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Table 1 Characteristics of included studies

From: Ethical issues and practical barriers in internet-based suicide prevention research: a review and investigator survey

StudyCountryIntervention descriptionMethod/ type of evaluationParticipantsSuicide/mental health inclusion criteriaSuicide/mental health exclusion criteriaSafety procedures
Published studies
 Hetrick et al., 2017 [35]AustraliaReframe IT: Self-help intervention based on CBT, administered in the presence of school wellbeing staff member. Participants could contact “moderator” via posting on “message board”. No social networking component.RCTSecondary school students recruited via school wellbeing staff.
N: 50
Mean age: 14.7
Suicide: SI in past four weeks
Mental health: none
Suicide: None
Mental health: Psychotic symptoms, assessed by
CAARMS; Intellectual disability
Participants completed a weekly SI screen. If they indicated current SI, a risk assessment was conducted by the school wellbeing staff member, who followed the school’s safety protocols.
The website was moderated once daily on weekdays by a psychologist who followed a safety protocol in case of risk (details not reported). It was clear to participants that the website was not moderated 24/7.
 Kennard et al., 2018 [36]USABRITE: Smartphone application that prompted participants to rate their emotional distress and provided personalised strategies for emotion regulation and safety planning. Supports inpatient intervention, As Safe as Possible (ASAP)RCTAdolescents recruited via psychiatric inpatient units at two academic medical centres.
N: 66
Mean age: 15.1
Suicide: Presented with recent SI + plan or intent OR recent SA
Mental health: none
Suicide: None
Mental health: None
Not reported
 King et al., 2015 [37]USAeBridge: Online screening + feedback and optional anonymous online counselling (motivational interviewing).RCTCollege students randomly selected from university database and invited to participate
N: 76
Mean age: 22.9
Suicide: Screened positive for suicide risk (depression and/or SI on PHQ-9; AND/OR reporting history of SA; AND/OR alcohol abuse on the AUDIT)
Mental health: none
Suicide: None
Mental health: Currently in mental health treatment
All students were provided with a list of mental health resources and received pop-up messages with information about emergency services if SI or a history of SA was reported.
No information regarding safety procedures in online counselling component
 Melvin et al., 2019 [38]AustraliaBeyondNow: Smartphone application for safety planning, used as an adjunct to existing interventions at a mental health service.Pre-test post-test case series/ open-label single-group trialRecruited from a tertiary mental health service.
N: 36
Mean age: 19.81
Suicide: Current or recent SI or behaviour
Mental health: current engagement with a tertiary mental health service
Suicide: None
Mental health: Psychosis; Intellectual disability
Not reported
 McManama O’Brien et al., 2017 [39]USACrisis Care: Smartphone application that gives immediate access to a set of coping skills identified as being helpful during a suicidal crisis, and enables user to access help (i.e., call an adult) immediately if necessary.Pilot test of prototype – reviewed app and provided feedbackAdolescent/ parent dyads recruited recruited from an outpatient psychiatry department.
N: 20
Adolescent mean age: 15.7
Suicide: Not reported
Mental health: not reported
Suicide: Not reported
Mental health: Not reported
Not reported
 Pauwels et al., 2017 [40]The NetherlandsBackUp: Smartphone application for safety planning, designed as an unguided self-help tool. Link to suicide hotline is permanently visible.Pre-test post-test pilot studyAdult participants recruited via the Flemish suicide prevention portal and Facebook advertising.
N: 21
Mean age: 30
Suicide: Some degree of SI (BSS > 1).
Mental health: none
Suicide: None
Mental health: None
BSS score > 25 triggered phone call by a staff member of the suicide prevention centre to assess suicide risk.
All participants received a referral card (at baseline and follow-up) with contact details of mental health care institutions
 Robinson et al., 2014 [41]AustraliaReframe IT (as above)Pre-test post-test pilot studySecondary school students recruited via school wellbeing staff.
N: 21
Mean age: 15.6
Suicide: SI in past month
Mental health: none
Suicide: None
Mental health: Psychotic symptoms, (assessed by
Intellectual disability
1) Detailed safety plan completed with each participant after baseline assessment.
2) All assessments and modules were completed at school.
3) Psychological distress and SI were measured weekly, the outcomes of both of these measures were fed back immediately to the school wellbeing staff member.
 Tighe et al., 2017 [42]Australiaibobbly: Culturally-relevant unguided smartphone application for Aboriginal and Torres Strait Islander people, based on acceptance therapies including ACTPilot wait-list RCTIndigenous Australians recruited via posters, Facebook advertising, and through health professionals.
N: 61
Mean age: 26.25
Suicide: SI in past 2 weeks (SI criteria later removed).
Mental health: score >  10 on PHQ-9 or > 25 on k10
Suicide: “Active intent” as assessed by interview
Mental health: Diagnosis of schizophrenia or psychotic disorder
In addition to providing helpline and service information, safety checks were conducted via telephone at 3 and 9 weeks. All participants had face-to-face or phone contact with the research officer/ psychologist at baseline assessment, 3 weeks (safety check) and 6-week follow-up. Waitlist group participants also received a further safety check at 9 weeks, and final follow-up assessment at 12 weeks.
 van Spijker et al., 2014 [43]The NetherlandsUnguided self-help intervention based on CBT, but also also makes use of DBT, PST, and MBCT. Participants receive up to six motivating automated e-mails and can ask questions using the FAQ function on the website.Wait-list RCTDutch-speaking adults recruited through online advertisements.
N: 236
Mean age: 40.93
Suicide: Moderate-severe SI (1–26 on the BSS)
Mental health: none
Suicide: Severe SI (> 26 on the BSS)
Mental health: Severe depression (> 39 on the BDI)
If participants in either condition exceeded cut-off scores of 26 on the BSS and/or 39 on the BDI, a psychologist contacted them by phone and a conducted a risk assessment. If necessary, their GP was contacted. Participants’ GPs were also contacted if a participant could not be reached by phone.
 van Spijker et al., 2018 [44]AustraliaLiving With Deadly Thoughts: unguided self-help intervention based on CBT, adapted from van Spijker 2014 (see above).RCTAustralian adults recruited via online media forums including websites, social networking websites, and advertising on search engines.
N: 418
Mean age: 40.6
Suicide: Current SI (single-item)
Mental health: none
Suicide: SA in the past month (single-item)
Mental health: History of diagnosed psychotic disorder
At each time point suicide risk was assessed using C-SSRS. Scores of 5 on any item alerted the participant to contact the Suicide Call Back Service (SCBS). Not doing this within 2 days triggered a reminder email to the participant, as well as a message to the SCBS asking them to contact the participant (if contact information was available, otherwise no further action was taken). The provision of contact information to the research team or to SCBS was voluntary.
 Wilks et al., 2018 [45]USAiDBT-ST: self-guided internet-delivered DBT skills
training intervention. Participants were emailed fillable DBT worksheets and encouraged to engage in skills practice via daily emails and/or text messaging
Pilot RCTRecruited via online forums accessible throughout the United States
N: 59
Mean age: 38.0
Suicide: SI in past month (> 1 on Item 1 of the SBQ-R)
Mental health: 2+ episodes of Heavy Episodic Drinking AND high emotion dysregulation
Suicide: None
Mental health: Diagnosis of Bipolar I or a psychotic disorder;
Enrolled in psychotherapy and unwilling to discontinue treatment
Weekly questionnaires assessing suicide risk were emailed to all participants. Participants endorsing a rating indicating high risk or an increase from the previous week were called and assessed for suicide risk. Additionally, the number for the National Suicide Prevention Lifeline was situated next to prompts on suicidality received by all participants.
Research underway
 Courtet, 2018 (NCT03410381) [46]FranceEcological Momentary Mental Assessment (EMMA): smartphone application requiring regular self-assessment of mood, risk and associated factors.Single-group study – participants complete assessments each month for 6 monthsRecruited method not reported
Target N: 100
Target age: 18+
Suicide: Recent suicidal attempt (<  8 days) or SI (≥ 2 on IDSC-30)
Mental health: none
Suicide: None
Mental health: None
An action plan is designed to support the participants, to help them facing difficult emotions and feelings, and to encourage them to ask for help. They can contact a relative or call the psychiatric emergency service directly by clicking on a button.
 De Jaegere et al., 2016 [47]BelgiumSelf-help intervention based on CBT, developed by van Spjiker 2014 (see above)RCTParticipants recruited via calls to suicide crisis hotline and via newspaper and online advertising.
Target N: 260
Target age: 18+
Suicide: Current SI (BSS > 0)
Mental health: none
Suicide: None
Mental health: None
Any participant who scores > 26 on BSSI and / or > 39 on BDI will be contacted by phone by a clinical psychologist. The psychologist will assess suicide risk, and if necessary, will contact the participant’s GP.
 Eylem, 2015
(NL4926 (NTR5028)) [48]
The Netherlands & EnglandSelf-help intervention based on CBT, culturally adapted from van Spijker et al., 2014 (see above)Wait-list RCTTurkish migrants, recruited via banners on relevant websites and through social media.
Target N: 286
Target age: 18+
Suicide: Mild to severe SI (>  1 on the BSS)
Mental health: none
Suicide: None
Mental health: None
Suicidal thoughts will be assessed once in every 2 weeks. If a participant scores above the cut-off (BSS > 29) then the researcher will ring them to conduct a risk assessment. If the participant does not answer their phone, they will be called for 3 working days at different times of the day. In case of no response after 3 days of attempting to call, a standardised e-mail will be sent asking the participant to contact the research team. The research team will also contact the participant’s GP to inform them about the high SI score. GP will be contacted if necessary following any risk assessment
 Larsen et al., 2017 [49]AustraliaRAFT: Text messages containing links to information and therapeutic contentSingle-group pre-test post-test studyRecruitment method not reported.
Target N: 50
Target age: 16–64
Suicide: Have presented to an emergency department in the previous 7 days for deliberate self-harm or suicidal behaviours
Mental health: none
Suicide: None
Mental health: Psychotic disorder
Not reported
 Nordentoft, 2016
(NCT02877316) [50]
DenmarkMyPlan: Smartphone application for safety planning, used in addition to face-to-face mental health treatment in collaboration with clinician.RCTClients of specialised suicide prevention outpatient service.
Target N: 546
Target age: All
Suicide: Current/recent suicidality (as indicated by being client of service)
Mental health: none
Suicide: None
Mental health: Severe alcohol or substance abuse disorder (DSM-V)
Not reported
et al., 2017 [51]
DenmarkSelf-help intervention based on CBT, adapted from van Spijker et al., 2014 (see above)Waitlist RCTDanish adults recruited via the Danish Lifeline, psychiatric hospitals and outpatient clinics.
Target N: 438
Target age: 18+
Suicide: SI (> 3 on BSS)
Mental health: none
Suicide: None
Mental health: None
1) Participants only enrolled in the study after they provide their telephone number and the number of a contact person; 2) BSSI administered every second week over the first 6 weeks, scores ≥27, trigger phone call from trial manager. Trial manager phones emergency contact if participant cannot be reached for 3 days. The same procedure will be carried out if a participant stops using the intervention without notifying the trial manager. 3) Trial website lists contact information for psychiatric hospitals and suicide preventive clinics. 4) Participants encouraged to contact The Lifeline or their GP in crisis.
If the trial manager is worried that a participant is at imminent risk, they can obtain access to the participant’s personal identifier number, track the person and request an ambulance or the police.
 Nuij et al., 2018 [52]The Netherlands2 smartphone applications –
BackUp: safety planning (as above)
Ecological Momentary Assessment: self-monitoring
Both used together as part of participants’ regular treatment.
Single-group cohort studyRecruited via 3 mental health organisations (current outpatient or day-care patients).
Target N: 80
Target age: 18+
Suicide: experience SI.
Mental health: Major depressive disorder or dysthymia
Suicide: None
Mental health: Psychotic symptoms
Not reported
  1. ACT Acceptance and Commitment Therapy, AUDIT Alcohol Use Disorders Identification Test, BDI Beck Depression Inventory, BSS Beck Scale for SI, CBT Cognitive Behavioural Therapy, CAARMS Comprehensive Assessment of At Risk Mental States, DBT Dialectical Behavioural Therapy, IDSC-30 Inventory of Depressive Symptomatology, MBCT Mindfulness Based Cognitive Therapy, PHQ-9 Patient Health Questionnaire-9, PST Problem Solving Therapy, SA suicide attempt, SBQ-R Suicide Behavior Questionnaire-Revised, SI Suicidal ideation