Over the years, there has been an increase in young people experiencing suicidal thoughts and behaviours (Han et al., 2019). Now, suicide is the fourth leading cause of mortality amongst young people worldwide (WHO, 2019).
Digital technologies are already being used in practice alongside more traditional mental health support for young people. For example, an online intervention for young people called Moderated Online Social Therapy (MOST), which is often delivered in addition to receiving support at a youth mental health service, has been found to be effective and acceptable in supporting young people with a range of mental health problems, including psychosis (Alvarez-Jimenez et al., 2018), depression (Rice et al., 2016) and suicidal ideation (Bailey et al., 2020).
However, there are challenges with integrating these digital tools into clinical practice (Schlief et al., 2022), which has been partly attributed to concerns around managing risk and safeguarding (Mendes-Santos et al, 2022), alongside a general lack of clinical guidelines. This means that, whilst digital tools are constantly being funded, developed, and tested, they are not necessarily being used; this causes issues with research waste, and potentially means that young people do not have access to interventions that could be potentially effective.
As such, Bailey et al. (2024) aimed to address this gap in resources by conducting a Delphi study to develop clinical guidelines for safely integrating digital tools into mental health care for young people experiencing suicidal thoughts or behaviours.
Digital therapies have already been tested alongside face-to-face support. However, implementation and integration are still a challenge, potentially because of the lack of evidence-based clinical guidelines.
Methods
This study used a Delphi methodology, which is a research method used to gather opinions and build consensus among a group of experts on a specific topic. Working with a range of stakeholders, the authors used this methodology to help identify items that should be included in clinical guidance. This was conducted in two phases: questionnaire development and consensus rounds.
- Questionnaire development: Published and non-published literature was searched for items to include in the second stage. The aim was to find statements that described what clinicians or services have done or should do when using digital technologies with young people experiencing suicidal thoughts or behaviours. The research team also conducted some qualitative interviews to supplement their literature search, involving both professional experts (n = 9) and young people with lived experience (n = 8).
- Consensus rounds: Generated statements were sent to experts, who were asked to rate them by importance to establish whether they should be included in the final guidelines. The researchers recruited two expert panels: academics and clinicians (n = 20) and young people with lived experience (n = 29). Two rounds of consensus checking were conducted. During the first round, all panel members were given the opportunity to suggest any additional items which should be included for the second round. The second round therefore included these additional items, as well as all items which did not reach consensus for either inclusion or exclusion in round 1. Items were included in the guidelines if they were rated as ‘essential’ or ‘important’ by at least 80% of participants in both panels and were excluded if less than 70% of panel members gave them these ratings.
Results
In total, 326 statements were identified and used for the Delphi consensus checking process, with 188 statements (57.7%) included in the final guidelines. Importantly, there was a statistically significant agreement between both panels on rating statements as either ‘essential’ or ‘important’, with a large effect (r = .84, p < .001). However, there were some statements where a consensus was not reached, including interactive digital tools (e.g., online forums), clinician’s viewing young people’s social media, and what constitutes ‘harmful content’ in digital tools.
The authors developed a three-part guidance document based on these included statements, with sections including:
1. Introducing digital tools into your clinical practice
This includes information about training clinicians to use digital tools, choosing appropriate digital tools, determining the role of the digital tool in managing a young person’s suicidal thoughts or behaviour, the use of online communities, explaining a tool to young people, and appropriate involvement of their parents or carers.
2. Identifying and managing risk of suicide or self-harm
This includes the steps that clinicians should take to monitor the risk of suicide or self‑harm conveyed via a digital tool. Steps include monitoring the impact of digital tools on a young person’s suicidal thoughts or behaviours, developing standard processes for monitoring risks, setting expectations with the young person, and documenting processes and conversations regarding the use of the digital tool.
3. Actions for services
This includes guidance for leadership and managers. Recommendations include the need for services to set up policies and procedures to specify how digital tools should or should not be used with young people experiencing suicidal thoughts or behaviours. These procedures should ensure equity amongst young people and promote the uptake of digital tools.
The full guidance document can be accessed from Orygen’s website here. Specific recommendations include the need to be careful not to recommend any digital tools which may contain harmful content, educating young people on how to safely use digital tools, and recommending digital tools which have previously been shown to be effective. The guidelines also contain a comprehensive list of recommended features for digital tools (e.g., trigger warnings, emotion regulation strategies, details for crisis support) and how to monitor the impact of the use of digital tools in practice.
There was strong agreement between the academic/clinical expert panel and lived experience young person expert panel regarding the items they thought were ‘essential’ or ‘important’ to include in the clinical guidelines.
Conclusions
This paper describes the development of the first evidence-informed guidelines for integrating digital tools into clinical care for young people experiencing suicidal ideation and behaviour. The content within these guidelines has been endorsed by both expert professionals and individuals with lived experience, with a strong consensus between these groups on the items which should be included. The guidelines aim to overcome significant barriers to the adoption of digital tools in clinical settings, particularly concerns about tool quality and the processes for assessing and managing suicide risk.
The authors concluded that whilst the creation of these guidelines represents a crucial first step towards enhancing the use of digital tools in mental health care, more work must be done to successfully implement these guidelines into clinical practice.
Developing these guidelines is an important first step; however, more work needs to be done to ensure they can be implemented into clinical practice.
Strengths and limitations
The authors should be commended for their commitment to involving young people with lived experience in this guideline development. It is vitally important that people with lived experience are involved in research to ensure that any outputs reflect their needs and ensures that their voices are heard. This is especially relevant with the current study, as the guidelines developed as a result of this research have the potential to shape how digital tools are offered to young people experiencing suicidal thoughts or behaviours in the real world.
However, there are some limitations of this research. Firstly, the content of these guidelines is biased towards specific high-income ‘Western’ countries including the USA, the UK, Canada, Australia and New Zealand, both in the experts recruited and in searching grey literature websites. Additionally, all the young people with lived experience were recruited from Australia – but, whilst there is some diversity across certain demographic characteristics, no young people from Aboriginal or Torres Strait Islander backgrounds took part in the panel, limiting generalisability and potential applicability to this population. The majority of young people also lived in metropolitan areas, so it may be useful for future research to focus on those living in more rural areas, as these populations may benefit more from digital technologies if they do not live within easy access of face-to-face services.
Further limitations associated with this study include the fact that only two rounds of the Delphi consensus process were conducted; whilst the authors highlight that there is a methodological precedent for ending at this stage, further rounds may have enabled the inclusion of additional items. The authors also decided to exclude participants who reported frequent suicidal ideation 1 week prior to participating, which means that the opinions of this potentially higher risk group are not represented.
Also, as noted by the authors, successfully implementing guidelines into practice is extremely challenging. This can be due to several factors, including features of the intervention itself (e.g., is it acceptable to service users and clinical staff, is it feasible to incorporate into existing clinical practice?), or associated costs or resource needs (e.g., staff training, equipment, or physical space; Proctor et al., 2011). Future research could perhaps look to the emerging field of implementation science to explore how to overcome these barriers.
A key strength of this Australian work is involving young people with lived experience in all stages of the project. However, demographic diversity was poor with no Aboriginal or Torres Strait Islander backgrounds involved.
Implications for practice
These guidelines may facilitate the use of digital technologies in supporting young people who are experiencing suicidal ideation or behaviours. It is understandable that clinicians are concerned about how to safely manage risk when young people are using digital technologies, and it is important that robust procedures are put in place to ensure appropriate risk management and safeguarding procedures are adhered to.
However, there is a well-known ‘implementation gap’, in which researchers have estimated that on average it takes research findings 17 years to become successfully embedded in clinical practice (Morris et al., 2011). Given the fast-changing nature of digital technologies, we run the risk of guidelines such as these being out of date by the time they are implemented in mental health services. It is important to consider the need to update these guidelines in time to incorporate new technological advances.
Digital technologies may be especially beneficial in improving access to mental health support for certain groups of young people, for example those with physical disabilities or those who live in rural areas, where it may be harder to travel to receive face-to-face support. These technologies could also encourage wider access to mental health services; a recent Mental Elf blog summaries a study which found that the use of an AI chatbot increased self-referrals for people from ethnic or gender minoritised groups. However, it is important to be mindful that these technologies may also not be suitable for all young people, or young people may prefer to access mental health support in person. Therefore, when considering a wider roll out of digital technologies in mental health care, it is vital to consider the preferences of those using the service and ensure that face-to-face care is also available for those who need it.
These guidelines could help clinicians safely use digital technologies to support young people experiencing suicidal thoughts or behaviours. However, considering the 17-year implementation gap, will these guidelines remain relevant?
Statement of interests
I have no conflict of interest with this study or the authorship team.
Links
Primary paper
Bailey, E., Bellairs-Walsh, I., Reavley, N., Gooding, P., Hetrick, S., Rice, S., … & Robinson, J. (2024). Best practice for integrating digital interventions into clinical care for young people at risk of suicide: a Delphi study. BMC Psychiatry, 24(1), 71.
Other references
Alvarez-Jimenez, M., Gleeson, J. F., Bendall, S., Penn, D. L., Yung, A. R., Ryan, R. M., … & Nelson, B. (2018). Enhancing social functioning in young people at Ultra High Risk (UHR) for psychosis: A pilot study of a novel strengths and mindfulness-based online social therapy. Schizophrenia Research, 202, 369-377.
Bailey, E., Bellairs-Walsh, I., Reavley, N., Gooding, P., Hetrick, S., Rice, S., Boland, A. and Robinson, J., (2023) Guidelines for integrating digital tools into clinical care for young people at risk of suicide. Melbourne: Orygen.
Han, B., Compton, W. M., Blanco, C., Colpe, L., Huang, L., & McKeon, R. (2018). National trends in the prevalence of suicidal ideation and behavior among young adults and receipt of mental health care among suicidal young adults. Journal of the American Academy of Child & Adolescent Psychiatry, 57(1), 20-27.
Meadows, R. (2024). Are chatbots the answer to minimising inequalities in treatment access? The Mental Elf.
Mendes-Santos, C., Nunes, F., Weiderpass, E., Santana, R., & Andersson, G. (2022). Understanding mental health professionals’ perspectives and practices regarding the implementation of digital mental health: qualitative study. JMIR Formative Research, 6(4), e32558.
Morris, Z. S., Wooding, S., & Grant, J. (2011). The answer is 17 years, what is the question: understanding time lags in translational research. Journal of the Royal Society of Medicine, 104(12), 510-520.
Proctor, E., Silmere, H., Raghavan, R., Hovmand, P., Aarons, G., Bunger, A., … & Hensley, M. (2011). Outcomes for implementation research: conceptual distinctions, measurement challenges, and research agenda. Administration and Policy in Mental Health and Mental Health Services Research, 38, 65-76.
Rice, S., Gleeson, J., Davey, C., Hetrick, S., Parker, A., Lederman, R., … & Alvarez‐Jimenez, M. (2018). Moderated online social therapy for depression relapse prevention in young people: pilot study of a ‘next generation’ online intervention. Early Intervention in Psychiatry, 12(4), 613-625.
Schlief, M., Saunders, K. R., Appleton, R., Barnett, P., San Juan, N. V., Foye, U., … & Johnson, S. (2022). Synthesis of the evidence on what works for whom in telemental health: rapid realist review. Interactive Journal of Medical Research, 11(2), e38239.
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