Best practice for integrating digital interventions into clinical care for young people at risk of suicide: a Delphi study.

BACKGROUND: Digital tools have the capacity to complement and enhance clinical care for young people at risk of suicide. Despite the rapid rise of digital tools, their rate of integration into clinical practice remains low. The poor uptake of digital tools may be in part due to the lack of best-practice guidelines for clinicians and services to safely apply them with this population. METHODS: A Delphi study was conducted to produce a set of best-practice guidelines for clinicians and services on integrating digital tools into clinical care for young people at risk of suicide. First, a questionnaire was developed incorporating action items derived from peer-reviewed and grey literature, and stakeholder interviews with 17 participants. Next, two independent expert panels comprising professionals (academics and clinical staff; n = 20) and young people with lived experience of using digital technology for support with suicidal thoughts and behaviours (n = 29) rated items across two consensus rounds. Items reaching consensus (rated as "essential" or "important" by at least 80% of panel members) at the end of round two were collated into a set of guidelines. RESULTS: Out of 326 individual items rated by the panels, 188 (57.7%) reached consensus for inclusion in the guidelines. The endorsed items provide guidance on important topics when working with young people, including when and for whom digital tools should be used, how to select a digital tool and identify potentially harmful content, and identifying and managing suicide risk conveyed via digital tools. Several items directed at services (rather than individual clinicians) were also endorsed. CONCLUSIONS: This study offers world-first evidence-informed guidelines for clinicians and services to integrate digital tools into clinical care for young people at risk of suicide. Implementation of the guidelines is an important next step and will hopefully lead to improved uptake of potentially helpful digital tools in clinical practice.

A Review of Systematic Reviews: Gatekeeper Training for Suicide Prevention with a Focus on Effectiveness and Findings.

OBJECTIVES: Suicide prevention gatekeeper training (GKT) is considered an important component of an overall suicide-prevention strategy. The primary aim of this study was to conduct the first robust review of systematic reviews of GKT to examine the overall effectiveness of GKT on knowledge, self-efficacy, attitudes, behavioral intentions, and behavioral change. The study also examined the extent to which outcomes were retained long term, the frequency of refresher sessions, and the effectiveness of GKT with Indigenous populations and e-learning delivery. METHODS: For this review of reviews, MEDLINE, PsycINFO, Embase; and the Cochrane Database of Systematic Reviews were searched. ROBIS was applied to assess risk of bias and findings were synthesized using narrative synthesis. RESULTS: Six systematic reviews were included comprising 61 studies, of which only 10 were randomized controlled trials (RCTs). Immediate positive effects of GKT on knowledge, skills, and self-efficacy were confirmed, including for interventions tailored for Indigenous communities. Evidence was mixed for change in attitude; few studies measured e-learning GKT, retention of outcomes, booster sessions, behavioral intentions, and behavioral change, with some positive results. CONCLUSIONS: Evidence supports the immediate effects of GKT but highlights a need for more high-quality RCTs, particularly for Indigenous and e-learning GKT. This review identified a concerning lack of long-term follow-up assessments at multiple time points, which could capture behavioral change and a significant gap in studies focused on post-training interventions that maintain GKT effects over time.

This first review of systematic reviews for GKT confirmed positive effects for GKT, although mixed evidence exists for changes in attitude.Very few studies include long-term measurement of retention of outcomes and what facilitates retention.There is an urgent need for more research into the effectiveness of GKT with Indigenous populations and e-learning GKT.

Exploring Counselor Practices and Risk Assessment in a Proactive Digital Intervention Through Instagram in Young People: Qualitative Study.

BACKGROUND: Suicide is one of the leading causes of preventable death in young people, and the way young people are communicating suicidality has evolved to include web-based disclosures and help-seeking. To date, mental health intervention services, both on the web and in person, have been conceived in the traditional model, whereby support is provided if a young person (or their family) actively seeks out that support when distressed. On the other hand, proactive outreach is an innovative approach to intervention that has been shown to be effective in other areas of health care. Live for Tomorrow chat was delivered on Instagram and comprised of counselors who reach out to provide brief person-centered intervention to young people who post content indicating distress or suicidality. OBJECTIVE: Our aim was to explore how counselors engaged young people in a proactive digital intervention and how risk assessment was conducted in this context. METHODS: We analyzed 35 transcripts of conversations between counselors and young people aged 13-25 years using the 6-step approach of Braun and Clarke's reflexive thematic analysis. These transcripts included a counseling intervention and a follow-up chat that was aimed at collecting feedback about the counseling intervention. RESULTS: A total of 7 themes emerged: using microskills to facilitate conversations, building confidence and capacity to cope with change, seeking permission when approaching conversations about suicidality or self-harm, conversations about suicidality following a structured approach, providing assurances of confidentiality, validation of the experience of suicidality, and using conversations about suicidality to identify interventions. Counselors were able to translate counseling microskills and structured questioning regarding suicidality into a digital context. In particular, in the digital context, counselors would use the young person's post and emojis to further conversations and build rapport. CONCLUSIONS: The findings highlight the importance of the counselor's role to listen, empathize, validate, and empower young people and that all these skills can be transferred to a digital text counseling intervention. Counselors used a structured approach to understanding suicidality in a permission-seeking, validating, and confidential manner to identify interventions with the young person. These practices allowed the conversation to move beyond traditional risk assessment practices to meaningful conversations about suicidality. Moving beyond traditional risk assessment practices and into conversations about suicidality allowed for the validation of the young person's experience and exploration of interventions and support that made sense and were seen to be helpful to the young person. This study highlighted the benefits of a proactive digital chat-based intervention, which is a novel approach to engaging with young people experiencing psychological distress and suicidality. Furthermore, this research demonstrates the feasibility and benefit of moving mental health intervention and support to a medium where young people are currently disclosing distress and intervening proactively.