice regarding the management of individuals experiencing suicidal thoughts or behaviors in studies of IBIs for depression.

Methods

Information pertaining to the management of suicidality was extracted from 24 studies. Additionally, researchers in the field completed a questionnaire (n = 13) before being interviewed (n = 11) about their procedures and considerations regarding the management of suicidality.

Results

In most trials (N = 17; 71%), individuals at risk of suicide were excluded based on varying criteria. N = 7 studies used structured interviews and N = 5 studies used single items of self-report questionnaires for assessing suicidality. The nature and degree of support provided to individuals at risk of suicide varied and only one intervention comprised suicide-specific content.

Limitations

Most experts referred to research on interventions with some level of human support (e.g. written feedback) which might limit the representativeness of the results of the interviews for unguided interventions.

Conclusions

Suicidality is often treated more as an exclusion criterion rather than a treatable condition in research on IBIs for depression. This paper provides an overview of the current practice and gives recommendations for the design of future trials.

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.

References (60)

  • N. Titov et al.

    Clinical and cost-effectiveness of therapist-guided internet-delivered cognitive behavior therapy for older adults with symptoms of depression: a randomized controlled trial

    Behav. Ther.

    (2015)
  • American Association of Suicidology, 2014. Depression and suicide risk [WWW Document]....
  • Practice guideline for the assessment and treatment of patients with suicidal behaviors

    Am. J. Psychiatry

    (2003)
  • A. Barak et al.

    Defining internet-supported therapeutic interventions

    Ann. Behav. Med.

    (2009)
  • A.T. Beck et al.

    Scale for suicide ideation: psychometric properties of a self-report version

    J. Clin. Psychol.

    (1988)
  • A.T. Beck et al.

    An inventory for measuring depression

    Arch. Gen. Psychiatry

    (1961)
  • C. Buntrock et al.

    Effectiveness of a web-based cognitive behavioural intervention for subthreshold depression: pragmatic randomised controlled trial

    Psychother. Psychosom.

    (2015)
  • S3-Leitlinie. Nationale Versorgungsleitlinie Unipolare Depression Langfassung

    Ärztliches Zent. für Qual. der Medizin

    (2015)
  • M. Domhardt et al.

    Internet- and mobile-based interventions for anxiety disorders: a meta-analytic review of intervention components

    Depress. Anxiety

    (2019)
  • D.D. Ebert et al.

    Efficacy of an internet-based problem-solving training for teachers: results of a randomized controlled trial

    Scand. J. Work. Environ. Heal.

    (2014)
  • D.D. Ebert et al.

    Internet- and mobile-mased psychological interventions: applications, efficacy, and potential for improving mental health

    Eur. Psychol.

    (2018)
  • A.J. Ferrari et al.

    Burden of depressive disorders by country, sex, age, and year: findings from the global burden of disease study 2010

    PLoS Med

    (2013)
  • M. First et al.

    Structured Clinical Interview for DSM-5 - Research Version (SCID-5-RV)

    (2015)
  • C.B. Fisher et al.

    Ethical issues in including suicidal individuals in clinical research

    IRB Ethics Hum. Res.

    (2002)
  • L. Gega et al.

    Screening people with anxiety/depression for suitability for guided self-help

    Cogn. Behav. Ther.

    (2005)
  • A.S. Geraedts et al.

    Short-term effects of a web-based guided self-help intervention for employees with depressive symptoms: randomized controlled trial

    J. Med. Internet Res.

    (2014)
  • S. Gilbody et al.

    Computerised cognitive behaviour therapy (cCBT) as treatment for depression in primary care (REEACT trial): large scale pragmatic randomised controlled trial

    BMJ

    (2015)
  • M. Hallgren et al.

    Physical exercise and internet-based cognitive-behavioural therapy in the treatment of depression: Randomised controlled trial

    Br. J. Psychiatry

    (2015)
  • M.A. Hom et al.

    Ethical issues and practical challenges in suicide research: collaboration with institutional review boards

    Crisis

    (2017)
  • K. Imamura et al.

    Effects of an Internet-based cognitive behavioral therapy (iCBT) program in Manga format on improving subthreshold depressive symptoms among healthy workers: a randomized controlled trial

    PLoS One

    (2014)
  • Cited by (20)

    View all citing articles on Scopus
    View full text