Information and communication technology-based interventions for suicide prevention implemented in clinical settings: A scoping review

Abstract

Background
There is a surplus of information communication technology (ICT) based interventions for suicide prevention. However, little is known about which of these ICTs are implemented in clinical settings and their characteristics. This scoping review aimed to map and characterize evidence of ICTs for suicide prevention implemented in clinical settings. Furthermore, this review identified and characterized implementation barriers and facilitators, evaluation outcomes, and measures.

Methods
We conducted this review following the Joanna Briggs Institute methodology for scoping reviews. A search strategy was completed using the following databases between August 17–20, 2021: MEDLINE, Embase, CINAHL, PsycINFO, Web of Science, and Library, Information Science and Technology Abstracts. We also supplemented our search with Google searches and scanning of reference lists of relevant reviews. We used the Preferred Reporting Items for Systematic Reviews and Meta-Analyses Extension for Scoping Reviews to report our findings.

Results
This review included a total of 75 articles, describing 70 studies and 66 ICTs for suicide prevention implemented in clinical settings. The majority of ICTs were computerized interventions and applications (n = 55). These ICTs were commonly used as indicated strategies (n = 49) targeting patients who were actively presenting with suicide risk. The three most common suicide prevention intervention categories identified were post-discharge follow-up (n = 27), screening and assessment (n = 22), and safety planning (n = 20). A paucity of reported information was identified related to implementation strategies, barriers and facilitators. The most reported implementation strategies included training, education, and collaborative initiatives. Barriers and facilitators of implementation included the need for resource supports, knowledge, skills, motivation as well as engagement with clinicians with research teams. Studies included outcomes at patient, clinician, and health system levels, and implementation outcomes included acceptability, feasibility, fidelity, and penetration.

Conclusion
The findings from this review illustrate several trends of the ICTs for suicide prevention in the literature and identify a need for future research to strengthen the evidence base for improving implementation. More effort is required to better understand and support the implementation and sustainability of ICTs in clinical settings. The findings can also serve as a future resource for researchers seeking to evaluate the impact and implementation of ICTs.

Full text

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Information and communication technology-based interventions for
suicide prevention implemented in clinical settings: A scoping review
Hwayeon Danielle Shin (  hdanielle.shin@mail.utoronto.ca )
Institute of Health Policy, Management, and Evaluation, University of Toronto, Ontario, Canada
Keri Durocher
Arthur Labatt Family School of Nursing, Western University, London, Ontario
Lydia Sequeira
Campbell Family Mental Health Research Institute, Centre for Addiction and Mental Health, Ontario
Juveria Zaheer
Gerald Sheff and Shanitha Kachan Emergency Department, Centre for Addiction and Mental Health, Ontario
John Torous
Department of Psychiatry, Beth Israel Deaconess Medical Center, Harvard Medical School, Massachusetts
Strudwick Gillian
Campbell Family Mental Health Research Institute, Centre for Addiction and Mental Health, Ontario
Research Article
Keywords: Information Communication Technology, eHealth, Suicide Prevention, Implementation, Digital Health, Health Informatics, Psychiatry,
Mental health
Posted Date: September 7th, 2022
DOI: https://doi.org/10.21203/rs.3.rs-1910437/v1
License:   This work is licensed under a Creative Commons Attribution 4.0 International License.  Read Full License

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Abstract
Background
There is a surplus of information communication technology (ICT) based interventions for suicide prevention. However, little is known about
which of these ICTs are implemented in clinical settings and their characteristics. This scoping review aimed to map and characterize evidence of
ICTs for suicide prevention implemented in clinical settings. Furthermore, this review identied and characterized implementation barriers and
facilitators, evaluation outcomes, and measures.
Methods
We conducted this review following the Joanna Briggs Institute methodology for scoping reviews. A search strategy was completed using the
following databases between August 17–20, 2021: MEDLINE, Embase, CINAHL, PsycINFO, Web of Science, and Library, Information Science and
Technology Abstracts. We also supplemented our search with Google searches and scanning of reference lists of relevant reviews. We used the
Preferred Reporting Items for Systematic Reviews and Meta-Analyses Extension for Scoping Reviews to report our ndings.
Results
This review included a total of 75 articles, describing 70 studies and 66 ICTs for suicide prevention implemented in clinical settings. The majority
of ICTs were computerized interventions and applications (n = 55). These ICTs were commonly used as indicated strategies (n = 49) targeting
patients who were actively presenting with suicide risk. The three most common suicide prevention intervention categories identied were post-
discharge follow-up (n = 27), screening and assessment (n = 22), and safety planning (n = 20). A paucity of reported information was identied
related to implementation strategies, barriers and facilitators. The most reported implementation strategies included training, education, and
collaborative initiatives. Barriers and facilitators of implementation included the need for resource supports, knowledge, skills, motivation as well
as engagement with clinicians with research teams. Studies included outcomes at patient, clinician, and health system levels, and implementation
outcomes included acceptability, feasibility, delity, and penetration.
Conclusion
The ndings from this review illustrate several trends of the ICTs for suicide prevention in the literature and identify a need for future research to
strengthen the evidence base for improving implementation. More effort is required to better understand and support the implementation and
sustainability of ICTs in clinical settings. The ndings can also serve as a future resource for researchers seeking to evaluate the impact and
implementation of ICTs.
Introduction
The World Health Organization (WHO) reports that there are over 700,000 annual deaths by suicide worldwide [1, 2]. Globally, suicide is the fourth
leading cause of deaths for youth and young adults [1], and specically it is the second in Canada and USA [3, 4], and the rst leading cause of
deaths for young people in Australia [5]. Suicide prevention is a top global health priority, which is also indicated in the United Nations Sustainable
Development Goals for 2030 [6].
Suicide is preventable with timely, evidence-based interventions [2]. Information and communication technology (ICT) [7] or eHealth [8] includes a
wide range of tools such as Internet, telemedicine, and mobile technologies. There is a large number of ICT-based interventions for mental health,
including suicide prevention strategies [9, 10]. Given the widespread use of technologies in this modern world, including mobile phones, ICTs have
the potential to improve suicide prevention by removing geographical barriers and increasing access and availability of evidence-based
interventions [10]. Furthermore, there is a growing body of evidence for the effectiveness of ICT-based interventions for suicide prevention [9, 11–
16].
Despite the signicant clinical potential and a large number of available ICTs for mental health, clinical integration remains limited and continues
to face challenges to achieve sustainable adoption [17–19]. It has been repeatedly reported that implementation of ICTs rarely moves beyond
feasibility trials or initial adoption, and sometimes ICTs become abandoned [20]. Healthcare is a complex adaptive system, which is shaped by
multiple, constant interdependent interactions and relationships [21, 22]. When complexities exist related to care settings or implementation
challenges, the less likely ICTs are to be adopted and sustained [20, 23]. As such, research teams are required to move beyond traditional cause-
and-effect thinking, embrace complexity, and examine dynamic processes inherent within. Specically for mental health apps, there was a recent
call for attention to complex contexts in which apps are being implemented [17]. It is critical to prospectively assess barriers and facilitators in the

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organizational and local context and then strategically develop implementation strategies. Efforts are needed to support clinical integration of
ICTs for suicide prevention as well as their spread and maintenance to ensure that useful ICTs are reaching people who are in need.
Currently, the literature on ICTs for suicide prevention describes their characteristics and/or evaluates their effectiveness in reducing suicide
behaviours and risks [9–14]. However, little is known about which ICTs have been implemented in clinical settings and their related barriers and
facilitators to implementation. Given the lack of successful clinical integration of ICTs [17–19], this review was needed as a rst step to inform
implementation efforts for useful ICTs for suicide prevention in clinical settings. Furthermore, this review was a part of a multi-phase project to
develop and evaluate implementation strategies for a mobile app-based intervention for suicide prevention in clinical settings. As such, the current
scoping review aimed to identify and characterize evidence on ICT-based interventions for suicide prevention implemented in clinical settings and
then to characterize barriers and facilitators to implementing these ICTs, as well as reported measures and outcomes. The ndings from this
review will be used as a knowledge base for the subsequent research to identify strategies to overcome barriers and leverage facilitators to
maximize implementation. A search of PROSPERO, the Cochrane Database of Systematic Reviews and Joanna Briggs Institute (JBI) Evidence
Synthesis and Open Science Framework was conducted in June-July 2021, and no current or ongoing systematic or scoping reviews on the topic
were identied.
Research questions
To achieve the research aims stated above, this scoping review addressed the following questions.
1. What ICT-based interventions for suicide prevention have been implemented in clinical settings?
1.1 What are the reported barriers and facilitators to implementing these ICT-based interventions?
1.2 What are the reported measures and outcomes?
Methods
This review followed the Joanna Briggs Institute (JBI) methodology [24, 25] and the Preferred Reporting Items for Systematic Reviews and Meta-
Analysis (PRISMA-ScR) extension for scoping reviews [26]. Our a priori protocol has been previously published [27]. Major steps of this scoping
review were: (1) Searching for relevant studies; (3) Screening and selecting relevant studies; (4) Extracting data; (5) Analyzing data; and (6)
Summarizing and presenting key ndings.
Inclusion/exclusion criteria
Participant
All types of clinicians who are licenced and regulated practitioners were included in this review. A wide range of health care professionals who
provide direct care in clinical settings (e.g., physicians, nurses, social workers, and medical residents) are commonly referred to as ‘clinicians’ [28,
29]. Additionally, unregulated practitioners and clinical support team members, such as peer support workers were also included since they are
increasingly being adopted in mental health clinical settings [30, 31]. There were no exclusion criteria based on gender, health care discipline, and
years of experience. Lastly, this review considered all ICT-based interventions that targeted patient populations of any age.
Concept
This review considered all types of ICT-based interventions related to suicide prevention. ICTs included, but were not limited to, computerized
resources, mobile apps, and telemedicine. Additionally, the following denition provided by the WHO was adopted to identify interventions: “A
health intervention is an act performed for, with or on behalf of a person or population whose purpose is to assess, improve, maintain, promote or
modify health, functioning or health conditions” [32]. Routine care (i.e., treatment as usual) provided via virtual platforms or telephones were
excluded unless a novel ICT was delivered. This review excluded crisis services since there has already been a systematic review investigating
their effectiveness [33]. The current review will use the umbrella term, suicide-related thoughts and behaviours, which refers to a spectrum of
suicide-related ideation, communication, behaviours, and attempts with having casual to persistent suicidal thoughts with actual, undetermined or
no suicidal intent [34]. ICT-based interventions for suicide prevention regarding any sub-category of suicide-related thoughts and behaviours,
including Non-Suicidal Self Injury (NSSI), were included. Lastly, ICTs related to all levels of suicide prevention following the WHO description (i.e.,
Universal, Selective, Indicated) [1] were included.
Context
All types of clinical settings including both in-patient and out-patient locations were considered for inclusion. For this review, a clinical setting was
dened as any context where clinician-patient interactions occurred in real-time. To be included, ICT-based interventions needed to be
implemented and initiated in clinical settings. Self-support tools that patients can freely download from app stores or tools that involved self-

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referrals after reading public advertisements were excluded as these were being initiated in non-clinical settings. Further to this, studies focusing
on the development of ICT(s) without implementing them in the clinical setting were excluded. See Table1 for summary of eligibility criteria.
Table 1
Eligibility criteria
Inclusion criteria Exclusion criteria
Population All members of clinical care team
• licenced and regulated practitioners
• Unregulated practitioners or clinical support teams such as peer support workers
All ages, genders, locations, and years of experience
Not a member of
clinical care team
Topic Information and Communication Technologies (ICTs): “A set of technologies resulting from the
convergence of information technology and advanced multimedia and telecommunications
techniques, which have enabled the emergence of more ecient means of communication, by
improving processing, storage, distribution and exchange some information” [7].
Suicide-related thoughts and behaviours [34]: represent a spectrum of suicide-related ideation,
communication, behaviours and attempts with having casual to persistent suicidal thoughts with
actual, undetermined or no suicidal intent. This review will consider ICT-based interventions for suicide
prevention regarding any sub-category of suicide-related thoughts and behaviours.
Suicide Prevention Intervention Category adapted from Wilson [39] and Zalsman [40])
• Screening and assessment
• Safety plan (e.g., identifying warning signs coping strategies, emergency contacts)
• Lethal means restriction and counselling
• Discharge or post-discharge follow up
• Behaviour or cognitive therapies
No ICTs
Crisis services
(phone, chat, text)
Care as usual
Setting Clinical/hospital setting or context (i.e., clinician-patient interaction in real time) Not a clinical setting
or context
Source Primary research papers including in press papers. If literature reviews, commentaries, and opinion
papers include relevant primary research studies, this review will include them in the screening phase
then hand-search their references to identify the original papers that meet the inclusion criteria.
Conference papers, reports from relevant health services organizations.
Books, theses,
commentaries,
opinion papers,
literature reviews,
preprints, abstracts
Type of
study All designs including study protocols N/A
Language English non-English
language

Search strategy
In collaboration with a health sciences librarian, a comprehensive search strategy was developed to nd relevant scholarly literature using
multiple bibliographic databases. This scoping review followed a three-step search strategy outlined in JBI methodology [25]. First, we developed
and rened a draft strategy in Medline, followed by an analysis of the text words contained in titles and abstracts of relevant articles and the
subject headings. After revising, testing, and nalizing this search strategy, a librarian translated and ran the search in the following databases on
August 17–20, 2021: MEDLINE (Ovid), Embase (Elsevier), CINAHL (EBSCO), PsycINFO (EBSCO), Web of Science, and Library, Information Science
and Technology Abstracts (LISTA). The search strategy was peer-reviewed by a second research librarian using the Peer Review of Electronic
Search Strategy (PRESS) guidelines [35]. All nal search strategies are presented in Additional File 1.
Types of sources
The targeted Google search method outlined by Godin [36] was used to identify international and national health service’s websites to locate
reports, additional studies, and other eligible sources. The rst step involved conducting ten unique Google searches with different combinations
of keywords and reviewing the rst 100 items of each search to identify relevant websites. The second step involved hand-searching identied
relevant websites to nd reports or other sources that met the inclusion criteria. This Google search was complementary to the database searches
to identify additional sources of evidence that our search strategy might have missed.
Study selection

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All identied citations were collated and uploaded into Covidence [37] and duplicates were automatically removed. Two reviewers (HDS, LS)
independently screened titles and abstracts against the inclusion and exclusion criteria. Next, relevant full-text articles were retrieved into
Covidence [37], and the primary reviewer (HDS) and a pair of reviewers (KD, LS) participated in the independent assessment of full-text, relevant
papers in detail against the eligibility criteria. Reasons for exclusion were recorded at the full-text screening phase. Any discrepancies between the
reviewers at each stage of the study selection process were resolved either through discussion or by a third reviewer. Scoping reviews do not
require methodological assessment [25], thus critical appraisal was not conducted.
Data extraction
We developed an extraction tool to capture the following information: Characteristics of the paper, setting, participating clinicians, implementation
strategies, ICT-based intervention(s), patient population, barriers and facilitators to implementing ICTs, and reported measures and outcomes.
Three reviewers (HDS, KD, LS) rst pilot-tested the extraction tool on three studies to identify any discrepancies or inconsistencies prior to data
extraction. See Additional File 2 for the nal version of the data extraction tool. The primary reviewer (HDS) and a pair of reviewers (KD, LS)
independently extracted data using Covidence [37]. Any conicts in data extraction were resolved either through discussion between the two
reviewers or by a third reviewer. Lastly, authors of the included articles were contacted to request any missing or additional information when
necessary.
Data analysis
Following data extraction, this review characterized extracted data using frameworks, typology, and taxonomy to address the proposed review
questions. First, identied ICT-based interventions were categorized using a typology for e-Mental Health created by the Mental Health
Commission of Canada (MHCC) [38]. Interventions were then characterized based on the suicide prevention interventions category adapted from
Wilson [39] and Zalsman [40], and the three levels of suicide prevention following the descriptions provided by the WHO [1]: (1) Universal, (2)
Selective, (3) Indicated. Second, we performed directed content analysis [41] to describe clinician-reported barriers and facilitators to
implementing ICT-based interventions using the Behaviour Change Wheel (BCW) [42, 43] and Theoretical Domains Framework (TDF) [44]. The
BCW [42, 43] and TDF [44] are comprehensive, evidence-based behaviour frameworks that capture both internal and external inuences on an
individual’s behaviour change. The BCW assumes that human behaviours are resultants of interactions between one’s capability, opportunity and
motivation, known as the COM-B model [42]. The TDF is a 14-domain behavioural framework that expands the COM-B [44]. When used together,
the TDF allows for granularity of behaviour analysis [45]. Furthermore, the BCW and TDF have been previously used across healthcare disciplines
to assess implementation problems and provide theory-informed suggestions for implementation [46–48]. In this review, narrative descriptions of
barriers and facilitators reported in the papers were coded onto the most appropriate domains of the COM-B and TDF. Third, this review
categorized reported measures and outcomes of interest. Outcomes were categorized as either implementation outcomes of the ICT or the impact
of ICTs at three levels. Implementation outcomes were characterized using Proctor’s Implementation Outcomes Framework: (1) Acceptability, (2)
Adoption, (3) Appropriateness, (4) Feasibility, (5) Fidelity, (6) Implementation cost, (7) Penetration, and (8) Sustainability [49]. The three levels of
impact included (1) Patient, (2) Health care provider (i.e., clinician), and (3) Health system. Patient level impact was further categorized into
patient-reported outcomes (PRO) [50], patient-reported experience (PRE) [51], and patient health outcomes (e.g., mortality) [52]. PRO is
measurement of “any report of the status of a patient’s health condition that comes directly from the patient” [50], measuring the patients’ views
of their health status and providing insight into the impact of an intervention [51]. In contrast to PRO, PRE measures “patients’ perceptions of their
experience whilst receiving care,” providing insight into the quality of care during the intervention and the process of the care on the patient’s
experience [51]. Health care provider level outcomes include conceptual knowledge use (i.e., proximal practice change), instrumental knowledge
use (i.e., observable practice change) [53], and other provider-reported experiences. Examples of conceptual knowledge use include levels of
knowledge, and examples of instrumental knowledge use include rates of completed assessments [53]. Lastly, system level outcomes include
resource utilization and economic outcomes (e.g., cost effectiveness, readmission rates) [52].
The data coding strategy was pilot tested for three studies and assessed for further modication. After nalizing the coding strategy, the primary
reviewer (HDS) coded all data, and then the second reviewers (KD, LS) veried them. Any disagreements that arose between the reviewers were
resolved through discussion. See Additional File 3 for the full coding strategy which includes denitions.
Data summarizing and reporting results
We charted the data in tabular forms to align with the review objectives. We also produced descriptive numerical summaries of the quantitative
data (i.e., frequency counts) and graphical gures. Lastly, we provided a narrative summary to accompany these presentations and addressed the
review questions and objectives.
Results
Our database searches resulted in 6,008 citations. After duplicate removal, 3,659 citations remained for assessment against the eligibility criteria.
After screening titles and abstracts, 242 citations remained for full-text review, and we identied an additional 6 relevant papers through Google

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searches and reviewing references of relevant reviews. This review included a total of 75 articles, describing 70 studies and 66 ICT-based
interventions. See Fig.1 for the PRISMA ow chart which includes the reasons for excluding full-text articles.
Characteristics of included studies
Of the 75 papers, 18 were protocols, of which ve of them had corresponding study reports. When not counting duplicate papers from the
protocol-study dyads (n = 5) [54–58], this review identied a total of 70 different studies. Seventy studies were a mix of experimental design (n =
22), observational design (n = 12), qualitative design (n = 3), case study (n = 1), quality improvement report (n = 1), and feasibility/pilot trial (n = 31)
that served as a precursor to a larger study. These 70 studies originated from USA (n = 32), France (n = 8), UK (n = 8), Australia (n = 5), Denmark (n
= 5), Canada (n = 4), Korea (n = 2), Netherlands (n = 1), Iran (n = 1), Sri Lanka (n = 1), Japan (n = 1), Spain (n = 1), and Portugal (n = 1). Studies took
place in out-patient clinical settings (n = 43), such as emergency departments (EDs) and clinics, in-patient clinical settings (n = 14), such as in-
patient psychiatric units, and a mixture of both (n = 11). Examples of involved clinicians included psychiatrists, nurses, physicians, social workers,
behaviour health clinicians, and psychologists. Lastly, there was a lack of reported theories, models, or frameworks (TMFs) guiding research.
Seven studies explicitly reported TMFs guiding their research [59–65], including the User-Centered Design Principles, Proctor’s Implementation
Outcomes Framework, Theory of Planned Behaviour, Interpersonal Psychological Theory of Suicide, Integrated Motivational-Volitional model of
suicidal behaviour, Medical Research Council, Process evaluation framework for analysis, and Normalisation Process Theory. Table2 summarizes
overall characteristics of included papers.

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Table 2
Characteristics of included papers
Author, Year Country of
origin Study design Research
aim/objectives/
questions
Patient
population Clinical setting
and type Clinician
characteristics
Andreasson et al.,
2017 [145]
(Protocol)
Denmark Experimental -Investigate if a
safety planning
tool delivered as
an app, compared
to a safety plan
delivered by
paper, can reduce
suicide ideation
after 12 months
of intervention in
patients referred
to Suicide
Prevention
Clinics.
Patients from
Suicide
Prevention
Clinics
Seven Suicide
Prevention Clinics
and their satellite
sites. Patients are
typically referred
to the clinics from
somatic and
psychiatric EDs
after a self-harm
episode.
Out-patient
Clinicians working at
the Suicide Prevention
Clinics
Bailey et al., 2020
[91] Australia Experimental -Evaluate the
safety, feasibility,
and acceptability
of a MOST
intervention
(“Anity”) among
a sample of
young people
who were
receiving
treatment for
major depressive
disorder and had
also experienced
past-four-week
suicidal ideation.
-Explore changes
in cognitive and
interpersonal
targets of the
Anity
intervention, as
well as changes
in self-reported
depression and
suicidal ideation.
Patients with
suicidal
ideation within
the past four
weeks
The Youth Mood
Clinic (YMC), a
tertiary-level
outpatient mental
health service
that is part of
Orygen, a state
government-
funded youth
mental health
service in
Melbourne,
Australia. YMC
specialises in the
treatment of
young people
with complex
depression.
Out-patient
Youth mental health
clinicians from the
youth mood clinic and
treating clinicians and
Anity staff
Berrouiguet and
Alavi et al., 2014
[54]
(Protocol)
HUGOPSYNetwork
et al., 2018 [146]
France Experimental
*Only reported
descriptive
results on
selected cases
-Determine
whether the
receipt of a text
message sent
regularly over a
six-month period
can reduce
suicidal and self-
harming
behaviour among
suicide
attempters.
-Identify cases of
patients recruited
in the SIAM study
that may
demonstrate the
capability of a
mobile-based
brief contact
intervention for
triggering patient
-Initiated contact
with a crisis
support team at
various time
points throughout
the mobile-based
follow-up period.
Patients who
attempted
suicide
Psychiatric EDs
and psychiatric
units. Public
funded specialist
mental health
services for
adults (Brest,
Rennes, Nantes,
Lille, Angers,
Tours, Vannes)
Mixture
Psychiatrist, general
physician

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Author, Year Country of
origin Study design Research
aim/objectives/
questions
Patient
population Clinical setting
and type Clinician
characteristics
Berrouiguet and
Gravey et al., 2014
[127]
France Pilot/Feasibility
trial -Assess the
technical
feasibility of an
automated and
tailored text
messaging tool in
a sample of
suicidal patients.
-Assess the
patient's
acceptability of
such intervention
through a phone
interview.
Patients who
attempted
suicide
Psychiatric ED
Out-patient
Psychiatrist, general
physician
Betz et al., 2020
[138] United
States Pilot/Feasibility
trial -Test the
feasibility and
acceptability of
Lock to Live (L2L)
among suicidal
adults in EDs.
Patients with
identied
suicide risk
4 large EDs in
Colorado: A
tertiary care
academic center,
an urban safety
net hospital, and
a regional
medical center
with 2 EDs in a
geographic region
with rearm
ownership rates
that are higher
than state
averages. All EDs
had 24/7
coverage by
behavioral health
specialists.
Out-patient
Not reported
Brand and
Hawton, 2021[95] United
Kingdom Pilot/Feasibility
trial -Ascertain the
usefulness for
patients and
clinicians of a
digital self-
monitoring
system alongside
outpatient follow-
up after patients
had presented to
a general hospital
with self-harm
Patients with
self-harm A large general
hospital in
Oxford, England.
The Emergency
Department
Psychiatric
Service (EDPS) is
based in a large
general teaching
hospital and
offers
psychosocial
assessment to
anyone aged over
13 years who
presents to a
hospital ED
following an
episode of self-
harm or any other
mental health
issue.
Out-patient
Five nurses in the
EDPS team
Bruen et al., 2020
[81] United
Kingdom Pilot/Feasibility
trial -Report the
practicalities and
acceptability of
setting up and
trialling digital
technologies
within an
inpatient mental
health setting in
the United
Kingdom and to
highlight the
implications of
these for future
studies
Services users
from acute
adult mental
health wards
6 National Health
Service acute
mental health
wards in
Northwest United
Kingdom
In-patient
NR

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Author, Year Country of
origin Study design Research
aim/objectives/
questions
Patient
population Clinical setting
and type Clinician
characteristics
Bush et al., 2015
[66] United
States Pilot/Feasibility
trial Research
questions:
-Can a
smartphone app
be developed that
contains the
essential
elements of a
hope box and
associated
elements of
CT/DBT in a
package
acceptable to and
usable by military
service members
and veterans?
-Is the VHB app
as usable,
acceptable,
convenient, and
ostensibly useful
as a conventional
hope box to a
clinical sample of
service veterans
at high risk of
self-harm and
suicide and their
providers?
High-risk of
self-harm
veterans who
either had
borderline
personality
disorder,
bipolar
disorder,
treatment
refractory
depression, or
PTSD
Large, regional
Veteran
Administration
(VA) behavioral
health clinic
Out-patient
6 Clinical social
workers and one
clinical psychologist,
with a mean of 7.9
years (range 1–16
years) in practice.
Bush et al., 2017
[67] United
States Experimental -Assess the
primary impact of
Virtual Hope Box
(VHB) on stress
coping skills over
12 weeks, the
secondary impact
of VHB on
suicidal ideation
and reasons for
living, the use of
VHB for
addressing
emotional dis-
equilibrium away
from the clinic,
and the patient
experience of
VHB through
objective usage
patterns and self-
reported usability
and perceived
benets.
Veterans who
currently
expressing
suicidal
ideation or had
expressed
suicidal
ideation within
the three
months before
recruitment
13 Treatment
programs within
Veteran Mental
Health Care
(Outpatient -
Veterans Affairs
Portland Health
Care System).
Out-patient
Behavioral health
clinicians
Buus et al., 2020
[147] Denmark Qualitative -Explore different
stakeholder
perspectives on
the MYPLAN app
for suicide
prevention safety
planning.
Young and
adult users
with variations
in
psychosocial
problems
Clinics that offer
short-term,
specialized
psychosocial
therapy to
patients at risk of
suicide.
Out-patient
Clinicians with median
age of 46 (range: 37–
60).
Female: n = 9
Male: n = 1
Cassola et al.,
2017 [69]
(Protocol)
Portugal Pilot/Feasibility
trial -Understand the
health
professional’s
satisfaction on
the use of the
platform for
depression and
suicidality
Patients with
depression and
suicidality
Primary health
care setting
Out-patient
18 Primary care health
professionals

Page 10/55
Author, Year Country of
origin Study design Research
aim/objectives/
questions
Patient
population Clinical setting
and type Clinician
characteristics
Cebrià 2013 [70] Spain Experimental -Determine the
effectiveness of
this specic
telephone
management on
patients
Patients who
attempted
suicide
Emergency room
of Corporacio
Sanitaria Parc
Taulı (CSPT) that
covers an area of
400,000
inhabitants and
provides urgent
medical attention
for all suicidal
behaviours
Out-patient
Nurse
Chen et al., 2010
[125] Canada Pilot/Feasibility
trial -Determine
whether a mobile
telephone
message
intervention
would be
acceptable to
suicide
attempters
-Explore the
operational
procedures of this
intervention to
help determine
the appropriate
content of
supportive
messages
-Test the
feasibility of cell-
phone message
interventions.
Patients who
attempted
suicide
EDs of two
general hospitals,
Tongji Hospital
and Union
Hospital, in
Wuhan, China.
Out-patient
Nurses and
psychologists
Chen et al., 2018
[68] United
States Observational -Describe usage
of specic app
subcomponents
and to determine
if specic
demographic and
clinical
characteristics
were associated
with higher or
lower overall use
of the VHB.
-Explore the
association
between usage of
the VHB and
psychosocial
outcomes
Patients with
recent or
ongoing
suicidal
ideation and
were engaged
in active
mental health
treatment
13 Clinical
programs at a
large, north-
western Veterans
Health
Administration
hospital
Out-patient
Not reported
Comtois et al.,
2019 [71] United
States Experimental -Test the
effectiveness of
augmenting
standard military
health care with
Caring Contacts
delivered via text
message to
reduce suicidal
thoughts and
behaviors over 12
months
Patients with
suicidal
ideation or
suicide
attempt
3 Military
installations: an
Army base in the
southern United
States, a Marine
Corps base and
air stations in the
southern United
States, and a
Marine Corps
base in the
western United
States.
Out-patient
Licensed masters level
mental health
clinicians, who were
called continuity
clinicians and
credentialed as
behavioural health
clinicians.

Page 11/55
Author, Year Country of
origin Study design Research
aim/objectives/
questions
Patient
population Clinical setting
and type Clinician
characteristics
Czyz et al., 2021
[128] United
States Pilot/Feasibility
trial -Investigate the
feasibility and
acceptability of
SMART study
procedures,
including the
sequencing of
intervention
components.
Patients with
suicidal
ideation or
suicide
attempt
In-patient
psychiatric unit
In-patient
A total of 3 masters
level training in
psychology or social
work (Counselors)
Czyz et al., 2020
[148] United
States Pilot/Feasibility
trial -Describe the
process of
development and
report on the
feasibility and
acceptability of
the text-based
intervention as a
continuity of care
strategy
promoting coping
and safety plan
use following
discharge.
Patients with
suicidal
ideation or
suicide
attempt
Adolescent
mental health
hospital
In-patient
NR
Davis et al.,
2021[139] United
States Observational -Describe levels of
adolescent
suicide risk
detected via
depression
screening in a
large primary care
network
-Understand
delity to the
system’s suicide
risk assessment
procedures
Examine follow-
up for
adolescents at-
risk for suicidality
in the year after
risk was detected.
Patients with
suicidal
ideation or
suicide
attempt
A large pediatric
healthcare facility
Mixture
NR
Depp et al.,
2021[72]
(Protocol)
United
States Pilot/Feasibility
trial -Rene
intervention
content and
safety protocol
with input from
community
stakeholders.
-Evaluate
feasibility,
engagement,
impact, and
preliminary
comparison of
START with
Mobile
Augmentation
versus START
alone.
Patients with
DSM-5 of
bipolar
disorder,
schizoaffective
disorder, or
schizophrenia
and having
suicidal
ideation
Public mental
health system
(Walk-in or same-
day clinics) in
San Diego,
California
Out-patient
A triage provider
(typically a social
worker)

Page 12/55
Author, Year Country of
origin Study design Research
aim/objectives/
questions
Patient
population Clinical setting
and type Clinician
characteristics
Dimeff et al.,2020
[59] United
States Pilot/Feasibility
trial
TMF:
User cantered
design
principles
-Design, develop,
and evaluate the
feasibility of “Dr.
Dave” and the
Virtual CAMS
system, including
electronic “Caring
Contacts,” for
suicidal patients
in EDs, as well as
a provider-facing
clinical decision
support tool to
aid in discharge
disposition to
reduce
unnecessary
hospitalization
Patients with
identied acute
suicide risk
EDs and 3 private
outpatient
specialty clinics
Mixture
21 Medical providers
Dimeff et al., 2021
[73] United
States Pilot/Feasibility
trial -Examine the
feasibility,
acceptability, and
effectiveness of
Jaspr Health for
adults who were
acutely suicidal in
the ED.
Patients with
suicide
attempt and/or
a lifetime
history of
engaging in
non-suicidal
self-injurious
behaviors
2 EDs from large
health systems in
Midwest US. Each
ED offered 24/7
psychiatric care
offered by
behavioral health
providers.
Out-patient
Behavioural health
providers, masters level
social workers and
physician, psychiatrist
and psychiatric nurse
practitioner
Duhem et al.,
2018 [92]
(Protocol)
France Experimental -Implement an
adaptive
recontact system
that smoothly
and effectively
combines
surveillance and
different types of
Brief Contact
Interventions that
t each patient’s
specic needs.
-Optimise the care
management of
patients
discharged from
the hospital after
a suicide attempt
by providing
health
stakeholders with
standardised
tools, effective
skills and
specialised
literacy.
-Offer
professionals
involved in the
follow-up of
suicide
attempters a
readily available
alert network to
improve their
coordination and
reactivity in case
of new suicidal
crises
Patients who
attempted
suicide
A total of 28
Centres in Nord–
Pas-de-Calais
region: EDs,
psychiatry crisis
centres,
psychiatry
departments, and
private clinics.
Mixture
Coordination team, and
a call team consisting
of 3 psychologists and
3 psychiatric nurses

Page 13/55
Author, Year Country of
origin Study design Research
aim/objectives/
questions
Patient
population Clinical setting
and type Clinician
characteristics
Etter et al., 2018
[149] United
States Observational -Assess the use of
a computerized
clinical decision
support system
(CDSS) to screen
adolescents for
suicide risk,
deliver follow-up
recommendations
to the provider,
and document
actual provider
follow-up actions
in a primary care
setting
Patients who
presented to
pediatric
primary care
clinic for an
annual or sick
visit
Federally
qualied health
center clinics that
utilize Child
Health
Improvement
through Computer
Automation
(CHICA) and are
part of an urban,
Midwest County
hospital system
(Eskenazi Health)
Out-patient
Physicians were
primarily trained in
pediatrics, family
medicine, and
combined internal
medicine and
pediatrics, with some
having completed
subspecialty
fellowship training in
adolescent medicine.
Fossi Djembi et
al., 2020 [88] France Observational -Test the
hypothesis of a
correlation
between the
decrease of SA
rate and the
amount of
coverage of
VigilanS
Patients who
attempted
suicide
21 hospitals
(EDs) in the Nord-
Pas-de-Calais
region.
Out-patient
Mental health care
professionals specially
trained in suicidal
crisis management
Fossi et al.,
2021[150] France Observational -Describe the
characteristics of
the patients, to
estimate the
mean time
between suicidal
iterations, and to
identify the
proles of
patients who had
a suicide
reattempt
compared to
other patients.
Patients who
attempted
suicide
Emergency
Department in
regional France
Out-patient
Not reported
Goodman et al.,
2020 [82]
(Protocol)
United
States Experimental -Examine if
Veterans who are
at high-risk for
suicide will
benet from the
novel group
intervention, PLF,
compared to
Veterans who
receive TAU (e.g.,
individual safety
planning).
Patients with
suicidal
ideation or
suicide
attempt
Multiple sites of
Veterans Health
Administration
(VHA) in New
York and
Philadelphia
Out-patient
2 Therapists
Gregory et al.,
2017 [83] Canada Observational -Examine whether
or not we could
effectively
integrate
smartphone-
based safety
planning into the
discharge process
on a child and
adolescent
inpatient
psychiatry unit.
Patients
discharged
from the child
and adolescent
psychiatry
inpatient unit
The child and
adolescent
psychiatry
inpatient unit at
London (Ontario)
Health Sciences
Centre
In-patient
Unit staff (either nurses
or child and youth
counsellors)

Page 14/55
Author, Year Country of
origin Study design Research
aim/objectives/
questions
Patient
population Clinical setting
and type Clinician
characteristics
Grist et al., 2018
[74] United
Kingdom Qualitative -Explore the
acceptability,
usability, and
safety of BlueIce
with young
people aged 12–
17 years who are
self-harming and
attending child
and adolescent
mental health
services
(CAMHS).
Patients with
self-harm CAMHS provided
by Oxford Health
NHS Foundation
Trust. The Trust
provides mental
healthcare for
children and
young people in
Buckinghamshire,
Oxfordshire,
Swindon,
Wiltshire, and
Bath and North-
East Somerset
Out-patient
37 clinicians
Gros et al., 2011
[94] United
States Case study -The case report
concerns a US
veteran of the
Afghanistan war
with PTSD, who
developed severe
suicidal ideation.
One patient
(case report)
-45yrs old
-PTSD
-Suicidal
ideation
-African
American
-Male
-Veteran
-Lived in trailer
with two adult
children
-Divorced
Hospital in South-
east US
Out-patient
2 Therapists
Hatcher et al.,
2020 [84]
(Protocol)
Canada Experimental -Evaluate the
relationship
between the
amount of
smartphone-
assisted problem-
solving therapy
(PST) and
suicidal ideas in
men over a 1-year
period.
Patients with
self-harm 10 Sites from the
department of
psychiatry and
department of
emergency
medicine in
Ontario, Canada
Mixture
Not reported
Hetrick et al., 2017
[131] Australia Pilot/Feasibility
trial Research
Questions:
-Whether the
online depression
and suicidal
ideation
monitoring tool
was feasible in
terms of
improving
monitoring,
-How acceptable
and useful the
tool was for
clinicians and
clients, and
-Whether a rened
(shorter) tool
could be
implemented
Patients with
depressive
symptoms or a
depressive
disorder
One primary, two
enhanced primary
care, and one
tertiary care
setting in Victoria.
In the primary
care setting
within a routine
general practice,
mental health
care was provided
to clients of all
ages. The tertiary
care setting was a
public mental
health service
(Orygen Youth
Health) for young
people aged 15–
24 years.
Out-patient
Clinicians from a range
of backgrounds
including clinical
psychologists and
other allied health
professionals.

Page 15/55
Author, Year Country of
origin Study design Research
aim/objectives/
questions
Patient
population Clinical setting
and type Clinician
characteristics
Hill et al., 2020
[60] United
States Pilot/Feasibility
trial
TMF:
Proctor ‘s
Implementation
Outcomes
Framework
-Evaluate whether
use of the Safety
Planning
Assistant resulted
in high quality,
completed safety
plans in a timely
manner and to
evaluate
participant
satisfaction with
the Safety
Planning
Assistant and
participant
completion of the
intervention
modules
Patients with
identied
suicide risk
Pediatric hospital
in major
metropolitan area
Out-patient
Social worker
Jeong et al., 2020
[61] Korea Pilot/Feasibility
trial
TMF: Theory of
Planned
Behaviour
-Develop and
evaluate a safety
plan mobile app
based on the TPB
for adolescent
suicide attempt
survivors (study
1).
-Evaluate its
effectiveness for
target users
(study 2).
Patients who
attempted
suicide
A mental health
promotion center
in Seoul
Mixture
Study 1: 6 healthcare
professionals who all
worked in an
emergency or
psychiatry department.
They all were involved
in treatment, nursing,
or consultation of
adolescent suicide
attempt survivors
Jerant et al., 2020
[75] United
States Experimental -Examine the
effect of Men and
Providers
Preventing
Suicide (MAPS)
on discussion of
suicide during
primary care
clinician visits by
middle-aged men
with recent active
suicidal thoughts.
-Explore
moderation of the
program’s effects
by the presence
of suicide
preparatory
behaviours, a risk
marker for suicide
Men who were
assigned to the
panel primary
care clinician
Primary care
oces in
Sacramento
(California) area
Out-patient
32 Primary care
clinicians: 21 (65%)
were family physicians
and 11 (35%) were
general internists; they
had practiced on aver-
age for 8 years (range
1–22); their mean age
was 44 (range 29–61);
21 (65%) were female;
19 (59%) were non-
Hispanic White, 7
(22%) non-Hispanic
Other race, and 5 (26%)
Hispanic

Page 16/55
Author, Year Country of
origin Study design Research
aim/objectives/
questions
Patient
population Clinical setting
and type Clinician
characteristics
Kasckow et al.,
2015 [96] United
States Experimental -Test the
hypothesis that
use of the
telehealth system
would result in a
greater reduction
in both suicidal
ideation and
depressive
symptoms on
standardized
measures
following
discharge from
an inpatient
service, relative to
a group that
received only
Usual Care.
-Assess feasibility
of telehealth
monitoring for
suicidal behavior
in this population.
Veterans with
recent suicidal
ideation or a
recent suicide
attempt and a
diagnosis of
schizophrenia
or
schizoaffective
disorder
Veterans Affairs
in Pittsburgh
Out-patient
Nurses
Kasckow et
al.,2016 [129] United
States Pilot/Feasibility
trial -Test the
feasibility of the
telehealth
monitoring
intervention for
suicidal behavior
in this population
of Veterans with
schizophrenia or
schizoaffective
dis-order
-Assess with a
random
assignment trial,
whether
augmentation of
intensive care
monitoring (ICM)
with our
intervention
would result in a
signicant
reduction in
suicidal ideation
relative to a group
that received only
ICM
Admitted
patients with a
diagnosis of
schizophrenia/
schizoaffective
disorder and
recent suicidal
ideation
Inpatient
psychiatric unit,
Veterans Affairs
In-patient
Nurses
Kennard et al.,
2018 [76] United
States Pilot/Feasibility
trial -To report on a
pilot study of an
inpatient
intervention for
suicidal
adolescents, As
Safe as Possible
[ASAP], supported
by a smartphone
app [BRITE] to
reduce post-
discharge suicide
attempts
Patients with
suicidal
ideation, intent
and/or a recent
suicide
attempt
Psychiatric
inpatient units at
two academic
medical centers
In-patient
A total of 5 therapist
who had at least
master’s level training
in
psychology/counseling
or were enrolled in a
clinical psychology
doctoral program

Page 17/55
Author, Year Country of
origin Study design Research
aim/objectives/
questions
Patient
population Clinical setting
and type Clinician
characteristics
Kleiman et al.,
2019 [140] United
States Pilot/Feasibility
trial -Examine whether
participants
would wear the
monitor the
majority of each
day over the
course of multiple
days.
-Investigate
whether
participants
would interact
with the monitor
(i.e., use the self-
initiated button
press).
-Investigate what
participants liked
(or disliked) about
wearing the
monitor.
Admitted
patients with
severe suicidal
ideation,
suicide
attempt, or
non-suicidal
self-injury
Psychiatric
inpatient units at
two academic
medical centers in
New Jersey
In-patient
Not reported
Kodama et al.,
2016 [89] Japan Pilot/Feasibility
trial -Identify whether
suicide
interventions sent
via mobile phone
text messaging
technologies is
feasible in
changing help-
seeking and self-
harming
behaviours
Patients with a
mental
disorder and
suicidal
ideation
University
hospital, a
psychiatric
hospital in Hyogo
Prefecture, 3
medical center
hospitals in Kobe
City, a private
psychiatric
hospital, and 3
psychiatric clinics
in Kobe City.
Out-patient
Psychiatrists
Kolva et al., 2020
[90] United
States Observational -Discuss an
approach to
preserve patient
safety while
optimizing
delivery of an
online survey of
suicidality in
cancer survivors
seeking
psychological
care
Patients from
outpatient
psycho-
oncology
comprehensive
cancer center
Outpatient
psycho-oncology
clinic
Out-patient
Psycho-oncology
provider
Kroll et al., 2020
[77] United
States Observational -Determine
whether
continuous virtual
monitoring, an
intervention that
facilitates patient
observation
through video
technology, can
be used to
monitor suicide
risk in the general
hospital and ED
Patient who
received a
psychiatric
consultation
and required
suicide
precautions
An academic
tertiary adult
hospital (Boston,
Massachusetts)
with 793 licensed
inpatient beds.
Mixture
Nurses and
psychiatrists and
psychiatry trainees

Page 18/55
Author, Year Country of
origin Study design Research
aim/objectives/
questions
Patient
population Clinical setting
and type Clinician
characteristics
Lawrence et al.,
2010 [151] United
States Observational -Implement
routine self-
administered
computerized
screening for
suicidal ideation
linked to
automated
activation of a
response team in
two high volume,
urban HIV clinics
-Identify factors
associated with
self-reported
suicidal ideation
as determined by
computerized
screening in a
contemporary
sample of HIV-
infected
individuals
Patients with
HIV Two
geographically
distinct academic
HIV primary care
clinics: University
of Alabama at
Birmingham
HIV/AIDS Clinic
Cohort and the
University of
Washington (UW)
Harborview
Medical Center
HIV Clinic.
Out-patient
4 Licensed mental
health professional
and social worker
supervisor and
physician
Levine et al., 1989
[152] United
Kingdom Observational -Assess the
incidence of
depressive
symptoms in
patients admitted
following
deliberate self-
harm using a self-
rating
modication of
Hamilton Rating
Scale for
Depression
delivered by
delivered by
computer
-Compare initial
clinical
assessment with
outcome in those
patients who
went on to
commit suicide
Patients who
attempted
suicide
District General
Hospital
In-patient
Psychiatrist
Ligier et al., 2016
[153]
(Protocol)
France Experimental -Determine
whether a short
message service
in addition to
usual care can be
used to: keep in
touch with
adolescent
suicide
attempters to
reduce the delay
in recurrence of a
suicide attempt,
and to improve
the evolution of
1) their social
network, 2)
depression and 3)
health-related
quality of life
Patients who
attempted
suicide
Pediatric and
adolescent
psychiatry unit at
hospitals in
eastern France:
CHU Besançon,
CHU Dijon, CHR
Metz-Thionville,
CHU Nancy, CHU
Reims, and CHU
Strasbourg
In-patient
Physicians

Page 19/55
Author, Year Country of
origin Study design Research
aim/objectives/
questions
Patient
population Clinical setting
and type Clinician
characteristics
Luxton et al., 2012
[62] United
States Pilot/Feasibility
trial
TMF:
Interpersonal
Psychological
Theory of
Suicide
-Evaluate the
program to
determine how to
best tailor the
caring letter
intervention to the
military setting
-Explore
preliminary group
differences
related to
psychiatric
rehospitalizations
-Compare the use
of handwritten
letters versus e-
mail
correspondence
-Gather data to
inform best
practices that will
assist the
development of a
multisite RCT
Retirees,
veterans, and
dependent
family
members
admitted in in-
patient
psychiatric
units
Veterans Hospital
(Mixture)
Inpatient psychiatry
treatment team
consisting of
psychiatric nurse
Luxton et al., 2014
[55]
(Protocol)
Luxton et al., 2020
[99]
United
States Experimental -Determine
whether the
intervention is
ecacious in
preventing suicide
behaviours
among U.S.
service members
and veterans
Veterans who
are currently
admitted to
psychiatric
inpatient units
Inpatient
psychiatry units:
Madigan Army
Medical Center,
Tripler Army
Medical Center,
Landstuhl
Regional Medical
Center, Navy
Medical Center
San Diego,
Veterans Affairs
Palo Alto, and
Veterans Affairs
Western New
York.
In-patient
NR
Mackie et al.,
2017 [97] Canada Qualitative -Inform the
production of a
treatment manual
for a larger cluster
randomised trial
of a smartphone-
assisted therapy
for men who
present to
hospital after
intentional self-
harm.
-Describe the
experience of
receiving and
delivering a novel
blended therapy
combining a
customised
smartphone
application with
problem solving
therapy (PST) for
this population.
Patients with
self-harm Emergency
department in a
major Canadian
urban centre (The
Ottawa Hospital)
Out-patient
Psychiatrists,
therapists

Page 20/55
Author, Year Country of
origin Study design Research
aim/objectives/
questions
Patient
population Clinical setting
and type Clinician
characteristics
Madan et al., 2015
[154] United
States Observational -Describe
integration of an
electronic suicide
risk alert system
to improve
assessment of
psychiatric, high-
risk patients
-Provide support
of using
aggregate data
over time to
inform
administrative
and clinical
decision-making
related to
changes in the
treatment delivery
system
Patients
admitted at the
specialty
psychiatric
hospital
Specialty
psychiatric
hospital
(Menninger Clinic,
Huston Texas): a
120-bed facility
that specializes in
the treatment of
individuals with
serious mental
illness
In-patient
Nurses
Marasinghe et al.,
2012 [155] Sri Lanka Experimental -Test whether a
Brief Mobile
Treatment (BMT)
intervention can
improve
outcomes relative
to usual care
among suicide
attempters.
Admitted
patients with
self-harm
Colombo South
Teaching Hospital
in Kalubowila, Sri
Lanka
In-patient
Not reported
McManama
O'Brien et al., 2017
[156]
United
States Pilot/Feasibility
trial -Test the usability,
feasibility, and
acceptability of a
web-based
prototype of
Crisis Care with
20 adolescents
with a history of
suicidal thoughts
and their 20
parents.
Patients from
outpatient
psychiatry
department
Outpatient
psychiatry
department at a
general pediatric
hospital in
Northeast US
Out-patient
Not reported
Melvin et al., 2019
[85] Australia Pilot/Feasibility
trial -Examine the
feasibility and
effectiveness of a
suicide prevention
smartphone
application.
Patients from
tertiary mental
health service,
and most of
them had
depressive
disorder and
suicide
attempt
Tertiary mental
health service in
Melbourne,
Australia
Not reported
Morthorst et al.,
2021 [78]
(Protocol)
Denmark Pilot/Feasibility
trial -Assess the
feasibility of
methods,
procedures, and
safety of internet-
based Emotion
regulation
individual therapy
(ERITA) in a
Danish context.
Patients with
non-suicidal
self-injury
(NSSI)
Outpatient clinics
in The Child and
Adolescent
Mental Health
Services in capital
region on
Denmark
Out-patient
Psychologists and
nurses with experience
within clinical child
and adolescent
psychiatry and with
psychotherapy and
special knowledge
about NSSI
Mousavi et al.,
2014 [141] Iran Experimental -Evaluate the
ecacy of
telephone follow
up on reduction
of suicidal
reattempt and
their relationship
with demographic
characteristics of
patients
Patients who
attempted
suicide
Intoxication
emergency
services, Noor
Hospital, Isfahan
In-patient
Psychiatry last-year
resident

Page 21/55
Author, Year Country of
origin Study design Research
aim/objectives/
questions
Patient
population Clinical setting
and type Clinician
characteristics
Muscara et al.,
2020 [79] Australia Pilot/Feasibility
trial -Assess the
feasibility and
acceptability of a
combination of
smartphone apps
to deliver a
digitized safety
plan, BeyondNow,
and personalized
management
strategies,
BlueIce, with
adolescents
discharged from
a mental health
inpatient ward
following self-
harm, suicidal
ideation and/or
behavior.
-Explore whether
any changes in
suicide resilience
and self-harming
behaviors were
able to be
detected six
weeks following
discharge.
Admitted
patients with
suicide
attempt
Inpatient mental
health ward
(Banksia) at the
Royal Children's
Hospital in
Melbourne,
Australia
In-patient
Not reported
Nuij et al., 2018
[63]
(Protocol)
Netherlands Pilot/Feasibility
trial
TMF:
Integrated
Motivational-
Volitional (IMV)
model of
suicidal
behaviour
-Evaluate the
feasibility of
mobile safety
planning and
daily mobile self-
monitoring in
routine care
treatment for
suicidal patients,
and to conduct
fundamental
research on
suicidal
processes.
Patient with
main
diagnosis of
major
depressive
disorder or
dysthymia and
current suicidal
ideation
3 Mental health
organizations
Out-patient
Not reported
O'Keefe et al.,
2019 [157]
(Protocol)
United
States Experimental Evaluate which
brief
interventions,
alone or in
combination,
have the greater
effect on suicide
ideation (primary
outcome) and
resilience
(secondary
outcome) among
American Indian
youth ages 10–
24 ascertained for
suicide-related
behaviours by the
tribal surveillance
system.
American
Indian/ Alaska
Indian youth
with suicide
ideation,
suicide
attempt or
binge
substance use
with suicide
ideation
WMAT suicide
surveillance
system (locally
known as
“CelebratingLife”),
mental health
centres located in
Fort Apache
Indian
Reservation in
Eastern Arizona
Mixture
Trained Apache
Community mental
health specialists

Page 22/55
Author, Year Country of
origin Study design Research
aim/objectives/
questions
Patient
population Clinical setting
and type Clinician
characteristics
O'Toole et al.,
2019 [98] Denmark Experimental -Compare the
effect between
treatment as
usual (TAU) with
(TAU + APP) and
without (TAU) the
assistance of the
mobile app on
individuals
referred to
outpatient suicide
prevention
treatment
Patients with
suicidal
ideation or
suicide
attempt
A specialized
outpatient suicide
prevention clinic
located at a
psychiatric
university
hospital in
Denmark. The
clinic provides
psychosocial
therapy for people
at risk of suicide,
typically
presenting with
adjustment
disorders and
mild to moderate
depression.
Out-patient
Therapists

Page 23/55
Author, Year Country of
origin Study design Research
aim/objectives/
questions
Patient
population Clinical setting
and type Clinician
characteristics
O’Connor et al.,
2019 [64]
(Protocol)
United
Kingdom Pilot/Feasibility
trial
TMF:
Medical
Research
Council,
Process
evaluation
framework for
analysis
-Determine
whether a safety
planning
intervention (SPI)
with follow-up
telephone support
(SAFETEL) is
feasible and
acceptable to
patients admitted
to UK hospitals
following a
suicide attempt.
-Adapt/tailor an
innovative SPI
with follow-up
tele-phone
support for use
within UK NHS
hospital settings.
-Investigate how
participants
engage with the
intervention.
-Assess feasibility
and acceptability
of the
intervention.
-Investigate trial
recruitment,
retention and
other trial
processes
including data
collection.
-Explore the
barriers and
facilitators to
intervention
implementation.
-Collect data on
readmission to
hospital following
self-harm in the 6
months following
the index suicide
attempt to inform
the sample size
required for a full
trial.
-Further develop
and test the logic
model and
theoretical basis
of the intervention
-Assess whether
an effectiveness
trial is warranted.
Admitted
patients with
suicide
attempt
4 National Health
Service hospitals
across two health
boards in
Scotland.
In-patient
The Liaison Psychiatry
team

Page 24/55
Author, Year Country of
origin Study design Research
aim/objectives/
questions
Patient
population Clinical setting
and type Clinician
characteristics
Olsen et al., 2021
[142]
(Protocol)
Denmark Pilot/Feasibility
trial -Assess the
feasibility and
safety of Internet-
based ERITA as
an add-on to
treatment as
usual in 13–17-
year-old patients
with NSSI referred
to the Child and
Adolescent
Mental Health
Service.
Patients with
non-suicidal
self-injury
Child and
Adolescent
Mental Health
Services in capital
Region of
Denmark
Out-patient
Therapists
Owens and
Charles, 2016 [65] United
Kingdom Pilot/Feasibility
trial
TMF:
Normalisation
Process Theory
-Test and rene
the intervention in
situ, before
proceeding to a
full trial.
Research
question:
-Can TeenTEXT
be administered
by CAMHS
clinicians within
the context of
everyday clinical
practice?
Patients with
self-harm Three Child and
Adolescent
Mental Health
Services
(CAMHS) teams
in South West
England
Out-patient
CAMHS Clinicians
Parkland 2018
[86] United
States Other: Quality
improvement -Describe steps in
developing and
implementing this
quality
improvement
program.
Patients in ED
and in-patient
units
ED and inpatient
units, Dallas-
based hospital
Mixture
Nurses
Pickett et al., 2021
[93] United
States Pilot/Feasibility
trial -Determine the
feasibility of
implementing a
self-administered
tablet-based
suicide screening
questionnaire in
an ED.
Patients in a
children's
hospital ED
ED from children's
hospital with an
annual census of
70 000 patient
visits
Out-patient
Nurses and nursing
assistants
Sayal et al., 2019
[126] United
Kingdom Pilot/Feasibility
trial -Determine the
acceptability and
feasibility of
carrying out an
RCT of remotely
delivered (video-
calling or mobile
phone) problem-
solving cognitive
behaviour therapy
(PSCBT) plus
treatment as
usual (TAU)
versus TAU in
adolescents and
young adults with
depression who
self-harm
Patients with
self-harm Adult or child and
adolescent
mental health
services that
assess people in
emergency rooms
or hospital wards
following a self-
harm
presentation,
adult or child and
adolescent
community
mental health
services that see
people with
depression and
self-harm, a third
sector
organization
providing
interventions and
support to people
who have self-
harmed
Mixture
Cognitive behaviour
therapist

Page 25/55
Author, Year Country of
origin Study design Research
aim/objectives/
questions
Patient
population Clinical setting
and type Clinician
characteristics
Seong et al., 2021
[158] Korea Observational -Investigate the
effects of Mobile
Messenger
Counseling on the
post-discharge
case
management
results for
patients with
suicide attempts
or self-harm.
Patients with
self-harm or
suicide
attempt
Regional ED
center that
operates through
the use of a
dedicated
medical team for
patients who
have attempted
self-harm or
suicide.
Out-patient
Physicians,
psychiatrists, and
social workers
Simon et al., 2016
[56]
(Protocol)
Simon et al., 2022
[159]
United
States Experimental -Compare 2 low-
intensity outreach
programs with
usual care for
prevention of
suicidal behavior
among
outpatients who
report recent
frequent suicidal
thoughts.
Patients from
an out-patient
mental health
or general
medical visit
who self-harm
3 Mental health
outpatient care in
Colorado. These
health systems
provide general
medical and
mental health
specialty care as
well as insurance
coverage to
dened
member/patient
populations.
Out-patient
Care managers, Skills
coach (Master’s-
prepared mental health
professional)
Stallard et al.,
2016 [57]
(Protocol)
Stallard et al.,
2018 [87]
United
Kingdom Experimental -Undertake a
preliminary
evaluation of a
smartphone app
(BlueIce), co-
produced with
young people and
designed to help
young people
manage distress
and urges to self-
harm.
-Assess the
acceptability,
safety, and use of
BlueIce and to
explore the
effects on the
primary outcome
of self-harm and
the secondary
outcomes of
psychological
functioning.
Patients with
self-harm Specialist child
and adolescent
mental health
services provided
by Oxford Health
NHS Foundation
Trust. The Trust
serves a wide
geographical area
that includes Bath
and North East
Somerset,
Buckinghamshire,
Oxfordshire,
Swindon, and
Wiltshire
Out-patient
A total of 37 clinicians:
Child psychiatrists,
clinical psychologists,
family therapists, child
psychotherapists,
occupational
therapists, and
community psychiatric
nurses
Stevens et al.,
2019 [130]
(Protocol)
Australia Experimental -Investigate
whether
Treatment As
Usual (TAU)
aftercare for DSH
patients plus
supportive SMS
text messages
delivered over 1-
year reduce DSH
re-presentations
to hospital,
compared to TAU
alone.
Patients with
self-harm Three public
hospitals (EDs) in
Western Sydney.
Nepean,
Blacktown and
West-mead
Hospitals
(Australia):
Toxicology
Centers,
Psychiatric
Emergency Care
Centers, and
Mental Health
Triage and
Assessment
Centers.
Out-patient
Psychiatrists, clinical
nurse consultants,
registered nurses,
psychiatry registrars

Page 26/55
Author, Year Country of
origin Study design Research
aim/objectives/
questions
Patient
population Clinical setting
and type Clinician
characteristics
Vaiva et al., 2006
[160] France Experimental -Determine the
effects over one
year of contacting
patients by
telephone one
month or three
months after
being discharged
from an
emergency
department for
deliberate self-
poisoning
compared with
usual treatment.
Patients who
attempted
suicide
13 EDs from
north of France
Out-patient
Psychiatrists with at
least ve years’
experience in
managing suicidal
crises
Vaiva et al., 2011
[58]
(Protocol)
Vaiva et al., 2018
[161]
France Experimental -Assess the
effectiveness of a
decision-making
algorithm for
suicide prevention
(ALGOS)
combining
existing Brief
Contact
Interventions in
reducing suicide
reattempts in
patients
discharged after a
suicide attempt
Patients who
attempted
suicide
23 EDs and
psychiatry crisis
centers
Out-patient
Psychologists, ED
physician
Wright et al., 2021
[80] United
States Pilot/Feasibility
trial -Verify methods
for assessing
adolescents and
young adults who
had signs or
symptoms of
depression or
suicide ideation
and for training
professionals to
implement mental
health
interventions
using telehealth
devices
Teenage and
young adult
patients
prescribed
lifelong home
parental
nutrition (HPN)
infusions
University of
Kansas Medical
Center
Out-patient
A total of 4
professionals. They
had either PhD and
extensive telehealth
experience. The other
professionals involved
were a master's
prepared pediatric
nurse observer, and
home parental nutrition
counsellor, and a
mental health nurse
specialist. The
psychologist and nurse
mental health
specialist were
experienced in
managing suicide
ideation, and mood
disorders, and
discussing sensitive
topics with
adolescents.
TMF: Theory, Model, Framework

What ICT-based interventions for suicide prevention have been implemented in
clinical settings?
This review identied a total of 66 ICT-based interventions for suicide prevention implemented in clinical settings. According to the WHO, universal
strategies “are designed to reach an entire population in an effort to maximize health and minimize suicide risk by removing barriers to care and
increasing access to help” [1]. Selective prevention strategies “target vulnerable groups within a population based on characteristics such as age,
sex, occupational status or family history” [1]. Selective strategies target individuals who may not be currently expressing suicidal behaviours but
are at an elevated risk of suicide due to biological, psychological, or socioeconomic factors [1]. Lastly, indicated prevention strategies “target
specic vulnerable individuals within the population,” who are “displaying early signs of suicide potential or who have made a suicide attempt” [1].
Identied ICTs were used as universal (n = 4), selective (n = 10), or indicated (n = 53) strategies for suicide prevention. One ICT (i.e., Virtual Hope
Box) was used as both selective and indicated strategies in different studies [66–68]. While most ICTs targeted individuals who were at an
imminent risk of suicide or were displaying early signs of suicide potential, fewer ICTs were used as selective strategies targeting veterans or

Page 27/55
patients living with HIV, or cancer. The 66 ICTs served multiple functions; they were used for suicide screening and assessment (n = 22), safety
planning (n = 20), lethal means restrictions and/or counselling (n = 3), discharge or post-discharge follow-up care (n = 27), therapy such as
dialectical behavior therapy (n = 4), and additional resources such as wellness tips and journals (n = 18). Other (n = 12) functions of ICTs included
reminders to appointments or care plans. Following the MHCC typology, most of the ICTs were computerized interventions, resources, and
applications (n = 55), of which 11 were text messages, 10 were mobile applications (apps), and two were emails. Other types included telehealth
and telemedicine (n = 16), wearable computing and monitoring (n = 1), virtual reality (n = 2), peer support through social media (n = 2), and a robot
(n = 1) (i.e., chatbot). See Table3 for more detail.
Implementation strategies
Overall, there was a lack of reporting on the implementation strategies for the included ICTs. Of the 75 included papers, 31 reported
implementation strategies, but the level of detail varied. Training clinicians (n = 15) was the most commonly reported implementation strategy for
the new ICT, focusing on building new skills [55, 56, 63, 69–80]. A few studies specically reported using demonstration [74] and simulation
methods for training [73]. Educational meetings or communication (e.g., phone, email) (n = 12) was the next common implementation strategy
which provided clinicians with new information and/or instructions required for the ICTs [64, 65, 72, 74, 79, 81–87]. Education or training were
sometimes accompanied by educational materials (e.g., written handouts or supportive tools like a pocket guide) (n = 6) [57, 65, 69, 72, 74, 82].
Training and education were made distinct in this review; training focused on building practical skills, whereas education focused on providing
new information or knowledge. Eight studies reported collaborative initiatives with clinicians, Information Technology (IT) consultants, ministry,
institutions and/or managers [62, 72, 77, 79, 84, 88–90]. For example, collaboratives initiatives involved nominating site staff as co-principal
investigators [84], or consulting key stakeholders before the start of the study [89]. Six reported providing ongoing supervision for using the ICT
[56, 71, 78, 86, 91, 92], of which one study specically conducted audits and provided daily reports to unit managers and nursing leaders [86].
Three studies provided opportunities for clinicians to participate in discussion for improvement in the implementation of the ICT, contributing to
iterative changes in the implementation process during the study [72, 77, 91]. Two studies reported tailored approaches to implementation; one
created a new clinical workow to ensure that the implementation was seamless and minimized interruptions by leveraging existing staff roles
and processes as much as possible [93], and the other provided site-specic training [55]. Lastly, one study provided onsite technical IT support
[86].
What are the reported barriers and facilitators to implementing these ICT-based
interventions?
Overall, there was a general lack of reporting on barriers and facilitators to implementation. Nineteen studies reported several barriers and/or
facilitators with a varying level of detail. Barriers and facilitators that were most frequently reported by identied studies were associated with
physical
(n = 12) or
social
(n = 10)
opportunity
within the COM-B/TDF. TDF domains for physical (i.e., external) opportunities include
environmental context and resources, whereas social opportunities include the social inuences, such as norms and cultural factors [44]. Internet
instability [80], limited telephone lines [94], lack of patients’ access to smart devices [95], time limited nature of clinical settings [65, 96–98], and
no access to research teams to troubleshoot technological issues [81] were physical barriers described in the included studies. Other physical
barriers included administrative challenges such as hospital policy that did not allow patients to use smartphones in the in-patient settings [83].
Therefore, even if patients had their own devices, hospital policy or the discharge norms limited patients’ access and did not allow enough
opportunity for clinicians to deliver the ICTs until the moment of discharge. This not only speaks to physical barriers (i.e., hospital policy), but also
reects social barriers of limiting ICT related interactions with patients [83]. Other barriers to implementing ICTs related to social opportunity
included lack of engagement with clinicians in the study and lack of buy-in and support from the clinicians [65, 79, 93]. Some of the facilitators
were the direct opposite of barriers. In contrast to lack of engagement with clinicians, positive working collaborations between clinicians and the
research team facilitated the implementation process [55, 65, 81, 86]. For example, one study had a hospital staff member in the role of principal
investigator at each study site [55]. Furthermore, leadership engagement, such as manager approvals for implementation, facilitated ICT
implementation, and some managers insisted on circulating implementation information to clinicians via e-mail [65].
Reective
(n = 14) and
automatic
(n = 3)
motivations
were the next commonly coded barriers and facilitators in this review. Motivation
encompasses all brain processes that direct behaviour [42]. This includes not just reective motivation, such as goals, analytical and conscious
decision-making that leads to behaviour, but it also includes autonomic motivation like habits and emotional responses [42]. Reective motivation
includes TDF domains of professional roles and identities, beliefs about consequences, beliefs about capabilities, optimism, intentions and goals
[44]. Dening roles and responsibility attributes [81], perceived burdens, and uncertainties associated with ICTs [65, 96, 98] were examples of
barriers noted among the reective motivation category. For example, clinicians were worried about ICT devices being stolen or broken [81] and
perceived that that the ICT may have a better t in other, non-clinical settings such as schools [65]. Clinicians also did not appreciate the perceived
burdens of implementing ICTs because introducing new ICTs possibly created new tasks, taking extra time in their usual clinical ow [96, 98].
When clinical settings included multi-disciplinary teams, clinicians were concerned about who should be responsible for the ICT, but identifying
appropriate professional roles and having designated staff for the new ICT were reported facilitators [81, 86, 99]. For example, one study
implemented caring emails as post-discharge follow-up care for suicide prevention and reported that the new task associated with this ICT could

Page 28/55
be reasonably done by existing hospital staff rather than hiring new staff [99]. Additionally, they reported minimal requirements for clinicians to
manage the new ICT, which facilitated implementation [99]. In contrast to uncertainties around ICTs, perceived benets and usefulness of ICTs
were facilitators [66, 97]. Automatic motivation refers to the TDF domain of emotion [44]. Negative (“technophobia”) or positive outlook about the
ICTs [59, 65, 97] were identied as barriers or facilitators.
Implementation barriers and facilitators related to
psychological
(n = 14)
capabilities
were the least frequently coded category. Psychological
capabilities include one’s knowledge, memory, and ability to make decisions and regulate behaviours [54]. Identied papers reported barriers and
facilitators related to the knowledge and skills about ICTs, awareness of necessary resources, and clinicians’ cognitive load. For example, having
no manual or guidelines to instruct clinicians on how ICTs should be introduced to patients and used for suicide prevention treatment was a
barrier [95, 98]. In contrast, training resources and education sessions were facilitators that helped to build clinicians’ psychological capabilities
[59, 66, 80, 86]. Additionally, a few ICTs helped to decrease clinicians’ cognitive burden [59, 65]. A summary of the COM-B/TDF analysis can be
found in Table4, and a full breakdown of extracted and analysed data can be found in Additional le 4.

Page 29/55
Table 4
Barriers and facilitators to implementing ICTs
COM-B TDF Domains Denitions Frequency
of
occurrence
Examples of barriers and facilitators
Capability Knowledge An awareness of the existence of something 7 • Educating staff about the reasons
for universal screening prior to
implementation (Facilitator)
• No manual or guidelines as to how
the mobile app should be introduced
and used throughout treatment
(Barrier)
Skills An ability or prociency acquired through
practice 5 • No access to appropriate training
to ensure that nurses feel able to use
innovative technology (Barrier)
• Training health care professionals
for assessing and caring for patients
from a distance using mobile
telehealth iPad interactions
(Facilitator)
Memory, attention
and decision
processes
The ability to retain information, focus
selectively on aspects of the environment and
choose between two or more alternatives
2 • Clinical decision support tool to
provide a denitive recommendation
about whether to hospitalize or
release a patient, decreasing
cognitive burden (Facilitators)
Motivation Social/professional
role and identity A coherent set of behaviours and displayed
personal qualities of an individual in a social or
work setting
6 • Concerned for who [which clinician]
would be responsible for monitoring
the devices (Barrier)
• Task can be reasonably done by
existing hospital staff and the
minimal requirement to manage
replies from participants who were in
crisis (Facilitator)
Optimism The condence that things will happen for the
best or that desired goals will be attained 2 • Clinicians and managers agreed
that the new ICT made sense and
was immediately appealing
(Facilitator)
Beliefs about
Consequences Acceptance of the truth, reality, or validity about
outcomes of a behaviour in a given situation 5 • Uncertainty about how well the
mobile app was incorporated in the
face-to-face treatment, and whether
this led to a positive or negative
effect (Barrier)
• Concerns about giving service
users iPhones and Fitbits for the
duration of the study, suggesting
that the equipment would either be
stolen or damaged (Barrier)
• Perceived value or benet of the
tool to help patients (Facilitator)
Goals Mental representations of outcomes or end
states that an individual wants to achieve 1 • Perception that the intervention
may have better t with schools and
universal youth services (Barrier)
Emotion A complex reaction pattern, involving
experiential, behavioural, and physiological
elements, by which the individual attempts to
deal with a personally signicant matter or event
3 • Perceived burdensomeness and
technophobia (Barrier)

Page 30/55
COM-B TDF Domains Denitions Frequency
of
occurrence
Examples of barriers and facilitators
Opportunity Environmental
context and
resources
(Physical)
Any circumstance of a person’s situation or
environment that discourages or encourages the
development of skills and abilities,
independence, social competence and adaptive
behaviour
12 • Occasional dropped or slow
connections, pixel blurring, and the
need for online security (Barrier)
• Taking extra time away from the
usual therapy (Barrier)
• Using the smartphone application
was more time consuming (Barrier)
• No access to the research team
available in participating wards to
troubleshoot technological issues in
a timely manner (Barrier)
• Patients' lack of access to the
technology (e.g., smart phones)
(Barrier)
• Inexpensive ICT (Facilitator)
Social inuences Those interpersonal processes that can cause
individuals to change their thoughts, feelings, or
behaviours
10 • Having a hospital staff member in
the role of principal investigator at
each site (Facilitator)
• Positive working collaborations
between clinicians and the research
team, including data scientists and
technicians, to ensure a continuous
ow of data (Facilitator)
• Waiting to download the app until
the moment of discharge limits the
opportunity for staff to facilitate the
adoption of a smartphone app
(Barrier)
• Limited buy-in at management
levels (Barrier)

What are the reported measures and outcomes?
As shown in Fig.2, studies reported PRO (n = 55), PRE outcomes (n = 31), and patient health outcomes (e.g., mortality) (n = 10). At health care
provider-level outcomes, studies reported clinician experiences (n = 7), clinicians’ instrumental knowledge use (n = 4), such as number of
documented referrals, and conceptual knowledge use (n = 1), such as professional knowledge about suicide. Thirteen studies reported health
system-level outcomes such as readmission rates and medical costs. Additionally, eight studies specied usage data as an outcome of interest.
Following Proctor’s denitions for implementation outcomes [49], studies reported feasibility (n = 20), acceptability (n = 14), delity (n = 10), and
penetration (n = 1) of the ICTs. None of the studies reported adoption, appropriateness, implementation cost, or sustainability outcomes of
implementation. See Table5 for summaries of the outcomes of interest, outcome measures, measurement tools, and key results of the 70
included studies.

Page 31/55
Table 5
Summary of the outcomes, measures, and key results
Author, Year Outcomes of
interest Outcome measures and
measurement tools Key results
Andreasson et al.,
2017 [145] Suicide ideation,
hopelessness,
depressive
symptoms, and
app/user
satisfaction
• Beck Suicide Ideation
Scale
• Beck hopelessness
scale
• Major depression
inventory
• Client satisfaction
questionnaire
NA - Protocol
Bailey et al., 2020
[91] Suicidal ideation,
depression,
perceived
burdensomeness
and thwarted
belongingness,
social
connectedness,
mindfulness, self-
compassion,
problem-solving,
suicide attempts,
self-harm, feasibility,
and acceptability
• Adult Suicidal Ideation
Questionnaire
• Patient Health
Questionnaire − 9
• 15-item version of the
interpersonal needs
questionnaire
• Social connectedness
scale - revised
• Mindful attention
awareness scale
• Self-compassion scale
– short form
• Negative problem
orientation
questionnaire
• Columbia Suicide
Severity Rating Scale
• Deliberate self-harm
inventory
• Usage data and
activity data
Overall, more than half of the participants logged in at least once
per week satisfying this criterion related to acceptability. There was
also signicant variability in Café activity (including posts, replies,
and likes/reactions), steps and actions completed, and amount of
user-initiated contact with moderators.
Berrouiguet and
Alavi et al., 2014
[54] (protocol)
HUGOPSY Network
et al., 2018 [146]
Suicide reattempt,
suicide deaths,
suicide ideation,
medical costs, and
satisfaction
• Columbia Suicide
Severity Rating Scale
• Medico-economic
questionnaire
Satisfaction
questionnaire
• Mini-international
neuropsychiatric
interview
• Narrative description
of circumstances
associated with their
participant-initiated
contact
In each case, the contact has been initiated by the study participant
immediately after receiving a message (Case 3) or a few days later
(Case 1 and 2). These cases highlight the potential for connecting
individuals to crisis services after an SA using automated text
messages. This text message-based brief contact intervention has
demonstrated the potential to reconnect suicidal individuals with
crisis support services while they are experiencing suicidal ideation
as well as in a period after receiving messages.
Berrouiguet and
Gravey et al., 2014
[127]
Feasibility,
acceptability • Text messages status
reports and the
transmission rates
issued by the web
server engine
• Standardized phone
interview and
questionnaire
Receiving text messages sent from an intranet program after a
suicide attempt is technically possible. This post-crisis outreach
program was accepted by the patients who found it to have a
positive preventive impact.

Page 32/55
Author, Year Outcomes of
interest Outcome measures and
measurement tools Key results
Betz et al., 2020
[138] Feasibility,
acceptability, suicide
severity
• Minutes for the patient
to complete L2L and
the completion rate
• Ottawa acceptability
scale
• Decisional conict
scale
• Columbia Suicide
Severity Rating Scale
The L2L decision aid appears feasible and acceptable for use
among adults with suicide risk and may be a useful adjunct to
lethal means counseling and other suicide prevention interventions
Brand and Hawton
2021 [95] Patients' and nurses'
experiences • Questionnaire (Likert-
scale questions, binary
questions, and open-
ended questions)
All the participants who attended more than two sessions (n = 8)
found the weekly True Colours questionnaires easy to use. Four of
the ve nurses who participated in the evaluation stated that they
found it easy to recruit patients and explain the benets of True
Colours to them. The remaining nurse found registering a patient
onto the True Colours system challenging. All the nurses who used
True Colours found it useful.
Bruen et al., 2020
[81] Acceptability,
engagement • Fitbit data
• Brief informal exit
interview
A total of 61 safety plans were completed, with an average of 2.5
plans per person. SWiM App was helpful: The ability to write-out
thoughts suited those people who might otherwise have had to
struggle to voice these verbally. Most participants provided positive
responses about using Fitbit, which included increased self-
awareness of levels of physical activity, goal setting, and peer
motivation.
Bush et al., 2015
[66] Patients' and
clinicians'
experiences
• Semi structured
interview
• Self-report
questionnaires (e.g.,
Likert-type rating scale)
• Electronic usage log
High-risk patients and their clinicians used the VHB more regularly
and found the VHB benecial, useful, easy to set up, and said they
were likely to use the VHB in the future and recommend the VHB to
peers.
Bush et al., 2017
[67] Coping, suicide
ideation, reasons for
living
• Coping self-ecacy
scale
• Beck Scale for
Suicidal Ideation
• Brief reasons for living
inventory
VHB users reported signicantly greater ability to cope with
unpleasant emotions and thoughts at three and 12 weeks
compared with the control group. No signicant advantage was
found on other outcome measures for treatment augmented by the
VHB.
Buus et al., 2020
[147] Patients' experience • Focus group Users found that the MYPLAN app was helpful for learning to
recognize early signs of an impending crisis, and for coping by
actively nding personalized problem-solving strategies. This study
indicates that there were huge variations in users’ engagement and
use of MYPLAN.
Cassola et al.,
2017 [69]
(Protocol with
preliminary results)
Satisfaction and
usability • System usability scale
questionnaire System usability surveys reveal that users were pleased with the
use of the system during the Stop Depression clinical trials.
Qualied users considered the platform to be straightforward and
with a low learning curve, having felt condent while using it.
Moreover, an extremely high percentage of users claimed that they
would use the system frequently.
Cebrià et al., 2013
[70] Suicide attempt and
reattempt • Telephone survey The results obtained suggest that the application of a telephone
management programme to patients discharged from an
emergency room for suicide attempts signicantly delays further
attempts and decreases the rates of reattempts in the context of a
general reduction.
Chen et al., 2010
[125] Patient experience,
suicide attempt • Interview Mobile telephone text message interventions could be a feasible
and acceptable follow-up method with suicide attempters. All
suicide attempters in our sample who were seen in emergency
departments have access to a mobile telephone, and there is no
charge for the user to receive text messages. After four message
contacts, most of them thought it was acceptable and said they
would like to receive the messages for a longer time.

Page 33/55
Author, Year Outcomes of
interest Outcome measures and
measurement tools Key results
Chen et al., 2018
[68] Suicide ideation,
coping, app usage • App usage logs
• Beck Scale for
Suicidal Ideation
• Coping self-ecacy
scale
Older age was correlated with higher levels of usage. Participants
who had 2 years or more of college had lower levels of VHB usage.
The ndings suggested a potential association between usage and
ecacy for stopping negative thoughts. Usage was associated with
increased ecacy for stopping negative thoughts, though this
relationship was attenuated among participants with high levels of
usage.
Comtois et al.,
2019 [71] Suicide ideation,
suicide attempt, ED
visit
• Suicide status
interview
• Treatment history
interview
• Suicide attempt self-
injury count
• Hurdle model
There was no signicant effect on the likelihood or severity of
current suicidal ideation or likelihood of a suicide risk incident; there
was also no effect on emergency department visits. However,
participants who received Caring Contacts had lower odds than
those receiving standard care alone of experiencing any suicidal
ideation between baseline and follow-up and fewer had attempted
suicide since baseline in the group receiving Caring Contacts vs the
standard-care group.
Czyz et al., 2020
[148] Hopelessness,
positive and
negative affect,
patient perceptions
and experiences
with messages
• Daily survey
• 10-item positive and
negative affect
• Schedule for children
• Open ended feedback
Quantitative and qualitative feedback across the 2 study phases
pointed to the acceptability of text-based support.
Czyz et al., 2021
[128] Suicide ideation,
self-ecacy, coping,
suicide attempt,
suicide injury, safety
plan use
• Ecacy to cope with
suicidal
parental self-ecacy
scale thoughts and
urges scale
• Columbia Suicide
Severity Rating Scale
• Self-assessed
expectations of suicide
risk scale
• Non-suicidal self-
injury portion of the
self-injurious thoughts
and behaviors interview
The results from this pilot study suggest that study procedures for
optimizing interventions for adolescents at elevated suicide risk
were feasible and acceptable. Moreover, results indicate that
specic intervention components and sequences inuenced key
mechanisms of change and have potential to reduce risk of suicidal
behavior.
Davis et al.,
2021[139] Suicide risk, delity
of screening process • Patient Health
Questionnaire (PHQ) –
modied for teens
• Columbia diagnostic
interview
• Schedule for children-
depression scale
• Manual chart review
The study results indicated the high degree of delity to the follow-
up suicide risk questions. Follow-up: suicide-specic follow-up
actions were relatively sparse in the year following PHQ-9-M
screening per a retrospective manual chart review.

Page 34/55
Author, Year Outcomes of
interest Outcome measures and
measurement tools Key results
Depp et al.,
2021[72] Suicide ideation,
suicide behaviour,
satisfaction, service
utilization,
acceptability,
adherence, and
delity
• Scale for suicide
ideation or Columbia
Suicide Severity Rating
Scale
• Outpatient follow-up
interval
• Composite suicide-
related crises
• Ecological Momentary
Assessment adherence
or outcomes
• Tablet routines
questionnaire
• Brief psychiatric rating
scale
• Treatment rationale
scale
• Timeline follow back
scale
• Intervention
satisfaction
questionnaire
NA-protocol
Dimeff et al.,2020
[59] Feasibility • Semi structured
interview
• Usability satisfaction
and acceptability
questionnaire ratings
• Open ended
qualitative data from
Dr. Dave (Articial
Intelligence avatar)
Technology tools including a patient-facing avatar and e-caring
contacts, along with provider-facing tools may offer a powerful
method of facilitating best-practice suicide prevention interventions
and point-of-care tools for suicidal patients seeking ED services and
their medical provider.
Dimeff et al., 2021
[73] Coping, patient
experience, adverse
events, acceptability,
feasibility
• Safety and imminent
distress questionnaire
• Suicide-related coping
scale
• Jaspr health patient
satisfaction
questionnaire
• Brief semi structured
interview
Of 14 Jaspr Health patients, all completed a comprehensive suicide
assessment and created a crisis stabilization plan, and 12 (85%)
patients engaged in lethal means counseling. Jaspr Health
participants also opted to learn 3 behavioral skills and gave Jaspr
Health high satisfaction ratings. In addition, no adverse events
occurred during its use. Jaspr Health appeared clinically effective.
Duhem et al., 2018
[92] Professional
knowledge about
suicide, suicide
attempt, health care
pathway,
acceptability, delity
• Regional suicide
mortality data
• Penetrance rate
• Quantitative appraisal
(digital survey)
• Qualitative appraisal
(semi structured
interviews)
• Two-step medico
economic assessment
of the programme
• Crisis card measures
NA - protocol

Page 35/55
Author, Year Outcomes of
interest Outcome measures and
measurement tools Key results
Etter et al., 2018
[149] Provider follow-up
action, suicide risk,
depression,
substance use
• A single question
based on American
Academy of Pediatrics
• Patient Health
Questionnaire − 2
• Chart abstraction
(provider worksheet)
Incorporating adolescent suicide screening and provider follow-up
guidance into an existing computer decision support system in
primary care is feasible and well utilized by providers.
Fossi Djembi et al.,
2020 [88] Suicide attempt,
penetration of
VigilianS
• VigilanS database
• Health administrative
data
Twenty-one centers were running VigilanS in 2018, with an average
penetrance of 32%. A signicant relationship was identied,
showing a sharp decrease in suicide attempt as a function of
penetrance.
Fossi et al., 2021
[150] Suicide reattempt • Second entry in
VigilanS Findings suggests the effectiveness of VigilanS on suicide
reattempt, from the rst entry into VigilanS. Maintaining contact is
of great importance for the patient’s future.
Goodman et al.,
2020 [82] Suicide behaviour,
depression,
hopelessness,
coping and
treatment utilization
• Medical record
abstraction
• Brief safety plan
scoring form
• Columbia Suicide
Severity Rating Scale
NA-protocol
Gregory et al., 2017
[83] Smartphone
ownership, app
usage, admission to
hospital
•
Questionnaires/surveys Of the 76 patients, 50 reported that they owned a smart phone. Of
the 26 who reported they did not own a smartphone, ve patients
reported that they still intended to download the Be Safe app later.
Of the 50 patients who owned a smartphone, nine downloaded the
Be Safe app in hospital. Of the 41 smartphone owners who did not
download in hospital, 34 stated they intended to download the app
later, and four additional patients stated they would “maybe”
download the app later. Fifty-one out of 74 patients were on their
rst admission to hospital.
Grist et al., 2018
[74] Usability,
acceptability, safety • Interview 6 key themes emerged: (1) appraisal of BlueIce,(2) usability of
BlueIce, (3) safety (4) benets of BlueIce, (5)agency and control,
and (6) BlueIce less helpful. Overall, BlueIce was deemed to be
helpful, easy to use, and safe.
Gros et al., 2011
[94] Ecacy and
symptoms • Beck's depression
inventory − 2
• Beck anxiety inventory
• Post-traumatic stress
disorder (PTSD)
checklist – military
version
The preliminary ndings in the present case support the use of
telehealth in the identication and intervention of suicidality at
home.

Page 36/55
Author, Year Outcomes of
interest Outcome measures and
measurement tools Key results
Hatcher et al., 2020
[84] Suicide ideation,
depression, anxiety,
PTSD symptoms,
meaning in life,
social support,
quality of life,
substance use,
health service use,
app usage
• Beck Scale for Suicide
Ideation
• Patient Health
Questionnaire
• Generalized anxiety
disorder 7-item scale
• Post-traumatic stress
disorder (PTSD) screen
• EuroQol 5-Dimension
5-level questionnaire
• Experienced meaning
in life scale
• Multidimensional
scale of perceived
social support
• Alcohol use disorders
identication test
• Drug abuse screening
test
• Administrative health
data
• Smartphone
application usage data
• Interviews
NA-protocol
Hetrick et al., 2017
[131] Feasibility,
acceptability,
perceived
usefulness,
depression
• Questionnaire about
acceptability and
usefulness including
open-end-ed questions
• Suicidal Ideation
Questionnaire – junior
• Patient Health
Questionaries − 9
The e tool was feasible to implement. Young people and clinicians
found the tool acceptable and useful for understanding symptoms
and risk.
Hill et al., 2020 [60] Depression, suicide
ideation,
satisfaction, patient
experience,
acceptability,
feasibility
• Time required to
complete the module
• Safety plan
completion
• Feedback form (open-
ended questions)
satisfaction
• Short mood and
feelings questionnaire
• Suicide ideation
questionnaire- junior
Adolescents’ reported satisfaction with the intervention was high at
both post-treatment and follow-up. At the follow-up assessment, 11
of the 15 adolescents reported using their safety plan, of whom 8
(72.7%) found their safety plan to be helpful and 7 (63.6%) reported
that their safety plan prevented them from making a suicide
attempt. The average time to complete the adolescent safety plan
module was 48.13 minutes. Data support the preliminary feasibility
of administering safety planning using the web-based tool and the
acceptability of the Safety Planning Assistant.
Jeong et al., 2020
[61] Attitudes, behaviour
control, suicide
attempts, user
experience
• System usability scale
questionnaire
Study 1: Results indicated no usability problems or minimal
usability problems with a low priority for revision, and the level of
usability of BoMM is acceptable. Study 2: In all participants,
attitude toward suicide attempts declined at each of the three time
points.

Page 37/55
Author, Year Outcomes of
interest Outcome measures and
measurement tools Key results
Jerant et al., 2020
[75] Whether the topic of
suicide was
discussed during the
visit, suicidal
thought, suicide risk
• Beck Scale for Suicide
Ideation
• Patient Health
Questionnaire
• Primary care PTSD
screen
• Alcohol use disorder
identication test
Any suicide discussion was more likely among the tailored Men and
Providers Preventing Suicide (MAPS) patients than controls. In the
examination of moderation of the intervention effect by the
presence or absence of any suicide preparatory behaviors, the
interaction effect was not statistically signicant.
Kasckow et al.,
2015 [96] Suicide ideation,
depression,
feasibility
• Suicide severity
interview
• Beck Scale for Suicide
Ideation
• Calgary depression
rating scale
• Percentage of days
active participants
downloaded responses
to the questions
Daily adherence in the use of the Health Buddy (HB) system during
months 1–3 was, respectively, 86.9%, 86.3%, and 84.1%. There were
signicant improvements in Beck Scale for Suicide Ideation scores
in HB participants. There were no changes in depressive symptoms.
Telehealth monitoring for this population of patients appears to be
feasible.
Kasckow et
al.,2016 [129] Suicide ideation,
depression, user
experience,
feasibility,
adherence
• Beck Scale for
Suicidal Ideation (BSSI)
• Calgary depression
rating scale
• Number of
participants accessed
the system
• Open-ended surveys
Our pilot ndings suggest that the use of our telehealth monitoring
system is feasible in monitoring post-discharge suicide risk in this
population. Monthly adherence for telehealth participants was >
80%. A qualitative analysis of endpoint surveys revealed that most
participants had positive responses. In both groups, there were
improvements in BSSI scores at endpoint relative to baseline.
Kennard et al.,
2018 [76] Suicide ideation,
suicide behaviour,
treatment utilization,
satisfaction
• Columbia Suicide
Severity Rating Scale
• Suicidal Ideation
Questionnaire–junior
• Child and adolescent
services assessment
• Post-study
satisfaction and
usability questionnaire
• Client satisfaction
questionnaire-8
Results show acceptability and feasibility of the As Safe as
Possible (ASAP) intervention and supporting BRITE app. The RCT
was not large enough to detect even substantial clinical effects, but
the rates of suicide attempt in those assigned to ASAP/BRITE were
half of those in TAU, indicating that this intervention is promising
and may have utility in the reduction of post-discharge suicide
attempts in hospitalized, suicidal adolescents.
Kleiman et al.,
2019 [140] Feasibility,
acceptability, user
experience
• Survey
• Wearable computer
comfort rating scale
• Usage data
• 4 open-ended
qualitative question
Results supported the feasibility and acceptability of this approach.
Participants wore the monitor for an average of 18hours a day and
reported that despite sometimes nding the monitor uncomfortable,
they did not mind wearing it.
Kodama et al.,
2016 [89] Suicide ideation,
social/personnel
resources
• Questionnaires
(multiple choice
questions and Likert
scale)
outcome data were
obtained from
participants’ physicians
At the 3- and 6-month time points of the intervention, more than
85% of participants reported that the text messages were helpful or
a little helpful. Participants who had committed self-harm during
the previous 6 months at baseline accounted for 27.6% of the
sample (n = 8), whereas the proportion at 6 months signicantly
decreased. Further, the intensity of suicidal ideation was
signicantly reduced after the intervention period.

Page 38/55
Author, Year Outcomes of
interest Outcome measures and
measurement tools Key results
Kolva et al., 2020
[90] Suicide ideation,
suicide attempt • Patient Health
Questionnaire (PHQ)
• Suicidal behaviors
questionnaire - revised
(SBQ-R)
Online assessment of suicidality in this sample of adults with
heterogeneous cancer diagnoses receiving outpatient psycho-
oncology care was feasible and ethically sound. Active suicidal
ideation as identied by the PHQ‐9 was rare, almost all participants
denied thoughts that they would be better off dead or active
thoughts of self‐harm. Few participants reported having these
thoughts for several days or more than half of the days. In contrast,
on the SBQ‐R, 28 participants reported thoughts of killing oneself
ranging from rarely to very often (n = 1, 1.1%) in the previous year.
Kroll et al., 2020
[77] Adverse events and
nurse preference for
observation
• Software running the
monitoring technician's
interface with the
mobile units
automatically logged
the information
• Free text entered by
monitoring technician
(MT)
• Nursing preference
survey
Average daily census for the MTs during the pilot phase was 6.2
patients. The maximum number of patients receiving virtual
monitoring for an indication of suicide precautions at a single time
was 3. There were no adverse behavioural events. Nurses who did
and did not care for patients on virtual monitoring both gave
moderately high favourability ratings, and no signicant differences
in favourability of virtual monitoring or 1:1 between nurses who did
and did not care for patients.
Lawrence et al.,
2010 [151] Suicide ideation • Patient Health
Questionnaire − 9
• Alcohol Use Disorders
Identication Test-
Concise
• Alcohol, Smoking and
Substance Involvement
Screening Test
(ASSIST)
The odds of reporting suicidality were increased with more severe
depression and current substance abuse, while advancing age was
associated with lower risk. Our experience supports the use of novel
technologies and user-friendly interfaces (i.e., touchscreens or
tablet computers) to facilitate the collection of self-reported
information in high volume clinical settings.
Levine et al., 1989
[152] Self-harm, suicide
ideation • Hamilton rating scale
for depression
• Suicidal Ideation
Questionnaire
Study result suggests that not only is the computer interview
acceptable to most patients, but the data suggest that the patients
are prepared to conde information to the computer that they may
be unwilling to tell the clinician. Further, the data also suggest a
signicant pathoplastic effect of the personality of the patient on
the perception of the psychopathology by the clinician. The
computer appeared to be a better predictor of suicidality than the
interview by the clinician.
Ligier et al., 2016
[153] Suicide attempt and
suicide reattempt • Data from
participating hospital
• Multidimensional
scale of perceived
social support
• Kidscreen-27 and
Vécu et Santé Perçue
des Adolescents
• Center for
Epidemiologic Studies
Depression Scale
NA-protocol
Luxton et al., 2012
[62] Feasibility,
readmission, length
of stay, staff
experience, patient
coping, depression,
suicide ideation, and
adverse events
• Reasons for living
inventory
• Patient Health
Questionnaire − 9
• Suicide ideation scale
• Phone interviews
Most participants indicated preference for e-mail versus postal
mail. Fifteen participants were readmitted for treatment compared
to 20 patients in usual care. Twenty participants sent responses,
and all were positive statements about the program. There were no
adverse events. This program is feasible for use at a military
treatment facility.

Page 39/55
Author, Year Outcomes of
interest Outcome measures and
measurement tools Key results
Luxton et al., 2014
[55]
(Protocol)
Luxton et al., 2020
[99]
Suicide mortality,
depression, suicide
ideation, coping,
belongingness,
perceived
burdensomeness,
capability for lethal
self-injury, positive
aspects in a person's
life, suicide
behaviour,
medical/psychiatric
treatment utilization
• Positive assets search
semi-structured
interview tool
• Acquired Capability
for Suicide Scale
• Patient Health
Questionnaire − 9
• Lifetime Parasuicide
Count
• Interpersonal Needs
Questionnaire
• Acquired Capability
for Suicide Scale
• Death certicates
recorded in the Centers
for Disease Control and
prevention
• National Death Index
Plus
• Rudd suicide ideation
scale
• Survey (phone
interview)
• Health administrative
data
No rm conclusions about the ecacy of the intervention can be
made because the study was inadequately powered. There were no
adverse events associated with the intervention, and
implementation of the procedures was feasible in the military and
veteran hospital settings.
Mackie et al., 2017
[97] Staff and patient
experience • Semi-structured
interview
• Written participants
exit questionnaire
• Patient Health
Questionnaire − 9 (PHQ-
9)
Seven men were enrolled in the study, and six completed the
qualitative interviews. The two main themes identied were of trust
and connection. Participants attended 85% of their appointments.
Madan et al., 2015
[154] Depression, suicide
ideation and
behaviour
• Patient Health
Questionnaire − 9 (PHQ-
9)
• Columbia Suicide
Severity Rating Scale
(CSSR-S)
At admission, 59.0% of patients endorsed suicidality on at least 1
of the suicide alert critical items. Patients endorsed critical item 1
(from the PHQ) most frequently and more often than any of critical
items 2 to 6 from the CSSR-S. Patients who endorse more items
may be experiencing more severe suicidality.
Marasinghe et al.,
2012 [155] Suicide ideation,
depression, social
support, alcohol use,
and drug check
• Beck Scale for
Suicidal Ideation
• Beck depression
inventory
• Medical outcomes
study social support
survey
• Alcohol use disorders
identication test
• Drug check problem
list
There were no signicant differences between the groups at
baseline. Intention-to-treat analyses showed that average scores for
both conditions improved on all outcome measures.
McManamaO'Brien
et al., 2017 [156] Patients and parent
experience related to
usability, and
satisfaction
• System usability scale
• Open ended survey
questions
Results demonstrated acceptability and usability, suggesting the
utility of technological interventions, such as Crisis Care, as an
adjunct to treatment for suicidal adolescents and their parents
following discharge from acute care settings.

Page 40/55
Author, Year Outcomes of
interest Outcome measures and
measurement tools Key results
Melvin et al., 2019
[85] Suicide ideation,
coping, feasibility • App usage data
• App feedback survey
(closed ended and
open-ended)
• Columbia Suicide
Severity Rating Scale
• Suicide related coping
scale
• Suicide resilience
inventory-25
• Coping strategy usage
questionnaire
A vast majority of participants used the app to view and edit their
safety plans and reported that the app was easy to use. A reduction
was observed in participant severity and intensity of suicide
ideation, and suicide-related coping increased signicantly. No
signicant changes were observed in suicide resilience.
Morthorst et al.,
2021[78] Feasibility, clinical
outcomes including
NSSI, quality of life,
sick days
• Phone interviews
• Completion of follow-
up, compliance
(completion of
modules)
• deliberate self-harm
inventory – youth
version
• Health-related quality
of life questionnaire
(kidscreen-10)
• Depression anxiety
stress scale
• Number of sick days
• Diculties in emotion
regulation scale–16
item version
• Borderline symptom
list
• Columbia Suicide
Severity Rating Scale
• The coping with
children’s negative
emotions scale
• The coping with
children's negative
emotions scale
adolescent
• Negative effects
questionnaire
• Strengths and
diculties
questionnaire
• Working alliance
inventory, short version
N/A - protocol
Mousavi 2014
[141] Suicide attempts,
suicide ideation,
hope of life,
compliance of
treatment
• Phone calls
(questionnaires) The only suicide attempt case in the intervention group occurred in
the 4th month after discharge, and in the control group there was
one case after the 1st month, 2 cases after the 2nd month and one
case after the 4th month. After discharge during the 6 month follow
up, one patient in the intervention group and 4 patients in the
control group had attempted suicide, no signicant difference of
suicide reattempt has been found between two groups. By the end
of the study period, 28 patients in the control group and 14 patients
in the intervention group had suicidal thoughts. 19 patients in the
control group and 50 patients in the intervention group had increase
in hope. There was no signicant difference for the compliance to
treatments after 6 months of follow up.

Page 41/55
Author, Year Outcomes of
interest Outcome measures and
measurement tools Key results
Muscara et al.,
2020 [79] Feasibility,
acceptability, suicide
resilience and self-
harm
• App log ins and use
data
• Self-report
questionnaire
• Suicide resilience
inventory-25 measure
Eight participants felt that the apps would not keep them safe when
in crisis, with nine and seven participants reported that BeyondNow
and BlueIce, respectively, did not help them to manage their
symptoms in crisis. Most participants rated both apps positively
regarding ease of use, and a small majority reported that they
would recommend both apps and were satised with the apps.
Most participants did not believe that they would use the apps in
the future. A signicant improvement was found on the Emotional
Stability Scale.
Nuij et al., 2018
[63] Feasibility, level of
explorative power of
the model, suicide
behaviour
• System usability scale
• Client satisfaction
questionnaire 8
• Survey comprised of
scale and
questionnaires
operationalised within
the Integrated
Motivational-Volitional
model
NA-protocol
O'Keefe et al., 2019
[157] Suicide ideation,
resilience,
depression, anxiety,
impulsivity, self-
ecacy, communal
mastery, self-
esteem, substance
use
• Suicide Ideation
Questionnaire
• Resiliency scales for
children and
adolescents
• Centers for
epidemiologic studies
depression scale
revised
• Children’s hope scale
• Alcohol, smoking and
substance involvement
screening test
• UPPS impulsive
behavior scale
• Multicultural mastery
scale
• Voices of Indian teens
cultural issues and
interest
• Rosenberg self-esteem
scale
• Index of local
indicators of well-being
• PROMIS pediatric
anxiety short form
NA-protocol
O'Toole et al., 2019
[98] Suicide risk,
depression, patient
perception of the
app
• Suicide Status Form
(SSF) II–R
• Major Depression
Inventory (MDI)
• Total app activity
• Unsafe of methods
library
A signicant main effect of time on SSF was found across the
whole intervention period, where self-reported suicide risk
decreased. Concerning MDI, the main effect of time across the
whole intervention period was signicant, showing a large decrease
across groups in depressive symptoms. Concerning the participants
who had used the mobile app measured as any type of clicks (N =
50), the total number of clicks was not signicant at either post-
treatment. The total number of methods used was not signicantly
associated with the effect.

Page 42/55
Author, Year Outcomes of
interest Outcome measures and
measurement tools Key results
O’Connor 2019 [64] Feasibility,
acceptability,
intervention
adherence, suicide
severity, coping
• Columbia Suicide
Severity Rating Scale
• The entrapment scale
• The interpersonal
needs questionnaire
• The ENRICHD social
support instrument
• The suicide-related
coping scale
• Semi-structured
interview and focus
group.
• NHS clinical
databases
NA
Olsen et al., 2021
[142] Feasibility, NSSI,
quality of life,
depression, anxiety,
and stress
• Deliberate self-harm
inventory–youth
version
• Kidscreen-10
• Depression anxiety
stress scale
• Proportion of sick
days during the last
month
• Diculties in emotion
regulation scale
• Borderline symptom
list
• Columbia Suicide
Severity Rating Scale
• Coping with children’s
negative emotions
scale
• Negative effects
questionnaire
NA-protocol
Owens and Charles
2016 [65] Feasibility, clinician
and patient
experience
• Interview Clinicians all understood the purpose of the intervention and
recognised that it could be valuable in the management of self-
harm and other problem behaviours, but heavy workloads, high
stress levels and possibly some technophobia contributed to a
perception that too much effort was required to master it and
incorporate it into their practice.
Parkland 2018 [86] Suicide risk • Columbia Suicide
Severity Rating Scale
• Clinical practice
screener-recent
In the ED, 6.3 percent of the screens were positive, as were 1.6
percent in the inpatient units, and 2.1 percent in the outpatient
clinics.
Pickett et al.,
2021[93] Feasibility, rate of
screening, suicide
risk
• Ask suicide screening
questions Suicide screening increased from 1.0–76.5%. The novel use of a
tablet-based universal suicide screening method was successfully
implemented in a busy ED and designed to optimize disclosure and
patient comfort, while preserving valuable provider/nursing time.

Page 43/55
Author, Year Outcomes of
interest Outcome measures and
measurement tools Key results
Sayal et al., 2019
[126] Depression, suicide
severity, anxiety,
hopelessness, and
health utility
• Beck Depression
Inventory-II
• Personal health
questionnaire – 9
• Beck hopelessness
scale
• Generalised Anxiety
Disorder Assessment
• Columbia Suicide
Severity Rating Scale
• Work and social
adjustment scale
• 5-level EuroQol 5-
dimensional
questionnaire
• Interviews
Recruitment to RCTs of remotely delivered CBT for young people
with depression and repeat self-harm is not feasible through recent
presentations to clinicians in self-harm services. Offering remotely
delivered PSCBT did not enhance the uptake of this intervention in
participants aged 16–30 years with depression who had recently
presented to medical services following self-harm.
Seong et al., 2021
[158] Successful case
management rate • Case management
database of the
hospital
The rate of patients who connected with their local psychiatric
healthcare center showed a signicant difference between the
Mobile Messenger Counselling (MMC) and non-MMC groups. The
use of mobile messengers for counseling self-harm or suicide
attempters leads to higher case management success rates by
increasing their likelihood of connecting to a local psychiatric
healthcare center.
Simon et al., 2016
[56](protocol)
Simon 2022 [159]
Self-harm, mortality
suicide attempt
• Electronic health
record data
• Death certicate
• Insurance claim data
Risk of fatal or nonfatal self-harm over 18 months did not differ
signicantly between the care management and usual care groups
but was signicantly higher in the skills training group than in usual
care.
Stallard et al., 2016
[57] protocol
Stallard et al., 2018
[87]
Depression, anxiety,
suicide behaviour,
safety, acceptability,
and self-harm,
usability, feasibility
• Mood and feelings
questionnaire
• Revised child anxiety
and depression scale
• Strengths and
diculties
questionnaire
• Rating questionnaires
• Semi-structured
interviews
• Referral pathways
No safety issues were identied and there were no unintended
negative effects on self-harm. Almost three-quarters of those who
had recently self-harmed reported reductions in self-harm after
using BlueIce for 12 weeks. There was a statistically signicant
mean difference on post use symptoms of depression and
symptoms of anxiety, which was evident across all anxiety
subscales. Ratings of app acceptability and usefulness were high.
Stevens et al.,
2019 [130] Hospitalization,
mortality • Routinely collected
data sources through
New South Wales
(NSW) health, other
government agencies,
and the centre for
health record linkage
NA-protocol
Vaiva et al., 2006
[160] Suicide reattempt,
death, number and
type of health care
contact
• Telephone interviews
• Electronic health
record data
• Emergency
departments health
records on all suicide
attempts, deaths, or
further suicide attempts
70% of participants in both intervention groups were successfully
contacted by telephone. Six participants died. On an intention to
treat basis, the three groups did not differ signicantly for
proportion with an adverse outcome. The number of participants
contacted at one month who reattempted suicide was signicantly
lower than that of controls. For participants contacted at three
months, the number who attempted further suicide was not
signicantly lower than that of controls. Participants in the
intervention groups talked about their attempted suicide with their
general practitioner more often than the controls.

Page 44/55
Author, Year Outcomes of
interest Outcome measures and
measurement tools Key results
Vaiva et al., 2011
[58] (protocol)
Vaiva et al., 2018
[161]
Suicide reattempt,
adverse events such
death by suicide
• Mini-international
neuropsychiatric
interview
• Phone survey
After 6 months, 58 participants in the intervention group
reattempted suicide compared with 77 in the control group. The
difference between groups was not signicant.
Wright et al., 2021
[80] Depression,
suicidality, and
patient experience
• Beck depression
inventory-II
•
Questions/observations
during sessions
(general comments on
iPad use)
Of the 40 patient participants, 25% selected one of the depressive
symptoms or one of the suicide responses on the depression
inventory, made comments or displayed depressive symptoms in
the audio-visual group sessions, or wrote about issues that caused
the professionals to be concerned about possible suicidal ideation.
All the patients commented on the iPad delivery being easy com-
pared with some other open-source methods they had used.
Various types of supportive interactions were observed among the
group participants, including armations, humor, and emotional
and in-formational support.
Discussion
Summary of evidence
This scoping review describes characteristics of ICT-based interventions for suicide prevention implemented in clinical settings. In this review, we
identied 75 papers that described 70 studies and 66 ICTs. Overall, the review ndings provide detailed characteristics of the existing ICTs for
suicide prevention implemented in clinical settings. We also identied common strategies for implementing ICTs, related barriers and facilitators,
as well as outcomes and measures. The ndings offer insights into how to better support the implementation of ICTs and highlights the important
role of collaborative initiatives in providing both technical and social support to facilitate implementation of ICTs in clinical settings.
Characteristics of included studies
Most of the included studies were experimental designs and feasibility trials, and nearly one quarter were protocols, indicating that many studies
are currently underway. Despite the growing evidence in this eld, we found a lack of qualitative evidence. This is a gap in the current literature,
and future research should consider qualitative study designs to evaluate implementation and/or impact of ICT-based interventions for suicide
prevention on patients, health care providers, and health systems. Clinical practice within hospitals is an example of a complex adaptive system.
Evaluating and understanding implementation of ICTs in complex systems will benet from using qualitative or mixed-methods designs because
quantitative methods alone cannot capture the complexity inherent within the phenomenon nor can it unpack interplay of contextual
characteristics that inuence implementation and impact of ICTs. Efforts are needed to move beyond traditional effectiveness trials and better
understand how and why innovations bring change [100]. Further to this, future research should consider explicitly reporting the use of TMFs to
guide their study. Despite the clinical potential of using mental health apps, integrating these apps into routine practice is limited, partly
attributable to a lack of theoretical foundations and rigour in research for implementation [18]. Future research can benet from leveraging TMFs
and qualitative and/or mixed methods designs to unpack the complexity and contribute to building a rich evidence base.
Implementation of ICTs in clinical settings
There was a general lack of reporting details related to implementation strategies, and related barriers and facilitators. Of the reported studies,
education and training were the most commonly reported implementation strategies for the ICTs. This is consistent with the current literature for
implementation practice and knowledge translation [101, 102]. Educational meetings and training workshops are often less costly and easier to
implement compared to more complex strategies that require organizational change [103]. Therefore, educational meetings and training
workshops could have been feasible options. However, barriers related to psychological capabilities were the least frequently coded category in
the included studies. It is important to note that improving clinicians’ level of knowledge and skills does not always lead to observable practice
changes leading to successful implementation of innovations [104]. Secondly, collaborative initiatives were the next commonly reported strategy
for implementation identied in this review. While partnership approaches such as co-design are common for innovation development, people
often think that implementing what has been designed is the responsibility of others [105]. This is not true; researchers can co-create changes in
the workow to support implementation [106]. We encourage researchers to continue to leverage collaborative initiatives within their studies as
they can foster important relationships between knowledge users and researchers. This will allow researchers to focus on real-world needs and
facilitating implementation efforts [107, 108].
Researchers need to consider the complex contexts in which apps are being implemented [17]. As such, reporting details of implementation plans
are strongly encouraged to advance our understanding of implementation processes and context. During implementation, the inuence of context,
such as barriers and facilitators, and interactions between them, are necessary to explain how or why certain outcomes are achieved, as well as
variations in outcomes across studies [109, 110]. Furthermore, implementation is a known determinant of intervention effectiveness, and barriers
can signicantly reduce the effectiveness of an intervention [49]. Not knowing contextual inuences may limit the generalizability of study

Page 45/55
ndings to different settings. In response to the general lack of reporting details identied in this review, we encourage future studies to consider
Proctor’s recommendations for specifying and reporting implementation strategies [111] and the Expert Recommendations for Implementing
Change (ERIC) taxonomy for implementation strategies [112]. Furthermore, considering the iterative nature of the implementation process, any
changes to original implementation plans are also encouraged to be reported. Future studies can consider the Framework for Reporting
Adaptations and Modications–Enhanced (FRAME) to guide the reporting of adaptations and modications to the design or delivery of an
intervention [113].
It has been reported that researchers are faced with challenges of selecting implementation strategies [114]. Furthermore, implementation
strategies have often been mismatched to existing barriers [115, 116]. For example, a review of 20 quality improvement studies found that many
studies utilized clinician-oriented (individual-level) strategies, such as education, to address organizational-level barriers [115]. Similarly, the
current review identied that the three most reported categories of barriers were related to physical opportunity, social opportunity and reective
motivation, and examples included poor internet connection, busy clinical settings, lack of buy-in from and engagement with clinicians, and
perceived uncertainties around ICTs. However, the most reported implementation strategies were education and training support, all of which
cannot address the barriers stated above. This is an example of missed opportunities and an area for future research efforts. Guided by the BCW,
we can identify intervention options that can address the barriers identied in this review. To overcome physical opportunity,
Training, Enablement,
Environment Restructuring
, or
Restriction
are recommended [42]. To overcome social opportunity,
Restriction, Environment Restructuring,
Modelling
, or
Enablement
are suggested [42]. The use of evidenced-based theories like the BCW can improve the selection of implementation
strategies and subsequent integration of ICTs in clinical settings [117, 118]. Additionally, clinical practice within health systems as well as human
behaviour are complex; it is not individual factors that facilitate implementation of a new innovation, but the dynamic interaction between them
[23, 119]. Nonetheless, the BCW accounts for interactions between both internal (i.e.,
capability
,
motivation
) and external (i.e.,
opportunity
) factors
that inuence behaviour change [42]. As such, the use of the behaviour change theories will not downgrade the complexity, but rather it can help
researchers organize complex data in a comprehensive way that is also accessible to work with. As such, we recommend future studies to use
TMFs to guide the selection of implementation strategies to overcome existing barriers. Additionally, considering the lack of qualitative evidence
in this eld, studies exploring users’ experiences of implementing and using ICTs for suicide prevention in clinical settings can provide an in-depth
understanding of the context to facilitate implementation efforts.
Consistent with the current review ndings, other external barriers associated with implementing ICTs are related to limited access to ICTs and
internet, and digital literacy skills [120]. Despite the widespread use of mobile phones, a phenomenon called the digital divide can occur due to
social equity factors such as education, income, age, and urban/rural residence [121–123]. To prevent digital divide amplication and to avoid
unintended harm, implementation efforts for new innovations must account for digital equity considerations [124]. However, very few included
studies considered equity concerns and provided patients with ICT devices [72, 74, 80, 84], free data plans [125], or options for alternative ICTs
(e.g., email instead of texts) as per patients’ preferences [71, 126]. In contrast, several studies made ownership of ICT devices as one of the
inclusion criteria [54, 63–65, 67, 68, 79, 97–99, 125, 127–130], and one study excluded participants who reported diculty using a computer
[131]. This is a critical area of future efforts for minimizing the digital divide. Van Dijk [132, 133], and Selwyn [134] recommend addressing the
digital divide through assessing patient ICT access, use, competence, and reasons for divided outcomes. As many ICTs are rapidly being adopted
and implemented for suicide prevention, this review identied a lack of attention to equity-related considerations in the current literature. This
highlights a critical direction for future research, as efforts are needed to prevent digital divide amplication and avoid unintended harm while
advancing ICT use.
Reported measures and outcomes
We identied that studies evaluated their ICTs and reported implementation outcomes and/or its impact on patients, clinicians, and/or health
systems. Most studies reported patient-level outcomes, such as suicide risk and behaviours, and implementation outcomes of adoption and
feasibility. However, no studies reported long-term outcomes of implementation such as sustainability. This is a gap in the current literature, and
future research should consider assessing long-term outcomes, or at least should consider sustainability potential beyond feasibility. The end
goal of implementing new innovations in clinical settings is routinization, achieving seamless integration of ICT use in routine clinical ow [135].
Despite the promising clinical benets of ICTs for suicide prevention, clinical integration remains limited [17–19]. This problem is consistent
across ICTs in general. It has been repeatedly reported that ICTs are not fully implemented, not moving beyond pilot trials or even being
abandoned [20, 136]. To move beyond initial adoption of useful ICTs, we encourage future research to consider sustainability outcomes early on.
Proctor’s Implementation Outcomes Framework [49] and the Reach, Effectiveness, Adoption, Implementation Maintenance (RE-AIM) [137] are
example tools to guide outcome selections related to implementation and sustainability of interventions. Several studies included in this review
measured both intervention impact and implementation outcomes in one study [60, 62–65, 72–74, 78, 79, 85, 87, 88, 91, 93, 96, 129, 131, 138–
142]. Similarly, future research can benet from leveraging effectiveness-implementation hybrid designs that have a dual focus of evaluating
intervention effectiveness and implementation outcomes simultaneously [143, 144]. Hybrid designs are encouraged to move interventions to the
real-world more rapidly because the traditional research approach of keeping ecacy, effectiveness, and implementation research separate and
sequential slows down the process and overlooks complex contexts inherent within [143, 144].

Page 46/55
Limitations
Several limitations may affect the interpretation and use of our review ndings. Many papers lacked detail on the barriers and facilitator to
implementation, which made challenging to categorize them into the three overarching domains of
capability
,
opportunity
, and
motivation
. We
conducted directed content analysis of the barriers and facilitators, but due to the limited reporting of the studies we did not achieve thematic
saturation. Therefore, we report the frequency counts of these barriers and facilitators. Furthermore, the categories within the COM-B and TDF are
not mutually exclusive; many barriers and facilitators interact with each other, and this is one of the underlining assumptions of the human
behaviour [42]. Future qualitative work exploring barriers and facilitators can be benecial to advance our understanding of implementing ICT-
based interventions for suicide prevention. Secondly, our search strategy was limited to papers published in English. This may partly explain our
nding that most studies originated from North America and Europe. As shown in the Fig.1, we excluded eight papers written in non-English
languages. We acknowledge that our search strategies may not have captured studies conducted in low and middle-income countries, and this
review does not reect evidence of ICTs for suicide prevention written in non-English languages.
Conclusions
This scoping review provides a comprehensive overview of published literature on the ICTs for suicide prevention implemented in clinical settings.
The ndings revealed the most common types of ICTs for suicide prevention, including apps, text messages, and telemedicine. These ICTs were
commonly used as a targeted strategy for suicide prevention and served multiple functions, including suicide screening and assessment, safety
planning, and post-discharge follow-up care. Additionally, the ndings revealed that the most common strategies for implementing these ICTs
included education, training, and collaborative initiatives. However, barriers collectively inuenced clinicians’ capability, opportunity, and
motivation to implement ICTs for suicide prevention. Therefore, implementation strategies must be tailored and multi-faceted to target specic
barriers in a given context in order to facilitate implementation efforts for ICTs in clinical settings. Along with the lack of qualitative evidence in
this eld, the lack of reporting of implementation strategies and related barriers and facilitators was an evident gap in this body of literature,
highlighting the need for more explorative research and a call for better reporting. Additionally, the lack of theoretical frameworks identied in
included studies encourages the use of established TMFs to guide future work. Lastly, the absence of sustainability outcomes and digital equity
considerations identied in the current literature highlights a critical direction for future research.
Abbreviations
ICT: information communication technology; BCW: behaviour change wheel; COM-B: capability opportunity motivation – behaviour; TDF:
theoretical domains framework; JBI: Joanna Briggs Institute; TMF: theory, model, framework
Declarations
Ethics approval and consent to participate
Not applicable.
Consent for publication
Not applicable.
Availability of data and materials
All data generated or analysed during this study are included in this published article [and its Additional les].
Competing interests
The authors declare that they have no competing interests.
Funding
As a PhD in Health Services Research trainee, HDS was funded through the Queen Elizabeth II/Mary Beck Queen Elizabeth II Graduate
Scholarships in Science and Technology and the Koerner Scholarship from the Centre for Addiction and Mental Health. The funders did not have
any role in content development.
Authors’ contributions
HDS designed the scoping review protocol including data collection and interpretation planning. HDS, LS performed the title and abstract
screening and HDS, LS, KD performed full-text screening. HDS, KD, LS performed data extraction. HDS conducted data analysis and LS, KD

Page 47/55
veried analyzed data. HDS wrote the rst draft of the manuscript. GS supervised all phases of the work. All authors (HDS, KD, LS, JZ, JT, GS)
critically reviewed and revised the manuscript and approved the nal version.
Acknowledgements
We wish to thank the librarians for generating and peer-reviewing comprehensive search strategies in this review.
Conicts of Interest
There are no conicts of interest to declare with this submission.
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Table
Table 3 is available in the Supplementary Files section.
Figures

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Figure 1
PRISMA ow chart

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Figure 2
Reported outcome types
Supplementary Files
This is a list of supplementary les associated with this preprint. Click to download.
AdditionalFile1FullSearchStrategy.docx
AdditionalFile2DataExtractionTool.docx
AdditionalFile3CodingStrategy.docx
Table3.docx
AdditionalFile4BarriersFacilitatorsFull.docx