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 < 0.001, d = 0.45) and T2 (p = 0.007, d = 0.34). There were no superior intervention effects for LifeBuoy on any secondary mental health outcomes from baseline to T1 or T2 [p-values: 0.069 to 0.896]. No serious adverse events (suicide attempts requiring medical care) were reported. The main limitations of the study are the lack of sample size calculations supporting the study to be powered to detect changes in secondary outcomes and a high attrition rate at T2, which may lead efficacy to be overestimated. 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

Digital solutions to promote adolescent mental health: Opportunities and challenges for research and practice

“…Digital solutions may also be particularly appropriate for expanding adolescent mental health services. Smartphone applications (apps) are one example of how technology can be used to promote adolescent wellness, as aptly illustrated in the accompanying research study in PLOS Medicine by Torok and colleagues, which investigated whether the LifeBuoy app could help reduce the severity of suicidal ideation among young adults [ 3 ]. This study adds to the small but growing body of research demonstrating the potential for novel technologies to transform adolescent mental health service delivery.…”

“…There is increasing evidence to support adolescents’ use of apps for a range of problems, including depression and anxiety [ 8 ], and apps could be a novel way to mitigate the increasing burden of adolescent suicidal behaviors. Torok and colleagues have now shown that apps may be an effective strategy to address suicide risk in young people [ 3 ]. In their randomized controlled trial, Torok and colleagues showed that 6 weeks of engagement with LifeBuoy, a self-guided app based on the principles of dialectical behavior therapy (DBT), led to reduced suicidal ideation among young adults (18 to 25 years old) compared to a visually similar but nontherapeutic control app [ 3 ].…”

“…Torok and colleagues have now shown that apps may be an effective strategy to address suicide risk in young people [ 3 ]. In their randomized controlled trial, Torok and colleagues showed that 6 weeks of engagement with LifeBuoy, a self-guided app based on the principles of dialectical behavior therapy (DBT), led to reduced suicidal ideation among young adults (18 to 25 years old) compared to a visually similar but nontherapeutic control app [ 3 ]. DBT is an evidence-based psychotherapy focused on developing skills such as mindfulness, distress tolerance, emotional regulation, and maintaining interpersonal relationships.…”

“…Ethically, it might be argued that adolescents deserve special protection and that guidelines or regulations should be more stringent when apps are designed for or marketed and prescribed to adolescents. One of the notable aspects of the Torok and colleagues study is that the LifeBuoy app was designed with feedback from young people with lived experience of suicidal behavior, a factor that the authors note may have contributed to the high levels of engagement and favorable outcomes observed [ 3 ].…”

“…It is interesting that while Torok and colleagues found reductions in suicidal behavior, no changes were observed in the secondary outcomes (i.e., depression and anxiety) [ 3 ], suggesting that perhaps specialized apps focused on very specific problems may be more effective than transdiagnostic approaches. With more than 10,000 mental health apps in the marketplace, finding the right app can be challenging [ 12 ].…”