The moderating role of working alliance in the association between depression and suicide ideation in messaging therapy (Preprint)

Abstract

BACKGROUND Suicide is one of the leading causes of death worldwide, and it can be prevented by psychotherapy. Nowadays, it is crucial to identify individuals at risk of suicide in technology-based therapies, such as messaging therapy. OBJECTIVE The objective of the study is to examine the risk factors predicting suicide ideation during a messaging psychotherapy, and the moderating role of working alliance in the association between baselined depression and later suicide ideation. METHODS A large outpatient sample (n = 4,388) engaged in daily messaging with licensed clinicians from a telemedicine provider. Using a longitudinal design, depression and anxiety symptoms were assessed at baseline, using the Patient Health Questionnaire (PHQ-8) for depression, and the Generalized Anxiety Disorder (GAD-7) for anxiety. The Working Alliance was measured with the short-version of the Working Alliance Inventory (WAI-SR) after three weeks of therapy, and suicide ideation was assessed at baseline and after six weeks of therapy, by item 9 of the Patient Health Questionnaire (PHQ-9). Demographic measures were also assessed. RESULTS Results indicate that depression, baseline suicide ideation and working alliance, especially its tasks subscale, significantly predicted suicide ideation after six weeks. Working alliance, especially the task and bond subscales, moderated the association between depression at baseline and suicide ideation after six weeks, so that experiencing higher quality of working alliance between the patient and the therapist decreased the association between depression and suicide ideation. CONCLUSIONS Suicide ideation may be reduced by experiencing the therapeutic relationship as beneficial, even among at-risk population, which suffer from depressive symptoms. It is the first study to show this moderation effect in any platform of therapy.