E-Learning to Improve Suicide Prevention Practice Skills Among Undergraduate Psychology Students: Randomized Controlled Trial.

BACKGROUND: Despite increasing evidence of the effectiveness of digital learning solutions in higher vocational education, including the training of allied health professionals, the impact of Web-based training on the development of practical skills in psychiatry and psychology, in general, and in suicide prevention, specifically, remains largely understudied. OBJECTIVE: This study aimed to determine the effectiveness of an electronic learning (e-learning) module on the adherence to suicide prevention guidelines, knowledge of practical skills, and provider's confidence to have a conversation about suicidal behavior with undergraduate psychology students. METHODS: The e-learning module, comprising video recordings of therapist-patient interactions, was designed with the aim of transferring knowledge about suicide prevention guideline recommendations. The program's effects on guideline adherence, self-evaluated knowledge, and provider's confidence were assessed using online questionnaires before the program (baseline and at 1 month [T1] and 3 months after baseline). The eligible third- and fourth-year undergraduate psychology students were randomly allocated to the e-learning (n=211) or to a waitlist control condition (n=187), with access to the intervention after T1. RESULTS: Overall, the students evaluated e-learning in a fairly positive manner. The intention-to-treat analysis showed that the students in the intervention condition (n=211) reported higher levels of self-evaluated knowledge, provider's confidence, and guideline adherence than those in the waitlist control condition (n=187) after receiving the e-learning module (all P values<.001). When comparing the scores at the 1- and 3-month follow-up, after both groups had received access to the e-learning module, the completers-only analysis showed that the levels of knowledge, guideline adherence, and confidence remained constant (all P values>.05) within the intervention group, whereas a significant improvement was observed in the waitlist control group (all P values<.05). CONCLUSIONS: An e-learning intervention on suicide prevention could be an effective first step toward improved knowledge of clinical skills. The learning outcomes of a stand-alone module were found to be similar to those of a training that combined e-learning with a face-to-face training, with the advantages of flexibility and low costs.

Effectiveness of a Web-Based Self-Help Program for Suicidal Thinking in an Australian Community Sample: Randomized Controlled Trial.

BACKGROUND: Treatment for suicidality can be delivered online, but evidence for its effectiveness is needed. OBJECTIVE: The goal of our study was to examine the effectiveness of an online self-help intervention for suicidal thinking compared to an attention-matched control program. METHODS: A 2-arm randomized controlled trial was conducted with assessment at postintervention, 6, and, 12 months. Through media and community advertizing, 418 suicidal adults were recruited to an online portal and were delivered the intervention program (Living with Deadly Thoughts) or a control program (Living Well). The primary outcome was severity of suicidal thinking, assessed using the Columbia Suicide Severity Rating Scale. RESULTS: Intention-to-treat analyses showed significant reductions in the severity of suicidal thinking at postintervention, 6, and 12 months. However, no overall group differences were found. CONCLUSIONS: Living with Deadly Thoughts was of no greater effectiveness than the control group. Further investigation into the conditions under which this program may be beneficial is now needed. Limitations of this trial include it being underpowered given the effect size ultimately observed, a high attrition rate, and the inability of determining suicide deaths or of verifying self-reported suicide attempts. TRIAL REGISTRATION: Australian New Zealand Clinical Trials Registry ACTRN12613000410752; https://www.anzctr.org.au/ Trial/Registration/TrialReview.aspx?id=364016 (Archived by WebCite at http://www.webcitation.org/6vK5FvQXy); Universal Trial Number U1111-1141-6595.

Trajectories of Suicidal Ideation in People Seeking Web-Based Help for Suicidality: Secondary Analysis of a Dutch Randomized Controlled Trial.

BACKGROUND: Suicidal ideation (SI) is a common mental health problem. Variability in intensity of SI over time has been linked to suicidal behavior, yet little is known about the temporal course of SI. OBJECTIVE: The primary aim was to identify prototypical trajectories of SI in the general population and, secondarily, to examine whether receiving Web-based self-help for SI, psychiatric symptoms, or sociodemographics predicted membership in the identified SI trajectories. METHODS: We enrolled 236 people, from the general Dutch population seeking Web-based help for SI, in a randomized controlled trial comparing a Web-based self-help for SI group with a control group. We assessed participants at inclusion and at 2, 4, and 6 weeks. The Beck Scale for Suicide Ideation was applied at all assessments and was included in latent growth mixture modeling analysis to empirically identify trajectories. RESULTS: We identified 4 SI trajectories. The high stable trajectory represented 51.7% (122/236) of participants and was characterized by constant high level of SI. The high decreasing trajectory (50/236, 21.2%) consisted of people with a high baseline SI score followed by a gradual decrease to a very low score. The third trajectory, high increasing (12/236, 5.1%), also had high initial SI score, followed by an increase to the highest level of SI at 6 weeks. The fourth trajectory, low stable (52/236, 22.0%) had a constant low level of SI. Previous attempted suicide and having received Web-based self-help for SI predicted membership in the high decreasing trajectory. CONCLUSIONS: Many adults experience high persisting levels of SI, though results encouragingly indicate that receiving Web-based self-help for SI increased membership in a decreasing trajectory of SI.

Efficacy of Adolescent Suicide Prevention E-Learning Modules for Gatekeepers: A Randomized Controlled Trial.

BACKGROUND: Face-to-face gatekeeper training can be an effective strategy in the enhancement of gatekeepers' knowledge and self-efficacy in adolescent suicide prevention. However, barriers related to access (eg, time, resources) may hamper participation in face-to-face training sessions. The transition to a Web-based setting could address obstacles associated with face-to-face gatekeeper training. Although Web-based suicide prevention training targeting adolescents exists, so far no randomized controlled trials (RCTs) have been conducted to investigate their efficacy. OBJECTIVE: This RCT study investigated the efficacy of a Web-based adolescent suicide prevention program entitled Mental Health Online, which aimed to improve the knowledge and self-confidence of gatekeepers working with adolescents (12-20 years old). The program consisted of 8 short e-learning modules each capturing an important aspect of the process of early recognition, guidance, and referral of suicidal adolescents, alongside additional information on the topic of (adolescent) suicide prevention. METHODS: A total of 190 gatekeepers (ages 21 to 62 years) participated in this study and were randomized to either the experimental group or waitlist control group. The intervention was not masked. Participants from both groups completed 3 Web-based assessments (pretest, posttest, and 3-month follow-up). The outcome measures of this study were actual knowledge, and participants' ratings of perceived knowledge and perceived self-confidence using questionnaires developed specifically for this study. RESULTS: The actual knowledge, perceived knowledge, and perceived self-confidence of gatekeepers in the experimental group improved significantly compared to those in the waitlist control group at posttest, and the effects remained significant at 3-month follow-up. The overall effect sizes were 0.76, 1.20, and 1.02, respectively, across assessments. CONCLUSIONS: The findings of this study indicate that Web-based suicide prevention e-learning modules can be an effective educational method to enhance knowledge and self-confidence of gatekeepers with regard to adolescent suicide prevention. Gatekeepers with limited time and resources can benefit from the accessibility, simplicity, and flexibility of Web-based training. TRIAL REGISTRATION: Netherlands Trial Register NTR3625; http://www.trialregister.nl/trialreg/admin/rctview.asp?TC=3625 (Archived by WebCite at http://www.webcitation.org/6eHvyRh6M).

Applying computer adaptive testing to optimize online assessment of suicidal behavior: a simulation study.

BACKGROUND: The Internet is used increasingly for both suicide research and prevention. To optimize online assessment of suicidal patients, there is a need for short, good-quality tools to assess elevated risk of future suicidal behavior. Computer adaptive testing (CAT) can be used to reduce response burden and improve accuracy, and make the available pencil-and-paper tools more appropriate for online administration. OBJECTIVE: The aim was to test whether an item response-based computer adaptive simulation can be used to reduce the length of the Beck Scale for Suicide Ideation (BSS). METHODS: The data used for our simulation was obtained from a large multicenter trial from The Netherlands: the Professionals in Training to STOP suicide (PITSTOP suicide) study. We applied a principal components analysis (PCA), confirmatory factor analysis (CFA), a graded response model (GRM), and simulated a CAT. RESULTS: The scores of 505 patients were analyzed. Psychometric analyses showed the questionnaire to be unidimensional with good internal consistency. The computer adaptive simulation showed that for the estimation of elevation of risk of future suicidal behavior 4 items (instead of the full 19) were sufficient, on average. CONCLUSIONS: This study demonstrated that CAT can be applied successfully to reduce the length of the Dutch version of the BSS. We argue that the use of CAT can improve the accuracy and the response burden when assessing the risk of future suicidal behavior online. Because CAT can be daunting for clinicians and applied scientists, we offer a concrete example of our computer adaptive simulation of the Dutch version of the BSS at the end of the paper.

Unbearable suffering and requests for euthanasia prospectively studied in end-of-life cancer patients in primary care.

BACKGROUND: An international discussion about whether or not to legally permit euthanasia and (or) physician assisted suicide (EAS) is ongoing. Unbearable suffering in patients may result in a request for EAS. In the Netherlands EAS is legally permitted, and unbearable suffering is one of the central compulsory criteria. The majority of EAS is performed in cancer patients in the primary care practice. In around one in every seven end-of-life cancer patients dying in the primary care setting EAS is performed. The prevalence of unbearable symptoms and overall unbearable suffering in relationship to explicit requests for EAS was studied in a cohort of end-of-life cancer patients in primary care. METHODS: A prospective study in primary care cancer patients estimated to die within six months was performed. Every two months suffering was assessed with the State-of-Suffering V (SOS-V). The SOS-V is a comprehensive instrument for quantitative and qualitative assessment of unbearable suffering related to 69 physical, psychological and social symptoms in five domains. RESULTS: Out of 148 patients who were asked to participate 76 (51%) entered the study. The studied population were 64 patients who were followed up until death; 27% explicitly requested EAS, which was performed in 8% of the patients. The final interview per patient was analyzed; in four patients the SOS-V was missing. Unbearable symptoms were present in 94% of patients with an explicit request for EAS and in 87% of patients without an explicit request. No differences were found in the prevalence of unbearable suffering for physical, psychological, social and existential symptoms, nor for overall unbearable suffering, between patients who did or who did not explicitly request EAS. CONCLUSIONS: In a population of end-of-life cancer patients cared for in primary care no differences in unbearable suffering were found between patients with and without explicit requests for EAS. The study raises the question whether unbearable suffering is the dominant motive to request for EAS. Most patients suffered from unbearable symptoms, indicating that the compulsory criterion of unbearable suffering may be met a priori in most end-of-life cancer patients dying at home, whether they request EAS or not.

The broad spectrum of unbearable suffering in end-of-life cancer studied in dutch primary care.

BACKGROUND: Unbearable suffering most frequently is reported in end-of-life cancer patients in primary care. However, research seldom addresses unbearable suffering. The aim of this study was to comprehensively investigate the various aspects of unbearable suffering in end-of-life cancer patients cared for in primary care. METHODS: Forty four general practitioners recruited end-of-life cancer patients with an estimated life expectancy of half a year or shorter. The inclusion period was three years, follow-up lasted one additional year. Practices were monitored bimonthly to identify new cases. Unbearable aspects in five domains and overall unbearable suffering were quantitatively assessed (5-point scale) through patient interviews every two months with a comprehensive instrument. Scores of 4 (serious) or 5 (hardly can be worse) were defined unbearable. The last interviews before death were analyzed. Sources providing strength to bear suffering were identified through additional open-ended questions. RESULTS: Seventy six out of 148 patients (51%) requested to participate consented; the attrition rate was 8%, while 8% were alive at the end of follow-up. Sixty four patients were followed up until death; in 60 patients interviews were complete. Overall unbearable suffering occurred in 28%. A mean of 18 unbearable aspects was present in patients with serious (score 4) overall unbearable suffering. Overall, half of the unbearable aspects involved the domain of traditional medical symptoms. The most frequent unbearable aspects were weakness, general discomfort, tiredness, pain, loss of appetite and not sleeping well (25%-57%). The other half of the unbearable aspects involved the domains of function, personhood, environment, and nature and prognosis of disease. The most frequent unbearable aspects were impaired activities, feeling dependent, help needed with housekeeping, not being able to do important things, trouble accepting the situation, being bedridden and loss of control (27%-55%). The combination of love and support was the most frequent source (67%) providing strength to bear suffering. CONCLUSIONS: Overall unbearable suffering occurred in one in every four end-of-life cancer patients. Half of the unbearable aspects involved medical symptoms, the other half concerned psychological, social and existential dimensions. Physicians need to comprehensively assess suffering and provide psychosocial interventions alongside physical symptom management.