Suicide prevention using self-guided digital interventions: a systematic review and meta-analysis of randomised controlled trials
Open accessAbstract
Background Digital interventions that deliver psychological self-help provide the opportunity to reach individuals at risk of suicide who do not access traditional health services. Our primary objective was to test whether direct (targeting suicidality) and indirect (targeting depression) digital interventions are effective in reducing suicidal ideation and behaviours, and our secondary analyses assessed whether direct interventions were more effective than indirect interventions. Methods In this systematic review and meta-analysis, we searched online databases MEDLINE, PubMed, PsycINFO, and Cochrane CENTRAL for randomised controlled trials published between database inception to May 21, 2019. Superiority randomised controlled trials of self-guided digital interventions (app or web based, which delivered theory-based therapeutic content) were included if they reported suicidal ideation, suicidal plans, or suicide attempts as an outcome. Non-inferiority randomised controlled trials were excluded to ensure comparability of the effect. Data were extracted from published reports, and intention-to-treat data were used if available. The primary outcome was the difference in mean scores of validated suicidal ideation measures (Hedges' g ) with the associated 95% CI for the analysis of digital intervention effectiveness on suicidal ideation. We also present funnel plots of the primary outcome measure (suicidal ideation) for direct and indirect interventions to assess for publication bias. We calculated I 2 (with I 2 CI) values to test heterogeneity. We used random-effects modelling for the meta-analyses to assess the primary and secondary outcomes. This study is registered with PROSPERO, CRD42018102084. Findings The literature search yielded 739 articles (including manual searching) for suicidality and 8842 articles for depression. After screening, 14 papers reporting on 16 studies were included in the narrative review and meta-analysis. The 16 studies (ten on direct interventions and six on indirect interventions) provided baseline data for 4398 participants. The primary outcome of overall post-intervention effect for suicidal ideation was small but significant immediately following the active intervention phase (Hedges' g −0·18, 95% CI −0·27 to −0·10, p<0·0001; I 2 =0%, I 2 CI 0·0–47·9). The secondary objective, comparing direct and indirect interventions, showed that direct interventions (targeting suicidality) significantly reduced suicidal ideation at post-intervention ( g −0·23, 95% CI −0·35 to −0·11, p<0·0001; I 2 =17·6%, I 2 CI 0·0–58·6), but indirect interventions (targeting depression) failed to reach significance ( g −0·12, 95% CI −0·25 to 0·01, p=0·071; I 2 =0%, I 2 CI 0·0–30·7). Interpretation Self-guided digital interventions directly targeting suicidal ideation are effective immediately post-intervention. Indirect interventions were not significant for reducing suicidal ideation. Our findings suggest that digital interventions should be promoted and disseminated widely, especially where there is a lack of, or minimal access to, health services. Funding Australian National Health and Medical Research Council.
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Meta-analyses focusing on Internet-delivered prevention reported small significant effects on subclinical symptoms, generally smaller or insignificant for adolescents compared to adults.
“Meta-analyses with a specific focus on Internet-delivered prevention reported small significant effects on subclinical symptoms [45, 61–63], which were generally smaller or even insignificant for adolescents compared to adults [62].”
From Efficacy of a transdiagnostic Internet prevention approach in adolescents (EMPATIA study): study protocol of a randomized controlled trial (2024) · cites this paper as [63]
The Discussion (page unavailable) reports small, significant effects of self-guided digital interventions on suicidal ideation immediately after intervention, supporting the first clause for that specific outcome. The Data analysis section (page unavailable) says an adolescent-versus-adult subgroup comparison was planned, but the passages found do not report smaller or insignificant effects for adolescents. The paper also does not establish the broader claim about subclinical symptoms generally. (LLM, conf=0.84)
Experimental — accuracy not yet measuredThere is emerging evidence that adults readily access and benefit from suicide prevention interventions delivered via smartphone-based apps.
“There is emerging evidence that adults readily access and benefit from suicide prevention interventions delivered via smartphone-based apps [25].”
From A mobile health intervention (LifeBuoy App) to help young people manage suicidal thoughts: protocol for a mixed-methods randomized controlled trial (2020) · cites this paper as [25]
The Results and Discussion support an emerging benefit: the review includes app-based trials with adults and reports a small reduction in suicidal ideation across the digital interventions studied. But that pooled finding also includes web-based programmes, and the paper does not establish that adults readily access apps; the Discussion identifies engagement as a major barrier. (LLM, conf=0.88)
Experimental — accuracy not yet measuredMeta-analyses have shown that interventions directly targeting suicidal behaviors can reduce ideation in the short-term, whereas broader mental health interventions are unable to.
“This need for development and testing of purpose designed treatments is because meta-analyses have shown that interventions directly targeting suicidal behaviors can reduce ideation in the short-term, whereas broader mental health interventions are unable to [14,20].”
From The effect of a therapeutic smartphone application on suicidal ideation in young adults: Findings from a randomized controlled trial in Australia. (2022) · cites this paper as [14]
The Abstract reports that self-guided digital interventions directly targeting suicidality significantly reduced suicidal ideation immediately after treatment, while interventions targeting depression did not reach statistical significance. The claim broadens the comparison from depression-targeted interventions to all broader mental health interventions and treats a nonsignificant result as proof that they are unable to reduce ideation. Page numbers are not provided in our copy. (LLM, conf=0.85)
Experimental — accuracy not yet measuredAdults can readily access and benefit from technology-enabled solutions that directly target suicidal ideation and/or behaviors.
“Adults can readily access and benefit from technology-enabled solutions that directly target suicidal ideation and/or behaviors [14,15]; however, the evidence for this is largely derived from trials of web-based programs rather than smartphone interventions.”
From The effect of a therapeutic smartphone application on suicidal ideation in young adults: Findings from a randomized controlled trial in Australia. (2022) · cites this paper as [14]
The Discussion (page not provided) reports that directly targeted self-guided digital interventions produced a small, significant reduction in suicidal ideation immediately after treatment. But the paper recommends making these interventions available more widely rather than establishing that adults can already readily access them; it also reports no significant reduction in suicidal behaviours. (LLM, conf=0.83)
Experimental — accuracy not yet measuredA sample size of 189 participants per intervention group is sufficient to detect an effect size of 0.30 for the primary outcome at postintervention with at least 80% power and an alpha criterion of 0.05.
“Power analyses determined that a sample size of 189 participants per intervention group would be sufficient to detect an effect size of 0.30 [14] for our primary outcome at postintervention with at least 80% power and an α criterion of 0.05.”
From The effect of a therapeutic smartphone application on suicidal ideation in young adults: Findings from a randomized controlled trial in Australia. (2022) · cites this paper as [14]
The citation is attached to the assumed effect size of 0.30, not to the citing authors’ power calculation. The Other non-CBT interventions section reports an imputed post-intervention effect estimate of −0.31 for direct interventions, close to 0.30 in magnitude. That is a conditional estimate, however; the paper reports an overall post-intervention effect of −0.18, so it does not establish 0.30 as the general effect size for the citing study’s primary outcome. (LLM, conf=0.76)
Experimental — accuracy not yet measured
This study strengthens the evidence base for the short-term efficacy of brief unsupervised and targeted digital therapeutics in young adults, and demonstrates that the LifeBuoy application has a favorable risk-benefit profile.
“Not only does this study strengthen the evidence base for the short-term efficacy of brief unsupervised and targeted digital therapeutics in young adults [14], but it also demonstrates that LifeBuoy application has a favorable risk–benefit profile.”
From The effect of a therapeutic smartphone application on suicidal ideation in young adults: Findings from a randomized controlled trial in Australia. (2022) · cites this paper as [14]
The Indirect interventions section reports a small, significant post-intervention reduction in suicidal ideation for self-guided interventions directly targeting suicide. The Results include young adults but also substantially older participants; the paper does not establish that pooled efficacy specifically for young adults. The LifeBuoy risk–benefit conclusion is the citing authors’ own finding, not the part attached to this citation. (LLM, conf=0.88)
Experimental — accuracy not yet measuredOur findings extend prior research showing that DBT can be effectively digitized to treat suicidal ideation by showing promise for this approach in young adults.
“Our findings extend prior research showing that DBT can be effectively digitized to treat suicidal ideation [14] by showing promise for this approach in young adults.”
From The effect of a therapeutic smartphone application on suicidal ideation in young adults: Findings from a randomized controlled trial in Australia. (2022) · cites this paper as [14]
Our results are consistent with pooled meta-analytic findings that digital therapeutics appear to be effective in reducing suicidal ideation, yet deviate from the effects reported in standalone trials.
“Our results are consistent with pooled meta-analytic findings that digital therapeutics appear to be effective in reducing suicidal ideation [14] yet deviate from the effects reported in standalone trials.”
From The effect of a therapeutic smartphone application on suicidal ideation in young adults: Findings from a randomized controlled trial in Australia. (2022) · cites this paper as [14]
There is evidence that treatment approach may be an important moderator of efficacy.
“In considering why our findings may differ from previous studies, there is evidence that treatment approach may be an important moderator of efficacy [14,20].”
From The effect of a therapeutic smartphone application on suicidal ideation in young adults: Findings from a randomized controlled trial in Australia. (2022) · cites this paper as [14]
While CBT has been successfully translated into digital interventions for depression and anxiety, it appears to have little impact on ideation or other suicidal outcomes in comparison to alternative therapies such as DBT.
“Certainly, while cognitive behavioral therapy (CBT) has been successfully translated into digital interventions for depression and anxiety [35], it appears to have little impact on ideation or other suicidal outcomes in comparison to alternative therapies such as DBT [14].”
From The effect of a therapeutic smartphone application on suicidal ideation in young adults: Findings from a randomized controlled trial in Australia. (2022) · cites this paper as [14]
Substantial human health resources will be saved if the CAIs are proven effective and suitable for widespread implementation.
“Substantial human health resources will be saved if the CAIs are proven effective and suitable for widespread implementation [14].”
From Conversational Agent Interventions for Mental Health Problems: Systematic Review and Meta-analysis of Randomized Controlled Trials (2023) · cites this paper as [14]
Self-guided digital interventions delivered by smartphone might be as effective as in-person suicide prevention.
“In addition, smartphones have introduced self-guided digital interventions as novel suicide prevention methods that may prove as effective as face-to-face interventions (264).”
From A brain-centric model of suicidal behavior (2020) · cites this paper as [264]
Digital mental health interventions can have significant small-to-moderate effects on alleviating or preventing symptoms of mental health disorders.
“While there is a growing body of evidence supporting that DMHIs can have significant small-to-moderate effects on alleviating or preventing symptoms of mental health disorders (6–10)”
From Effect of Engagement With Digital Interventions on Mental Health Outcomes: A Systematic Review and Meta-Analysis (2021) · cites this paper as [10]
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- Authors
- Torok, M., Han, J., Baker, S., Werner-Seidler, A., Wong, I., Larsen, M. E., & Christensen, H.
- Affiliations
- Black Dog Institute (AU)
- Corresponding author
- Torok, Michelle
- Venue
- The Lancet Digital Health
- Publisher
- Elsevier BV
- Published
- 2020-01
- Volume
- 2
- Issue
- 1
- Pages
- e25-e36
- ISSN
- 2589-7500 (ISSN-L)
- OpenAlex
- W2991439719
- Cited by
- 273
- References
- 47
- Citations by year
- 2026: 26 · 2025: 64 · 2024: 43 · 2023: 44 · 2022: 41 · 2021: 34 · 2020: 19 · 2019: 1 · 2013: 1
- FWCI
- 3.32
- Type
- journal article
- Language
- en
- Open access
- gold
- doi.org
- Licence
- Locations
- The Lancet Digital Health (publishedVersion, cc-by)
- PubMed (publishedVersion)
- UNSWorks (UNSW Sydney) (submittedVersion, cc-by-nc-nd)
- DOAJ (DOAJ: Directory of Open Access Journals) (submittedVersion, cc-by-sa)
- Funders
- National Health and Medical Research Council
- Topics
- Social Sciences › Psychology › Applied Psychology › Digital Mental Health Interventions
- Social Sciences › Psychology › Clinical Psychology › Suicide and Self-Harm Studies
- Social Sciences › Psychology › Social Psychology › Mental Health via Writing
- Keywords
- suicide prevention, suicidal ideation, depression, mental health apps, online intervention, suicide attempts, suicide planning, psychological self-help, digital mental health
- MeSH terms
- Digital Technology, Suicide Prevention, Humans, Self Care, Randomized Controlled Trials as Topic
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