The effect of a therapeutic smartphone application on suicidal ideation in young adults: Findings from a randomized controlled trial in Australia

Abstract

Background Suicidal ideation is a major risk for a suicide attempt in younger people, such that reducing severity of ideation is an important target for suicide prevention. Smartphone applications present a new opportunity for managing ideation in young adults; however, confirmatory evidence for efficacy from randomized trials is lacking. The objective of this study was to assess whether a therapeutic smartphone application (“LifeBuoy”) was superior to an attention-matched control application at reducing the severity of suicidal ideation. Methods and findings In this 2-arm parallel, double-blind, randomized controlled trial, 455 young adults from Australia experiencing recent suicidal ideation and aged 18 to 25 years were randomly assigned in a 2:2 ratio to use a smartphone application for 6 weeks in May 2020, with the final follow-up in October 2020. The primary outcome was change in suicidal ideation symptom severity scores from baseline (T0) to postintervention (T1) and 3-month postintervention follow-up (T2), measured using the Suicidal Ideation Attributes Scale (SIDAS). Secondary outcomes were symptom changes in depression (Patient Health Questionnaire-9, PHQ-9), generalized anxiety (Generalized Anxiety Disorder-7, GAD-7), distress (Distress Questionnaire-5, DQ5), and well-being (Short Warwick–Edinburgh Mental Well-Being Scale, SWEMWBS). This trial was conducted online, using a targeted social media recruitment strategy. The intervention groups were provided with a self-guided smartphone application based on dialectical behavior therapy (DBT; “LifeBuoy”) to improve emotion regulation and distress tolerance. The control group were provided a smartphone application that looked like LifeBuoy (“LifeBuoy-C”), but delivered general (nontherapeutic) information on a range of health and lifestyle topics. Among 228 participants randomized to LifeBuoy, 110 did not complete the final survey; among 227 participants randomized to the control condition, 91 did not complete the final survey. All randomized participants were included in the intent-to-treat analysis for the primary and secondary outcomes. There was a significant time × condition effect for suicidal ideation scores in favor of LifeBuoy at T1 (p Conclusions LifeBuoy was associated with superior improvements in suicidal ideation severity, but not secondary mental health outcomes, compared to the control application, LifeBuoy-C. Digital therapeutics may need to be purposefully designed to target a specific health outcome to have efficacy. Trial registration Australian New Zealand Clinical Trials Registry ACTRN12619001671156 In a randomized controlled trial, Michelle Torok, Jin Han, and colleagues study the effectiveness of the LifeBuoy therapeutic smartphone application for reducing suicidal ideation in young adults in Australia. Author summary Why was this study done? Young people are a priority group for suicide prevention efforts, accounting for around one-third of all suicides. Suicidal ideation confers a moderate risk for suicide attempt and death, making it a novel, modifiable target for suicide prevention. Young people are poor help seekers for suicidal thoughts and behaviors; however, their willingness to engage with technology for mental health support creates enormous potential for smartphone interventions to improve access to help in this group. We identified only 2 prior trials of smartphone applications for treating suicidal ideation in younger people, neither which was tested in general population, nonclinical samples. Randomized trials are needed to understand if self-guided digital therapeutics work, are safe, and should be made available to young people. What did the researchers do and find? We conducted a 2-arm parallel randomized controlled trial to examine the effects of a brief, self-guided smartphone intervention (LifeBuoy) designed to reduce the severity of suicidal ideation by teaching emotional regulation and distress tolerance skills compared to a nontherapeutic, attention-matched “sham” application. Participants had access to the application they were randomly assigned to for 6 weeks and then were assessed at the end of the intervention period and 3 month later to determine if their baseline suicidal ideation scores had reduced. Young adults who received the LifeBuoy application showed greater reductions in suicidal ideation both immediately and at 3 months after the intervention compared to those who had received the control application. At postintervention, approximately 3 out of 4 young adults in the LifeBuoy group no longer had suicidal ideation score in a threshold that placed them at high risk of suicide attempt, compared to 1 out of 2 in the control group. Depression, anxiety, distress, and well-being symptoms improved from baseline to postintervention for young adults in both groups, but the LifeBuoy application did not lead to superior improvements above and beyond those observed in the control group. The LifeBuoy application appeared to be safe, with no young adults in the intervention group reporting suicide attempts at final follow up. What do these findings mean? Despite its brief nature and self-guided format, this dialectical behavior therapy (DBT) smartphone application can be used to modestly reduce the severity of suicidal ideation in young adults, making it a potentially useful therapeutic support for young people who might not otherwise be able or willing to access face-to-face treatment. Smartphone applications appear to work best when designed to target a specific health problem, with the current study supporting findings from other studies that digital therapeutics appear to be less effective for secondary health problems. Further investigation is needed to understand the full clinical meaningfulness of the findings, including which young people might benefit the most from this intervention.