Exploring the use of the internet in relation to suicidal behaviour: identifying priorities for prevention

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1 Exploring the use of the internet in relation to suicidal behaviour: identifying priorities for prevention Dr Lucy Biddle, Dr Jane Derges, Dr Carlie Goldsmith

2 Study team/ steering group Bristol University: Lucy Biddle, Jane Derges, Jenny Donovan, David Gunnell, Jon Heron, Becky Mars, Prianka Padmanathan, John Potokar Samaritans: Carlie Goldsmith, Stephanie Stace PAPYRUS: Martyn Piper Advisers: Rachel Holley, Chris O Sullivan Acknowledgements All material presented is drawn from independent research commissioned and funded by the Department of Health Policy Research Programme ( Exploring the Use of the Internet In Relation To Suicidal Behaviour: Identifying Priorities for Prevention, PRP023/0163). The views expressed in this talk are those of the authors and not necessarily those of the Department of Health. All study participants Bristol Liaison Psychiatry teams Bristol Self-Harm Surveillance Register ALSPAC

3 Minimising the risks of the internet while harnessing its potential for good is one of the most significant emerging challenges for suicide prevention

4 Study aim and objectives To provide detailed empirical evidence about the use of the internet for suicide-related purposes and how this influences suicidal feelings and behaviour Estimate the prevalence and patterning of suicide-related use Examine how, for what purpose and with what impact internet is used Describe content that is commonly accessed and how this is interpreted Obtain evaluations of online help provision Explore utility of asking patients about internet use during assessment

5 Overview of study design 1. Surveys of use Young adults (ALSPAC cohort) Hospital presenting patients (following suicide attempt) 2. In-depth interviews with users Conducted with multiple samples 3. Internet search study Content analysis of hits: 12 suicide-related search terms 4 search engines 4. Clinician focus groups Psychiatric liaison team staff

6 Survey of young adults Survey of 3946 young adults, aged 21yrs All young adults 22.5% reported some suicide-related use 9.1% discussed suicidal feelings on social media 7.5% used a search engine to access suicide content 8.2% viewed sites offering help/ support 3.1% viewed information about how to kill yourself Mars et al, JAD 2015

7 Percentage of sample No self-harm Self-harm Suicidal thoughts Suicidal plans Suicide attempts S/Sh related Internet use Sites offering help, advice or support Sites offering information on how to hurt/kill yourself Key points Suicide-related internet use is a marker of severity and potential risk Young people commonly turn to the internet for information and dialogue about suicide. Suicide attempters: 1 in 2 used search engine to find suicide information 1 in 3 discussed feelings online 1 in 5 viewed information about how to kill yourself Distressed young people access more helpful than harmful sites 7 03 March University 2017of

8 Patients presenting after a suicide attempt Data on suicide-related internet use collected by clinicians from 1198 patients during psychosocial assessment Use: reported by 8.4%; Purpose of use: Research suicide methods: 74.3% Buy poison/ drugs for overdose: 8.1% Search for help/ support: 5.4% associated with: Age: 11.8% amongst <25yrs; children s hospital data showed prevalence of 26% (age 8-17yrs) Intent: 24% in group with high suicidal intent Padmanathan et al, forthcoming

9 In-depth interviews 4 samples: Young adults (community-based); n=13 Patients who have attempted suicide (hospital-based); n=20 Adults recruited via Samaritans online survey (community-based); n=20 Bereaved informants of suicides with internet involvement recruited via PAPYRUS (community-based); n=10 Total n=63

10 Lower severity: Pessimistic browsing communicating Purpose: mixed - understand and manage feelings & explore suicide Gathering: broad and unstructured Processing: browsing stalled by emotional responses Put off of suicide by emotional response to content but low mood not resolved. Higher severity: Purposeful researching Purpose: specific find/ research methods Gathering: deliberate, structured and specific Processing: mining of details, used to evaluate and shop between methods Quest to develop expertise/ perfect method Information suggests undesirable details leading to ruling out some methods. Implementation/ trying out methods Highly distressed Distressed. Ambivalent/ uncertain about suicide Emotionality Sociability (desire to connect) Interest in Help Decision to pursue suicide Avoidance of help Detachment

11 Increasing physical accessibility 1. Internet informed attempts Examples Trying methods learnt or ideas formulated via searching/ browsing Discovering how to use everyday items Using to inform planning and effective implementation Obtaining physical means online

12 Increasing cognitive accessibility 2. Internet-based encouragement/ validation Examples Identifying good methods Normalising suicidal feelings Legitimising suicide as a course of action

13 But can also reduce accessibility Suicide revealed to be: Too hard (physical) Too terrible (cognitive)

14 Internet as a help resource Sub-group of participants reported positive impact of: Peer support / interaction as part of an online community Expressing feelings (incl. via blog writing) Use for distraction Web-based apps (eg. MoodScope) Several thought online activity had stopped them making an attempt.

15 Criticisms of formal help provision Impersonal, unemotional: like a shop window ; a face ; corporate ; the train leaves at ; not my safe space ; You can find information but that s all you can find Lacking immediacy and uniqueness: Suggesting unobtainable solutions Not age sensitive

16 Clinician focus groups 2 psychiatric liaison teams Groups exploring: 1. Acceptability 2. Clinical usefulness Padmanathan et al. 2016, forthcoming

17 Mostly acceptable, but: clinicians tended to build in or ask in a roundabout way some feared asking could be risky : could be alerting somebody to possibility they hadn t considered some did not always ask if patient acutely distressed Knowing about use seen as part of a jigsaw that could: enhance perceptions of risk and intent identify those actively planning Most clinicians unaware of use of specific sites to obtain methods information

18 Implications

19 Implications for internet industry Maintain ongoing prevention strategies to reduce risk (e.g. based on search algorithms, predictive searching, structuring search data) and partnerships (e.g. with Samaritans) Develop and promote safe internet use and digital citizenship

promote suicide or self-harm Wikipedia to review its policies/ guidelines to cover

20 internet industry cont d. Continue to explore ways to restrict access to sites/ chatrooms primarily existing to promote suicide or self-harm Wikipedia to review its policies/ guidelines to cover regulation of suicide-related content Hosts and moderators of blog sites and discussion forums to ensure policies and guidelines in place to cover suicide-related content

21 Implications for providers of online help Review and redesign formal help provision to: Focus on providing immediate responses within the online environment (rather than signposting) Provide age-appropriate material for young people Develop novel approaches to engage individuals in active suicidal crisis Ensure site moderation is in place to safeguard peer support and safe spaces Moderators of all online community forums to be aware of National Suicide Prevention Alliance guidance for online moderators

Implications for clinicians/ clinical resources Training to increase clinicians understanding of the online environment and suicide-related use Consider exploring internet use as part of suicide risk

22 Implications for clinicians/ clinical resources Training to increase clinicians understanding of the online environment and suicide-related use Consider exploring internet use as part of suicide risk assessment Clinicians could support patients to: recognize how and when their use is harmful devise personalized online safety practices as part of crisis planning Strategies to reduce risks associated with medical sites and open access research: publication guidelines for researchers

23 Samaritans 1. Provided additional evidence to support established and ongoing dialogue, relationship and joint working with social media companies and search engines. 2. Identified new and important areas of work, for example developing guidance for clinicians that Samaritans plans to take forward, in partnership. 3. Made an important contribution to Samaritans understanding of suicide, which will be embedded in its longer term strategic and service development.

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