Internet-Based Cognitive Behavioral Therapy to Reduce Suicidal Ideation

Abstract

IMPORTANCESuicidal ideation is a widespread phenomenon. However, many individuals at risk for suicide do not seek treatment, which might be addressed by providing low-threshold, internetbased self-help interventions. OBJECTIVE To investigate whether internet-based self-help interventions directly targeting suicidal ideation or behavior are associated with reductions in suicidal ideation. DATA SOURCES 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. STUDY SELECTION 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.DATA EXTRACTION AND SYNTHESIS 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 randomeffects model. MAIN OUTCOMES AND MEASURESSuicidal ideation was the a priori primary outcome. RESULTS 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 (I 2 = 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; I 2 = 36%). Studies did not report sufficient data on completed suicides and suicide attempts to assess potential associations. CONCLUSIONS AND RELEVANCEThese results show that iCBT interventions are associated with significant reductions in suicidal ideation compared with control conditions. Considering their high (continued)

Effectiveness of Internet- and Mobile-Based Cognitive Behavioral Therapy to Reduce Suicidal Ideation and Behaviors: Protocol for a Systematic Review and Meta-Analysis of Individual Participant Data

“…As many individuals who experience suicidal ideation will transit to suicidal behavior [ 2 ], safe and effective treatment options are required. There is some emerging evidence that iCBT for SIB might be effective in reducing suicidal ideation [ 27 , 28 , 29 , 34 ]. However, the confidence in the effectiveness of iCBT is limited because the effect sizes are small, there are low levels of treatment adherence, and there might be imprecisions in effect estimates.…”

“…In addition, it remains unclear whether treatment adherence can be predicted by characteristics of participants or interventions. Thus, the present protocol outlines the methods of a planned study that will extend knowledge derived from previous meta-analyses [ 27 , 28 , 29 , 34 ] by analyzing individual participant data. Thereby, this IPD-MA will provide an effect estimate while controlling for participant-level covariates and offering novel insights into differential effects on participant level.…”

“…Previous systematic reviews and meta-analyses found mixed results for their effectiveness. Some reviews suggest that they might be effective in reducing suicidal ideation [ 27 , 28 , 29 , 30 , 31 ], with effect sizes in meta-analyses of randomized controlled trials ranging from Hedges’ g = −0.23, 95% CI −0.35 to −0.11 [ 27 ] to g = −0.29, 95% CI −0.40 to −0.19 [ 28 ] at post-intervention. Other reviews, however, did not find significant positive effects on suicidal ideation [ 32 , 33 , 34 ].…”

“…Other reviews, however, did not find significant positive effects on suicidal ideation [ 32 , 33 , 34 ]. Low treatment adherence further limits the confidence in the benefits of this new treatment approach for clinical practice [ 27 , 28 , 29 ].…”

Factors influencing suicidal ideation among female late adolescents from a Korean rural province

“…프로그램을 사용하여 유의수준(α)= 0.05, 독립 변인 7개(우울, 주관적 안녕, 주변 사람의 자살, 구체적 자살 동기, 연령, 소득, 폭력 경험), 효과 크기 0.15, 검정력 0.80 기준으로 회 귀분석 표본 크기를 산출하였을 때 103명이었다. 효과 크기는 자살 생각 관련 메타 분석의 Hedge's g값을 참조하였다[13]. 본 연구에 서는 청소년 자살관련 선행연구의 응답률인 40%와 68%의 응답률 평균을 사용하여[14] 200명의 대상자에게 설문지를 배부하고 197 명(회수율 98.5%)의 자료를 분석하였다.…”