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Jan. K. Mokkenstorm M.D., psychiatristDirector 113 Online

j.mokkenstorm@113online.nlmokkenstorm@gmail.com info@113online.nl

• Background: why online help may benefit suicide prevention

• Outline of the online services

• Preliminary results: help seeker characteristics, site use, service use, application of railway suicide prevention

• Conclusion

113OnlineFirst two year results

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• Netherlands: 16 million inhabitants• 1600 suicides per year• 96.000 attempts registered

• > 500.000 individuals

with death wish or suicidal ideation> 2 weeks• 40 % of attempters no treatment sought <1 year• 33% of attempters no treatment sought ever(Ten Have et al 2011 NEMESIS 2 Results of the Netherlands Mental Health Survey and

Incidence Study)

The problem

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• Low perceived need• Wish for autonomy, control• Stigma• Structural & financial barriers

• Negative experiences with regular care?

Help seeking barriers(Pagura et al 2009, Bruffaerts et al 2011)

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– Specific competence & knowledge– Empathy and respect– Shared decision making– Open communication

Unmet needs and expectations in regular care(Pirkis et al 2001, Taylor et al 2009)

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• Reach: large scale dissemination• Low treshold and easy acces• Autonomy and control of the help seeker• Online disinhibition effects enhance therapeutic

processes• Online interventions are effective

Why online help may benefit suicide prevention

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6

Stage 1Website +telephone hotline

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Education

AdviceHotline

Pioneer online interactiveSAHAR

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Peer support

Hotline

Acute chat

Stage 2: online interactive

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Education

Peer support

Advice

Hotline

Acute chat

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Stage 3 Multi levelonline platform

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Education

Self Test

Peer support

Self HelpCourse

Brief Online

Therapy

DirectReferral

Advice

Hotline

Acute chat

Site stats

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Site usage 5 / 10 / 09-20 / 03 /12 Average per day

SitevisitsUnique visitorsPageviewsVisit Duration

7303676,2

00:03:053

Visitors Yough<18 yr Adult 18+ Total

Suicidal 14,8% 53,8% 68,6%

Concerned 5,8% 17,6% 23,4%

Bereaved 1,4% 6,7% 8,0%

Total 21,9% 78.1% 100%

Selftests & Autoreplies

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Selftest Age< 23 SIQ J (0-72)

Age 23+: BSI (0-39)

Average tests per day 6 10

Age 19,2 (sd 6,7) 36,6 (sd 11,8)

% Female 72% 60%

Average Score 40,7 (sd 20,7) 20,5 (sd 8,5)

Autoreply Advice Age<23 Age 23+

Absent-Low 10% 5%

Mild 5% 2%

Suicidal 8% 38%

Severely Suicidal 78% 55%

• DEMAND>> Supply

• Av. duration: 61 min (sd 39 min). • 48% female, 15 % male, 37% ?. Av. 25,6• 46% of callers in a form of mental health treatment• Content: 41% psychiatric symptoms and treatment• 63 % of callers thanked the helper spontaneously • 15 % dissatisfied

Acute chat calls: use and satisfaction

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Comparison Mishara silent monitoring study1-800-SUICIDE Telephone vs 113Online ChatSuicide and Life-Threatening Behavior 37(3) June 2007

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1-800: n=1431 tel.calls113: n=396 chats Worse No change Better

1-800 113 1-800 113 1-800 113

Apprehensive/ Confident 11% 7% 49% 52% 38% 43%Sad / Happy 9% 5% 67% 51% 22% 44%Helpless / Resourcefull 10% 15% 41% 44% 49% 41%Hopeless / Hopefull 11% 8% 47% 46% 40% 46%Confused/Decided 10% 8% 36% 54% 52% 39%Depressive mood 7% 8% 74% 56% 18% 36%Desperate 6% 7% 77% 55% 16% 38% Sustain thoughts 8% 56% 37%Suicide ambivalence (n=121)

2% 8% 84% 69% 14% 23%

Online Psychotherapy by chat or e-mail

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• Anonymous, free • Solution Focused; CBT/DBT/ACT elements • Treatment manual• Trained & supervised psychologists• Brief: max 8 sessions/exchanges• Average number sessions = 5• Av. number of completed therapies = 25/week

Routine Outcome MonitorEffect studies (RCT)

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T2 FOLLOW-UP

T1 END

THERAPY PROCESS

T0 START

T2:BSS/SIQ

CES-D

T1:BSS/SIQ

CES-D

Gould&ORS

TherapySession orExchange

SRS

T0:BSS/SIQ

CES-D

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• 260 of 2443 unique acute chat callers (10,6%) refer to the railways as a means of suicide. In 16 cases this related to someone else. There were 3 direct and positive references tot the “ I Listen” signs

Railway related content acute chats

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Situation Number % of 260

On the railway now 10 3,8%

Today-yesterday 19 7,3%

This week 10 3,8%

Ever 27 10,3%

Urge or a plan now 64 24,6%

Decided against rail suicide 32 12,3%

Ambivalent on rail suicide 23 8,8%

Adverse events

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• We know of 3 suicides, in 2 cases the client was in regular treatment as well.

• Suicide attempts occur during calls or sessions and have been dealt with by emergency services if caller/client revealed location.

• Management received 3 formal complaints regarding unmet expectations.

• 113Online reaches a large number of (very) suicidal, concerned or bereaved individuals.

• A substantial number did not seek help otherwise.

• 113Online meets needs and expectations (partially) unmet in regular care.

• Effectivity remains to be proven

• Less than expected adverse events.

Conclusion

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• Professionals and Volunteers of 113Online and Ex6

• Management and volunteers of Sensoor Helpline

• Mady Samuels; Netherlands Ministry of Health Care (VWS)

• ProRail

• Prof. Ad Kerkhof

• Prof. Brian Mishara

• Prof. Jan Smit

• Dr. Annemiek Huisman

• Lucy Stut

• Anouk Romers

• Merijn Eikelenboom

• Dr. Bregje van Spijker

• Leo Wijnbelt

• Ed Claasens

• Age Nils Holstein

Acknowledgments and thanks

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References

• Bruffaerts,R., Demyttenaere, K., Hwang, I., Chiu, W.T. Sampson, N. ,Kessler, R.C., Alonso, J., Borges, G., Girolamo, G de , Graaf, R. de, Florescu, S, Gureye, O., Hu, C., Karam, E.G., Kawakami, N., Kostyuchenko, S., Kovess-Mastety, V., Lee, S., Levingson, D., Matschinger, H., Posada-Villa, J., Sagar, R., Scott, K.M., Stein, D.J., Tomov, T., Viana, M.C., Nock, M.K. Treatment of suicidal people around the world BJP 2011; 199(1): 64–70.

• Krysinska, K.E. and D. De Leo, Telecommunication and suicide prevention: hopes and challenges for the new century. Omega - Journal of Death & Dying, 2007. (3): p. 237-53.

• Mishara BL, Chagnon F, Daigle M, Balan B, Raymond S, Marcoux I, et al. Which helper behaviors and intervention styles are related to better short-term outcomes in telephone crisis intervention? Results from a silent monitoring study of calls to the U.S. 1-800- SUICIDE network. Suicide Life Threat Behav 2007a; 37: 291-307.

• Pagura J, Fotti S, Katz LY, Sareen J. Help seeking and percieved need for mental health care among individuals in Canada with suicidal behaviors. Psychiatr Serv 2009; 60: 943-49.

• Pirkis J, Burgess P, Meadows G, Dunt D. Self-reported needs for care among persons who have suicidal ideation or who have attempted suicide. Psychiatr Serv 2001; 52: 381-83.

• Taylor, T.L., Hawton,K., Fortune, S., Kapur, N. Attitudes towards clinical services among

people who self-harm: systematic review Br.J.Psych (2009) 194, 104–110.

Thank Youwww.113online.nl

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