Now Matters Now: An Online Suicide Prevention Program

Reducing the risk of suicide attempt and suicide is a public health priority. There has been
no substantial decrease in suicide for the past two decades. Prevention efforts to date have
focused on primary (e.g. public service announcements) and tertiary (e.g. interventions
following suicide attempt) methods. Secondary or indicated prevention has been relatively
unexplored. Secondary prevention requires both accurate screening methods and effective
interventions. These essential elements are now available. Our recent research demonstrates
that responses to the suicidal ideation item of the PHQ depression scale are a powerful
predictor of subsequent suicide attempt and death. Availability of the PHQ in electronic
medical records creates an opportunity for accurate population-level screening. Dialectical
behavior therapy (DBT) has strong evidence of tertiary efficacy for preventing suicide
attempts in clinical populations. Brief outreach tertiary interventions such as caring
messages have some evidence for preventing suicide attempts. These clinical or tertiary
prevention interventions provide the best available evidence for use in building secondary
prevention programs. Resulting programs could then be linked to population-level screening
data in electronic medical records. The first goal of the research plan is to adapt DBT and
caring messages to fit delivery models suitable for the large numbers of at-risk patients
identifiable in healthcare settings. The second goal is to evaluate the feasibility,
acceptability, and safety of these alternative online suicide and self-injury secondary
prevention programs. Online delivery models are suitable because they are scalable and can be
provided securely, cheaply, and utilizing existing systems in healthcare. Three brief online
interventions will be evaluated: caring email (CE); CE + DBT online program; and CE + DBT
online program + coach. Each intervention will supplement usual care among high- risk
patients identified via PHQ depression scales collected at outpatient primary care and mental
health visits. Intervention content will be drawn from the principles of DBT and caring
messages. The study design will be additive in order to examine alternative intervention
models that vary widely in resources required for large- scale delivery. However, these
interventions will require vastly fewer resources than in-person or telephone interventions.
The project will involve intervention feasibility (pretesting, N=60) and acceptability and
safety testing (pilot, N=400). Acceptability wll be assessed by patient intervention
engagement levels (requiring the large pilot sample) and qualitative/formative intervention
feedback from patients. Safety will be assessed via rates of psychiatric hospitalizations and
self-injury diagnoses in the medical record in the intervention conditions compared to those
receiving just continued usual care. Results of the pilot study will inform the design of a
full-scale effectiveness trial examining the impact of one or more of these interventions on
risk of suicide attempt and/or suicide death.

Inclusion Criteria:

1. Group Health members who are ID verified for secure email messaging

2. Age 18 or older

3. Results of PHQ assessment completed with a medical provider (Group Health primary care
or mental health) as part of ongoing care indicate increased risk for self-injury
(item 9, 2 or 3 response)

Exclusion Criteria:

1. Patient has had a recent self-injury (past 60 days), as a more traditional clinical
intervention would be more appropriate.