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

March 2023
BMC Health Services Research 23(1)

DOI:10.1186/s12913-023-09254-5

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CC BY 4.0

Authors:

Keri Durocher

Western University

Lydia Sequeira

Kids Help Phone

Juveria Zaheer

Centre for Addiction and Mental Health

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Background A large number of information and communication technology (ICT) based interventions exist for suicide prevention. However, not much is known about which of these ICTs are implemented in clinical settings and their implementation characteristics. In response, this scoping review aimed to systematically explore the breadth of evidence on ICT-based interventions for suicide prevention implemented in clinical settings and then to identify and characterize implementation barriers and facilitators, as well as evaluation outcomes, and measures. Methods We conducted this review following the Joanna Briggs Institute methodology for scoping reviews. A search strategy was applied to the following six 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 hand-searching reference lists of relevant reviews. To be included in this review, studies must include ICT-based interventions for any spectrum of suicide-related thoughts and behaviours including non-suicidal self-injury. Additionally, these ICTs must be implemented in clinical settings, such as emergency department and in-patient units. We used the Preferred Reporting Items for Systematic Reviews and Meta-Analyses Extension for Scoping Reviews (PRISMA-ScR) checklist to prepare this full report. Results This review included a total of 75 citations, describing 70 studies and 66 ICT-based interventions for suicide prevention implemented in clinical settings. The majority of ICTs were computerized interventions and/or 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/or 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 This review presents several trends of the ICT-based interventions for suicide prevention implemented in clinical settings and identifies 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.

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Shinetal. BMC Health Services Research (2023) 23:281

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BMC Health Services Research

Information andcommunication

technology-based interventions forsuicide

prevention implemented inclinical settings:

ascoping review

Hwayeon Danielle Shin1,2*, Keri Durocher2,3,4, Lydia Sequeira2, Juveria Zaheer5,6,7, John Torous8 and

Gillian Strudwick1,2

Abstract

Background A large number of information and communication technology (ICT) based interventions exist for

suicide prevention. However, not much is known about which of these ICTs are implemented in clinical settings and

their implementation characteristics. In response, this scoping review aimed to systematically explore the breadth of

evidence on ICT-based interventions for suicide prevention implemented in clinical settings and then to identify and

characterize implementation barriers and facilitators, as well as evaluation outcomes, and measures.

Methods We conducted this review following the Joanna Briggs Institute methodology for scoping reviews. A search

strategy was applied to the following six databases between August 17–20, 2021: MEDLINE, Embase, CINAHL, Psy-

cINFO, Web of Science, and Library, Information Science and Technology Abstracts. We also supplemented our search

with Google searches and hand-searching reference lists of relevant reviews. To be included in this review, studies

must include ICT-based interventions for any spectrum of suicide-related thoughts and behaviours including non-

suicidal self-injury. Additionally, these ICTs must be implemented in clinical settings, such as emergency department

and in-patient units. We used the Preferred Reporting Items for Systematic Reviews and Meta-Analyses Extension for

Scoping Reviews (PRISMA-ScR) checklist to prepare this full report.

Results This review included a total of 75 citations, describing 70 studies and 66 ICT-based interventions for suicide

prevention implemented in clinical settings. The majority of ICTs were computerized interventions and/or applica-

tions (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/or 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 imple-

mentation strategies included training, education, and collaborative initiatives. Barriers and facilitators of implemen-

tation 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.

*Correspondence:

Hwayeon Danielle Shin

hdanielle.shin@mail.utoronto.ca

Full list of author information is available at the end of the article

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Page 2 of 60

Shinetal. BMC Health Services Research (2023) 23:281

Conclusion This review presents several trends of the ICT-based interventions for suicide prevention implemented in

clinical settings and identiﬁes a need for future research to strengthen the evidence base for improving implementa-

tion. 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 imple-

mentation of ICTs.

Keywords Information communication technology, eHealth, Suicide prevention, Implementation, Digital health,

Health Informatics, Psychiatry, Mental health

Introduction

e World Health Organization (WHO) reports that

there are over 700,000 annual deaths by suicide world-

wide [1, 2]. Globally, suicide is the fourth leading cause

of deaths for youth and young adults [1], and speciﬁcally

it is the second in Canada and USA [3, 4], and the ﬁrst in

Australia [5]. As such, suicide prevention is a top global

health priority [6]. Suicide is preventable with timely, evi-

dence-based interventions [2]. ere are evidence-based

interventions for suicide prevention, such as risk assess-

ment, safety planning interventions, and follow-up care

[7, 8], all of which are delivered in clinical settings, such

as emergency departments. We also recognize the impor-

tance of population-level approaches to suicide preven-

tion, such as gatekeeper training programs in schools [8].

However, clinical attention for suicide prevention cannot

be overlooked, and individuals who suﬀer from suicide

ideation must receive clinical attention [9, 10].

A review published in 2002 investigated 40 studies

from the United States (US), United Kingdom (UK), Can-

ada, Finland, and Sweden and found that 33% of individ-

uals who died of suicide had contact with mental health

services in the year before death and 20% in the month

before death [11]. Not much has changed since then, and

we continue to observe missed opportunities. In Can-

ada, a study in 2014 examined 8,851 suicide deaths and

found 50% of these individuals had visited an emergency

department in the year before death, and one third had

died within the month of discharge [12]. is speaks to a

critical opportunity for suicide prevention in clinical set-

tings, which will be the focus of this review.

Information and communication technology (ICT)

[13] or eHealth [14] includes a wide range of digi-

tal tools such as internet, telemedicine, and mobile

technologies. In this review, we refer to ICTs collec-

tively as technologies, advanced multimedia, software

programmes and/or telecommunications that allows

eﬃcient communication, management, storage, dis-

semination and exchange of information [13], and

eHealth refers to use of ICTs for health [14]. ere is

a large number of ICT-based interventions for men-

tal health, including suicide prevention strategies [15,

16]. For example, Rassy etal. identiﬁed 115 ICT-based

interventions for suicide prevention, and they include

web-based tools, online programs, and mobile applica-

tions [16]. Given the widespread use of technologies in

this modern world, including mobile phones, ICTs have

the potential to improve suicide prevention by remov-

ing geographical barriers and increasing access and

availability of evidence-based interventions [16]. Addi-

tionally, ICTs may not replace clinical encounters, but

it can be augmented to expand existing suicide preven-

tion care.

ere is a growing body of evidence for the eﬀective-

ness of ICT-based interventions for suicide preven-

tion [15, 17–21]. For example, Witt etal. identiﬁed 14

online programs and mobile apps for self-management

of suicide ideation and concluded with some evidence

of reductions in suicidal ideation associated with using

these digital interventions [20]. Arshad etal. also identi-

ﬁed 22 clinical trials of ICT-based interventions for sui-

cide prevention, which included online support tools for

coping skills often derived from a well-established cog-

nitive behavioural therapy and concluded with a favour-

able eﬀect on reducing suicide thoughts [19]. Despite the

clinical potential and a large number of available ICTs for

mental health, clinical integration remains limited, and

clinicians, service users, and hospitals continue to face

challenges to achieve sustainable adoption [22–24]. It has

been repeatedly reported that implementation of ICTs

rarely moves beyond feasibility trials or initial adoption,

and sometimes ICTs are abandoned [25].

Healthcare is a complex adaptive system, which is

shaped by multiple, constant interdependent interac-

tions and relationships [26, 27]. When complexities

exist related to care settings or implementation chal-

lenges, the less likely ICTs are to be adopted and sus-

tained [25, 28]. As such, research teams are required

to move beyond traditional cause-and-eﬀect thinking,

embrace complexity, and examine dynamic processes

inherent within. Speciﬁcally for mental health apps,

there was a recent call for attention to complex con-

texts in which apps are being implemented [22]. It is

critical to prospectively assess determinants of imple-

mentation and then strategically develop implementa-

tion strategies to match the contextual needs.

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Shinetal. BMC Health Services Research (2023) 23:281

Eﬀorts are needed to support clinical integration of

ICT-based interventions for suicide prevention as well as

their spread and maintenance to ensure that useful ICTs

are reaching people who are in need. Currently, the lit-

erature on ICT-based interventions for suicide preven-

tion describes their characteristics and/or evaluates their

eﬀectiveness in reducing suicide behaviours and risks,

but not much is known about clinical integration of ICTs

[15–20]. For example, it remains unknown how many

of 115 ICT-based interventions for suicide prevention

identiﬁed by Rassy etal. have been implemented in clini-

cal settings [16]. Research has not yet comprehensively

explored evidence on ICTs implemented in clinical set-

tings and their implementation characteristics, including

barriers and facilitators. Given the lack of successful clin-

ical integration of ICTs [22–24], this review was needed

as a ﬁrst step to inform implementation eﬀorts for useful

ICTs for suicide prevention in clinical settings. Scoping

reviews are suggested when researchers need to identify

the types of available evidence and key characteristics

related to a concept rather than to perform a meta-analy-

sis to make practice recommendations [29, 30]. Further-

more, this review was needed to determine the range of

studies before carrying out our future multi-phase pro-

ject to develop and evaluate implementation strategies

for a mobile app-based intervention for suicide preven-

tion in clinical settings. As such, the current scoping

review aimed to systematically explore the breadth of evi-

dence on ICT-based interventions for suicide prevention

implemented in clinical settings and then to character-

ize barriers and facilitators to implementation, as well as

measures and outcomes reported in this body literature.

Research questions

To achieve the research aim stated above, this scoping

review addressed the following questions.

1. What ICT-based interventions for suicide preven-

tion 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

of these ICT-based interventions?

Methods

is review followed the Joanna Briggs Institute (JBI)

methodology [31, 32] and this report was prepared

following the Preferred Reporting Items for System-

atic reviews and Meta-Analyses extension for Scoping

Reviews (PRISMA-ScR) checklist [33]. Our a priori

protocol has been previously published [34]. We also

searched PROSPERO, the Cochrane Database of

Systematic Reviews and JBI Evidence Synthesis and Open

Science Framework in June-July 2021 and identiﬁed no

ongoing systematic or scoping reviews on the same topic.

Inclusion/exclusion criteria

Population

All clinicians both licenced and regulated practition-

ers were considered for inclusion in this review. Various

healthcare professionals, such as physicians, nurses and

social workers, provide direct care, and they are often

collectively referred to as ‘clinicians’ [35, 36]. Addition-

ally, unregulated clinical support team members and peer

support workers were considered for inclusion because

these roles are increasingly integrated into mental health

care settings [37, 38]. is population criterion was rela-

tively less signiﬁcant than the context criterion because

who implemented ICT-based interventions was often

part of the context.

Concept

is review considered all types of ICT-based interven-

tions for suicide prevention. Routine care (i.e., treatment

as usual) provided via virtual platforms or telephones

were excluded unless an ICT-based intervention was

delivered to patients. erefore, following the WHO’s

deﬁnition for intervention, ICT-based interventions

needed to assess, improve or promote service users’

health outcomes [39]. Suicide-related thoughts and

behaviours is an umbrella term that refers to a spectrum

of suicide ideation, communication, behaviours, and

attempts with having any frequencies of suicidal thoughts

with actual, undetermined, or no suicidal intent [40]. To

be included, ICT-based interventions must be related to

any sub-category of suicide-related thoughts and behav-

iours including non-suicidal self-injury (NSSI). Although

NSSI is a unique phenomenon from actual suicide

attempt, we decided to include it because NSSI is one of

the risk factors for future attempt and suicide [41, 42].

According to WHO, there are three levels of suicide pre-

vention: 1) Universal, 2) Selective, 3) Indicated. Univer-

sal strategies for suicide prevention work at a population

level [1]. Selective prevention strategies target individuals

who may not be currently expressing suicidal behaviours

but are at a greater risk of suicide based on their char-

acteristics such as age, sex and/or medical history [1].

Indicated prevention strategies target individuals who

are presenting active risk or early signs of suicide poten-

tial, such as suicide attempt [1]. ICT-based interventions

for any levels of suicide prevention were considered for

inclusion. Suicide prevention interventions in this review

included, but were not limited to, suicide risk assessment,

safety planning intervention and lethal means restriction

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Shinetal. BMC Health Services Research (2023) 23:281

[7, 8]. Lastly, this review considered all ICT-based inter-

ventions that targeted patients of any age.

Context

All hospitals or clinical settings were considered for

inclusion. For this review, a clinical setting was deﬁned as

any context where clinician-patient interactions occurred

in real-time. erefore, who implemented the ICT-based

intervention was part of the context. To be considered for

inclusion, ICT-based interventions needed to be imple-

mented and initiated in clinical settings. erefore, this

review excluded crisis services because they are ﬁrst ini-

tiated by patients, often in a public context, which we

assumed to have diﬀerent implementation characteristics

compared to ICTs initiated in clinical settings. Addition-

ally, there has already been a systematic review investi-

gating eﬀectiveness of crisis lines [43]. Self-support tools

that patients can freely download from app stores or tools

that involved self-referrals after reading public advertise-

ments were also excluded as these were being initiated in

non-clinical settings. Further to this, studies focusing on

the development of ICT(s) without implementation were

excluded. See Table1 for summary of eligibility criteria.

Search strategy

We worked with a health sciences librarian to develop a

comprehensive search strategy to ﬁnd relevant scholarly

literature in several bibliographic databases. is scop-

ing review followed a three-step search strategy outlined

in JBI methodology [31, 32]. First, a librarian devel-

oped and reﬁned a draft strategy in Medline, then ana-

lyzed text words and index terms contained in titles and

abstracts of relevant articles as well as the subject head-

ings. Second, relevant text words and index terms from

the selected articles were used to develop a full search

strategy. ird, the search strategy comprised of all

identiﬁed keywords and index terms was adapted for all

included databases. is required iterative steps of revis-

ing and testing, and the ﬁnal search strategies were peer-

reviewed by a second research librarian using the Peer

Review of Electronic Search Strategy (PRESS) guidelines

[44]. A librarian ran the search in the following databases

on August 17–20, 2021: MEDLINE (Ovid), Embase (Else-

vier), CINAHL (EBSCO), PsycINFO (EBSCO), Web of

Science, and Library, Information Science and Technol-

ogy Abstracts (LISTA). e selection of the listed data-

bases was informed by consultation with a librarian, and

they provide full coverage of literature likely to provide

information speciﬁc to ICTs in clinical settings. All ﬁnal

search strategies are presented in Additional File 1.

Godin’s targeted Google search method [45] was used

to locate additional eligible sources. First, we conducted

ten unique Google searches with combinations of key-

words and then reviewed the ﬁrst ten pages of each

Table 1 Inclusion criteria

Inclusion criteria

Population All members of clinical care team

• Licenced and regulated practitioners

• Unregulated practitioners or clinical support teams such as peer support workers

Concept • Information and Communication Technologies (ICTs): “A set of technologies

resulting from the convergence of information technology and advanced multi-

media and telecommunications techniques, which have enabled the emergence

of more eﬃcient means of communication, by improving processing, storage,

distribution and exchange some information” [13]

• Suicide-related thoughts and behaviours [40]: 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 (e.g.,

NSSI). This review will consider ICT-based interventions for suicide prevention

regarding any sub-category of suicide-related thoughts and behaviours

• Suicide prevention interventions included but was not limited to the following

list adapted from Wilson [7] and Zalsman [8]

• Screening and assessment

• Safety plan (e.g., identifying warning signs coping strategies, emergency con-

tacts)

• Lethal means restriction and counselling

• Discharge or post-discharge follow up

• Behaviour or cognitive therapies

Context Clinical/hospital setting or context (i.e., clinician-patient interaction in real time)

Source • Primary research studies of any design

• Study protocols

• Conference papers, reports from relevant health services organizations

Language English

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Shinetal. BMC Health Services Research (2023) 23:281

search results to identify international and national

health services websites. Second, we hand-searched rel-

evant websites identiﬁed in the ﬁrst step to ﬁnd eligible

sources. ese two steps were carried out in incognito’

mode, which limited the impact of previous search his-

tory on new results. is Google search was comple-

mentary to the database searches to identify additional

sources of evidence that our search strategy might have

missed.

Types ofsources

All research study designs were included (e.g., quantita-

tive, qualitative, mixed methods). Although study pro-

tocols did not have empirical data, we included them to

capture relevant details. Protocols tend to include details

on interventions and implementation, such as interven-

tion components, implementation plans, implementa-

tion blueprints, and discrete implementation strategies.

Such information is useful characteristics to identify. Fur-

thermore, by including protocols, we can reﬂect upcom-

ing trends, such as the most used research designs in

the upcoming years. Reference lists of relevant litera-

ture reviews, commentaries, and opinion papers were

reviewed to identify additional primary studies that met

our eligibility criteria. We also considered grey literature

for inclusion, such as conference papers and reports from

relevant health organizations. Sources had to be available

in English, and no date parameters were applied.

Study selection

All identiﬁed citations were uploaded into Covidence

[46] and duplicates were automatically removed by

Covidence. Two reviewers (HDS, LS) independently

screened titles and abstracts against the eligibility crite-

ria. Next, relevant full-text articles were retrieved into

Covidence [46], and the primary (HDS) and secondary

reviewers (KD, LS) independently assessed them in detail

against the eligibility criteria. Reasons for exclusion were

recorded at the full-text screening phase and reported in

the PRISMA ﬂow diagram. Any discrepancies between

the reviewers (HDS and LS or HDS and KD) at each

stage were resolved either through discussion or by a

third reviewer (KD or LS). Scoping reviews generally do

not require methodological assessment [32], thus critical

appraisal was not conducted.

Data extraction

We developed an extraction tool in Covidence to capture

characteristics of the paper, setting, participating clini-

cians, implementation strategies, descriptions of ICT-

based intervention(s), patient population, barriers and

facilitators to implementing ICTs, and reported meas-

ures and outcomes. ree reviewers (HDS, KD, LS) ﬁrst

pilot-tested the extraction tool on three studies to iden-

tify any discrepancies or inconsistencies prior to data

extraction. Each person extracted the same three stud-

ies independently using the extraction tool. We initially

proposed to pilot-test the extraction tool on ﬁve stud-

ies. However, after testing on three studies for calibra-

tion exercise, the team agreed that all relevant data were

captured, so we decided to start independent extraction

without testing on two more studies. Minor changes to

the original extraction tool were made, such as extract-

ing the reported use of theories, models, or frameworks.

e primary (HDS) and secondary reviewers (KD, LS)

independently extracted data using Covidence [46]. Any

conﬂicts in data extraction were resolved either through

discussion between the two reviewers (HDS and LS or

HDS and KD) or by a third reviewer (KD or LS). Final

version of the data extraction tool is included in Addi-

tional File 2.

Data analysis

Following data extraction, we characterized extracted

data using frameworks, typology, and taxonomy. First,

identiﬁed ICT-based interventions for suicide prevention

were categorized using a typology for e-Mental Health

created by the Mental Health Commission of Canada

(MHCC) [47]. Intervention descriptions were then char-

acterized based on the suicide prevention interventions

category adapted from Wilson [7] and Zalsman [8], and

the WHO’s three levels of suicide prevention [1].

Second, we performed directed content analysis [48]

using the Behaviour Change Wheel (BCW) [49, 50] and

the eoretical Domains Framework (TDF) [51] to map

clinician-reported barriers and facilitators to imple-

menting ICT-based interventions. ey are comprehen-

sive, evidence-based behaviour frameworks that capture

internal and external inﬂuences of behaviour change.

e Capability, Opportunity and Motivation – Behaviour

(COM-B) model within the BCW explains behaviours by

describing interactions between one’s capability, oppor-

tunity and motivation [49]. TDF is a 14-domain behav-

ioural framework that expands the COM-B [51], so when

used together, TDF allows for granularity of behaviour

analysis [52]. Furthermore, beneﬁts of using BCW and

TDF for assessing implementation barriers and facilita-

tors have been previously documented across healthcare

disciplines [53–55]. Narrative descriptions of reported

barriers and facilitators were mapped onto the COM-B

and TDF.

ird, this review categorized reported measures and

outcomes of ICT-based interventions for suicide pre-

vention. Outcomes were categorized as either imple-

mentation outcomes or impact outcomes of the ICTs.

Implementation outcomes were further categorized

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Shinetal. BMC Health Services Research (2023) 23:281

using Proctor’s Implementation Outcomes Framework:

(1) Acceptability, (2) Adoption, (3) Appropriateness,

(4) Feasibility, (5) Fidelity, (6) Implementation cost, (7)

Penetration, and (8) Sustainability [56]. Impact out-

comes or intervention outcomes were categorized into

three levels: (1) Patient, (2) Health care provider (i.e.,

clinician), (3) Health system. Patient level impact was

further categorized into patient-reported outcomes

(PRO) [57], patient-reported experience (PRE) [58],

and patient health outcomes (e.g., mortality) [59]. PRO

comes from patients and often records patients’ view of

their health status and condition [57]. Patients’ views of

their own health can provide insight into the impact of

an intervention [58]. In contrast to PRO, PRE measures

patients’ perceptions and experiences of receiving care,

providing insight into the quality of care during the

intervention and the process of care [58]. Health care

provider level outcomes include conceptual knowl-

edge use (i.e., proximal practice change), instrumental

knowledge use (i.e., observable practice change) [60],

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 [60]. Lastly, system

level outcomes include resource utilization and eco-

nomic outcomes such as cost eﬀectiveness, and read-

mission rates [59]. Additional File 3 provides the full

coding strategy with operationalized deﬁnitions.

e coding strategy was pilot tested on three studies

by the primary reviewer (HDS), who has experience in

qualitative research. en second reviewers (LS, KD)

who also have qualitative research experience reviewed

the coded data generated by HDS to identify discrep-

ancies and ensure consistency in coding. LS reviewed

the coded data for barriers and facilitators and KD

reviewed the categorized outcomes. LS and KD each

reviewed half of the coded data for the characteris-

tics of ICT-based interventions for suicide prevention.

No changes were made to the coding strategy after

pilot testing, and the primary reviewer (HDS) coded

the rest of the data. en the second reviewers (KD,

LS) reviewed all coded data to verify HDS’s work. Any

disagreements between the reviewers were resolved

through discussion.

Data summarizing andreporting results

We charted the data in a tabular form that aligns with the

review questions and aim. We also produced descriptive

numerical summaries of the quantitative data (i.e., fre-

quency counts) and graphical ﬁgures. We then provided

narrative summaries to accompany these presentations

and addressed the review questions and aim.

Results

Our database searches resulted in 6,008 citations. After

duplicate removal, 3,659 citations remained for assess-

ment against the eligibility criteria. After screening titles

and abstracts, 242 citations remained for full-text review,

and we identiﬁed an additional 6 relevant papers through

Google searches and reviewing references of relevant

reviews. is review included a total of 75 citations,

describing 70 studies and 66 ICT-based interventions.

See Fig.1 for the PRISMA ﬂow chart which includes the

reasons for excluding full-text articles.

Characteristics ofincluded studies

Of the 70 papers, there were 52 research studies and

18 study protocols. ere were ﬁve protocols of com-

pleted studies (i.e., protocol-study dyads) [61–65]. Sev-

enty studies were a mix of experimental design (n = 22)

[66–87], observational design (n = 12) [88–99], qualita-

tive design (n = 3) [100–102], case study (n = 1) [103],

quality improvement report (n = 1) [104], and feasibility/

pilot trial (n = 31) [105–135] that served as a precursor

to a larger study. ese 70 studies originated from USA

(n = 32) [69, 71, 73, 75, 76, 78, 81, 83, 88–90, 94–96, 98,

103, 104, 106, 109, 112–116, 118, 120–122, 124, 125, 132,

134], France (n = 8) [68, 72, 77, 86, 87, 91, 92, 105], UK

(n = 8) [84, 97, 101, 107, 108, 131, 133, 135], Australia

(n = 5) [67, 85, 117, 126, 128], Denmark (n = 5) [66, 82,

100, 127, 130], Canada (n = 4) [74, 93, 102, 111], South

Korea (n = 2) [99, 119], Netherlands (n = 1) [129], Iran

(n = 1) [80], Sri Lanka (n = 1) [79], Japan (n = 1) [123],

Spain (n = 1) [70], and Portugal (n = 1) [110]. Studies

took place most commonly in out-patient clinical settings

(n = 43) [66, 67, 69–71, 73, 75, 76, 82–88, 90–92, 94, 96,

99–103, 105–107, 109–111, 114, 115, 117, 118, 123, 125,

127, 129–132, 134], such as emergency departments and

clinics, then in-patient clinical settings (n = 14) [77–80,

93, 97, 98, 108, 113, 120–122, 128, 135], such as in-patient

psychiatric units, and a mixture of both (n = 11) [68, 72,

74, 81, 89, 95, 104, 116, 119, 124, 133]. e remaining

two studies were conducted in mental health hospitals

but did not report speciﬁc clinical setting characteris-

tics [112, 126]. Examples of involved clinicians included

psychiatrists, nurses, physicians, social workers, and

behaviour health clinicians, such as psychologists. Lastly,

there was a lack of reported theories, models, or frame-

works (TMFs) guiding research. Seven studies explicitly

reported TMFs guiding their research [116, 118, 119, 124,

129, 131, 135], including the User-Centered Design Prin-

ciples, Proctor’s Implementation Outcomes Framework,

eory of Planned Behaviour, Interpersonal Psycho-

logical eory of Suicide, Integrated Motivational-Voli-

tional model of suicidal behaviour, Medical Research

Council, Process evaluation framework for analysis, and

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Normalisation Process eory. Table2 summarizes over-

all characteristics of included papers.

What ICT‑based interventions forsuicide prevention have

been implemented inclinical settings?

is review identiﬁed a total of 66 ICT-based interven-

tions for suicide prevention implemented in clinical

settings. Based on the WHO levels of suicide preven-

tion strategies, identiﬁed ICT-based interventions were

used as universal (n = 4), selective (n = 10), or indicated

(n = 53) strategies for suicide prevention. One ICT (i.e.,

Virtual Hope Box app) was used as both selective and

indicated strategies in diﬀerent studies [69, 88, 109].

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 strat-

egies targeting at-risk populations, such as veterans, or

patients living with human immunodeﬁciency virus, or

cancer. A few ICT-based interventions were used as uni-

versal strategies aimed at population level, which may be

explained by this review’s inclusion criteria being clinical

context.

e 66 ICT-based interventions for suicide preven-

tion served multiple functions; they were used for sui-

cide 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, care plans, and

peer supports. Following the MHCC typology, most of

the ICTs were categorized as computerized interven-

tions (e.g., web-based tools), 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), wear-

able computing and monitoring (n = 1), virtual reality

(n = 2), peer support through social media (n = 2), and

a robot (n = 1) (i.e., chatbot). Table3 summarizes above

characteristics of ICT-based interventions for suicide

prevention.

Implementation strategies

Overall, there was a lack of reporting on the implementa-

tion 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 [62, 63,

70, 71, 75, 95, 101, 110, 114, 115, 121, 127–129, 134]. A

few studies speciﬁcally reported using demonstration

Fig. 1 PRISMA ﬂow chart

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Table 2 Characteristics of included studies

Author, Year Country of origin Study design Research aim/objectives/

questions Patient population Clinical setting and type Clinician characteristics

Andreasson et al., 2017 [66]

(Protocol) Denmark Experimental -Investigate if a safety plan-

ning tool delivered as an

app, compared to a safety

plan delivered by paper,

can reduce suicide ideation

after 12 months of interven-

tion 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 [67] Australia Experimental -Evaluate the safety,

feasibility, and acceptability

of a MOST intervention

(“Aﬃnity”) 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 interper-

sonal targets of the Aﬃnity

intervention, as well as

changes in self-reported

depression and suicidal

ideation

Patients with suicidal idea-

tion within the past four

weeks

The Youth Mood Clinic

(YMC), a tertiary-level out-

patient mental health ser-

vice that is part of Orygen,

a state government-funded

youth mental health service

in Melbourne, Australia.

YMC specialises in the treat-

ment of young people with

complex depression

Out-patient

Youth mental health clini-

cians from the youth mood

clinic and treating clinicians

and Aﬃnity staﬀ

Berrouiguet and Alavi et al.,

2014 [61]

(Protocol)

HUGOPSYNetwork et al.,

2018 [68]

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 demon-

strate the capability of a

mobile-based brief contact

intervention for triggering

patient

-Initiated contact with a

crisis support team at vari-

ous 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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Table 2 (continued)

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 [105]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 [106] United States Pilot/Feasibility trial -Test the feasibility and

acceptability of Lock to Live

(L2L) among suicidal adults

in EDs

Patients with identiﬁed

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

ﬁrearm 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[107]United Kingdom Pilot/Feasibility trial -Ascertain the usefulness

for patients and clinicians of

a digital self-monitoring sys-

tem 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 [108] United Kingdom Pilot/Feasibility trial -Report the practicalities

and acceptability of setting

up and trialling digital tech-

nologies 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

Not reported

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Table 2 (continued)

Author, Year Country of origin Study design Research aim/objectives/

questions Patient population Clinical setting and type Clinician characteristics

Bush et al., 2015 [109] 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 vet-

erans who either had bor-

derline personality disorder,

bipolar disorder, treatment

refractory depression, or

PTSD

Large, regional Veteran

Administration (VA) behav-

ioral 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 [69] 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 beneﬁts

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 [100] Denmark Qualitative -Explore diﬀerent stake-

holder 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 [110]

(Protocol) Portugal Pilot/Feasibility trial -Understand the health pro-

fessional’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 pro-

fessionals

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Table 2 (continued)

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 eﬀec-

tiveness of this speciﬁc

telephone management on

patients

Patients who attempted

suicide Emergency room of Cor-

poracio 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 [111] Canada Pilot/Feasibility trial -Determine whether a

mobile telephone mes-

sage intervention would

be acceptable to suicide

attempters

-Explore the operational

procedures of this interven-

tion to help determine the

appropriate content of

supportive messages

-Test the feasibility of cell-

phone message interven-

tions

Patients who attempted

suicide EDs of two general hos-

pitals, Tongji Hospital and

Union Hospital, in Wuhan,

China

Out-patient

Nurses and psychologists

Chen et al., 2018 [88] United States Observational -Describe usage of speciﬁc

app subcomponents and

to determine if speciﬁc

demographic and clinical

characteristics were associ-

ated 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 Veter-

ans Health Administration

hospital

Out-patient

Not reported

Comtois et al., 2019 [71] United States Experimental -Test the eﬀectiveness of

augmenting standard mili-

tary health care with Caring

Contacts delivered via text

message to reduce suicidal

thoughts and behaviors

over 12 months

Patients with suicidal idea-

tion 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

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Table 2 (continued)

Author, Year Country of origin Study design Research aim/objectives/

questions Patient population Clinical setting and type Clinician characteristics

Czyz et al., 2021 [113] United States Pilot/Feasibility trial -Investigate the feasibility

and acceptability of SMART

study procedures, including

the sequencing of interven-

tion components

Patients with suicidal idea-

tion 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 [112] United States Pilot/Feasibility trial -Describe the process of

development and report on

the feasibility and accept-

ability of the text-based

intervention as a continuity

of care strategy promoting

coping and safety plan use

following discharge

Patients with suicidal idea-

tion or suicide attempt Adolescent mental health

hospital

Undetermined

Not reported

Davis et al., 2021[89] United States Observational -Describe levels of adoles-

cent suicide risk detected

via depression screening

in a large primary care

network-Understand ﬁdel-

ity 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 idea-

tion or suicide attempt A large pediatric healthcare

facility

Mixture

Not reported

Depp et al., 2021[114]

(Protocol) United States Pilot/Feasibility trial -Reﬁne 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, schizoaf-

fective disorder, or schizo-

phrenia 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)

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Table 2 (continued)

Author, Year Country of origin Study design Research aim/objectives/

questions Patient population Clinical setting and type Clinician characteristics

Dimeﬀ et al., 2020 [116] United States Pilot/Feasibility trial TMF:

User-centered design

principles

-Design, develop, and

evaluate the feasibility of

“Dr. Dave” and the Virtual

CAMS system, including

electronic “Caring Contac ts,”

for suicidal patients in EDs,

as well as a provider-facing

clinical decision support

tool to aid in discharge dis-

position to reduce unneces-

sary hospitalization

Patients with identiﬁed

acute suicide risk EDs and 3 private outpa-

tient specialty clinics

Mixture

21 Medical providers

Dimeﬀ et al., 2021 [115] United States Pilot/Feasibility trial -Examine the feasibility,

acceptability, and eﬀective-

ness 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 sys-

tems 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 prac-

titioner

Duhem et al., 2018 [72]

(Protocol) France Experimental -Implement an adaptive

recontact system that

smoothly and eﬀectively

combines surveillance

and diﬀerent types of Brief

Contact Interventions that

ﬁt each patient’s speciﬁc

needs.-Optimise the care

management of patients

discharged from the hospi-

tal after a suicide attempt

by providing health stake-

holders 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 depart-

ments, and private clinics

Mixture

Coordination team, and a

call team consisting of 3 psy-

chologists and 3 psychiatric

nurses

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Table 2 (continued)

Author, Year Country of origin Study design Research aim/objectives/

questions Patient population Clinical setting and type Clinician characteristics

Etter et al., 2018 [90] United States Observational -Assess the use of a com-

puterized clinical decision

support system (CDSS) to

screen adolescents for sui-

cide 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 qualiﬁed health

center clinics that utilize

Child Health Improvement

through Computer Auto-

mation (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 adoles-

cent medicine

Fossi Djembi et al., 2020

[91]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 profes-

sionals specially trained in

suicidal crisis management

Fossi et al., 2021[92] France Observational -Describe the character-

istics of the patients, to

estimate the mean time

between suicidal iterations,

and to identify the proﬁles

of patients who had a sui-

cide reattempt compared

to other patients

Patients who attempted

suicide Emergency Department in

regional France

Out-patient

Not reported

Goodman et al., 2020 [73]

(Protocol) United States Experimental -Examine if Veterans who

are at high-risk for suicide

will beneﬁt from the novel

group intervention, PLF,

compared to Veterans who

receive TAU (e.g., individual

safety planning)

Patients with suicidal idea-

tion or suicide attempt Multiple sites of Veterans

Health Administration

(VHA) in New York and

Philadelphia

Out-patient

2 Therapists

Gregory et al., 2017 [93] Canada Observational -Examine whether or not

we could eﬀectively inte-

grate smartphone-based

safety planning into the dis-

charge 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)

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Table 2 (continued)

Author, Year Country of origin Study design Research aim/objectives/

questions Patient population Clinical setting and type Clinician characteristics

Grist et al., 2018 [101] 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 men-

tal health services (CAMHS)

Patients with self-harm CAMHS provided by Oxford

Health NHS Foundation

Trust. The Trust provides

mental healthcare for chil-

dren and young people in

Buckinghamshire, Oxford-

shire, Swindon, Wiltshire,

and Bath and North-East

Somerset

Out-patient

37 clinicians

Gros et al., 2011 [103] United States Case study -The case report concerns a

US veteran of the Afghani-

stan 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 [74]

(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 depart-

ment of psychiatry and

department of emergency

medicine in Ontario,

Canada

Mixture

Not reported

Hetrick et al., 2017 [117] 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

reﬁned (shorter) tool could

be implemented

Patients with depressive

symptoms or a depressive

disorder

One primary, two enhanced

primary care, and one ter-

tiary 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 clini-

cal psychologists and other

allied health professionals

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Table 2 (continued)

Author, Year Country of origin Study design Research aim/objectives/

questions Patient population Clinical setting and type Clinician characteristics

Hill et al., 2020 [118] 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 par-

ticipant completion of the

intervention modules

Patients with identiﬁed

suicide risk Pediatric hospital in major

metropolitan area

Out-patient

Social worker

Jeong et al., 2020 [119] Korea Pilot/Feasibility trial TMF:

Theory of Planned Behav-

iour

-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 profes-

sionals 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 Prevent-

ing Suicide (MAPS) on

discussion of suicide during

primary care clinician

visits by middle-aged men

with recent active suicidal

thoughts. -Explore modera-

tion 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 oﬃces in Sac-

ramento (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

Kasckow et al., 2015 [76] 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 standard-

ized 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 Pitts-

burgh

Out-patient

Nurses

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Table 2 (continued)

Author, Year Country of origin Study design Research aim/objectives/

questions Patient population Clinical setting and type Clinician characteristics

Kasckow et al., 2016 [120] United States Pilot/Feasibility trial -Test the feasibility of the

telehealth monitoring

intervention for suicidal

behavior in this population

of Veterans with schizo-

phrenia or schizoaﬀective

dis-order-Assess with a

random assignment trial,

whether augmentation of

intensive care monitoring

(ICM) with our intervention

would result in a signiﬁcant

reduction in suicidal idea-

tion 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 [121] United States Pilot/Feasibility trial -To report on a pilot study

of an inpatient intervention

for suicidal adolescents, As

Safe as Possible [ASAP], sup-

ported by a smartphone

app [BRITE] to reduce post-

discharge suicide attempts

Patients with suicidal idea-

tion, 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/coun-

seling or were enrolled in a

clinical psychology doctoral

program

Kleiman et al., 2019 [122] United States Pilot/Feasibility trial -Examine whether par-

ticipants 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 [123] Japan Pilot/Feasibility trial -Identify whether suicide

interventions sent via

mobile phone text messag-

ing technologies is feasible

in changing help-seeking

and self-harming behav-

iours

Patients with a mental dis-

order and suicidal ideation University hospital, a psy-

chiatric 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

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Table 2 (continued)

Author, Year Country of origin Study design Research aim/objectives/

questions Patient population Clinical setting and type Clinician characteristics

Kolva et al., 2020 [94] United States Observational -Discuss an approach to

preserve patient safety

while optimizing delivery of

an online survey of suicidal-

ity in cancer survivors seek-

ing psychological care

Patients from outpatient

psycho‐oncology compre-

hensive cancer center

Outpatient psycho-oncol-

ogy clinic

Out-patient

Psycho‐oncology provider

Kroll et al., 2020 [95] United States Observational -Determine whether con-

tinuous virtual monitoring,

an intervention that facili-

tates 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, Massa-

chusetts) with 793 licensed

inpatient beds

Mixture

Nurses and psychiatrists and

psychiatry trainees

Lawrence et al., 2010 [96] United States Observational -Implement routine self-

administered computerized

screening for suicidal idea-

tion 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 Ala-

bama 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 physi-

cian

Levine et al., 1989 [97] United Kingdom Observational -Assess the incidence of

depressive symptoms in

patients admitted following

deliberate self-harm using

a self-rating modiﬁcation

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

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Table 2 (continued)

Author, Year Country of origin Study design Research aim/objectives/

questions Patient population Clinical setting and type Clinician characteristics

Ligier et al., 2016 [77]

(Protocol) France Experimental -Determine whether a short

message service in addition

to usual care can be used

to: keep in touch with

adolescent suicide attempt-

ers to reduce the delay

in recurrence of a suicide

attempt, and to improve

the evolution of 1) their

social network, 2) depres-

sion 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

Luxton et al., 2012 [124] 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 rehospitaliza-

tions-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 mem-

bers admitted in in-patient

psychiatric units

Veterans Hospital

Mixture Inpatient psychiatry treat-

ment team consisting of

psychiatric nurse

Luxton et al., 2014 [62]

(Protocol)

Luxton et al., 2020 [78]

United States Experimental -Determine whether the

intervention is eﬃcacious in

preventing suicide behav-

iours 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 West-

ern New York

In-patient

Not reported

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Table 2 (continued)

Author, Year Country of origin Study design Research aim/objectives/

questions Patient population Clinical setting and type Clinician characteristics

Mackie et al., 2017 [102] 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 cen-

tre (The Ottawa Hospital)

Out-patient

Psychiatrists, therapists

Madan et al., 2015 [98] 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 [79] Sri Lanka Experimental -Test whether a Brief Mobile

Treatment (BMT) interven-

tion 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 [125]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 North-

east US

Out-patient

Not reported

Melvin et al., 2019 [126] 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 depres-

sive disorder and suicide

attempt

Tertiary mental health ser-

vice in Melbourne, Australia

Undetermined

Not reported

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Table 2 (continued)

Author, Year Country of origin Study design Research aim/objectives/

questions Patient population Clinical setting and type Clinician characteristics

Morthorst et al., 2021 [127]

(Protocol) Denmark Pilot/Feasibility trial -Assess the feasibility of

methods, procedures, and

safety of internet-based

Emotion regulation indi-

vidual therapy (ERITA) in a

Danish context

Patients with non-suicidal

self-injury (NSSI) Outpatient clinics in The

Child and Adolescent Men-

tal Health Services in capital

region on Denmark

Out-patient

Psychologists and nurses

with experience within

clinical child and adoles-

cent psychiatry and with

psychotherapy and special

knowledge about NSSI

Mousavi et al., 2014 [80] Iran Experimental -Evaluate the eﬃcacy of tel-

ephone follow up on reduc-

tion of suicidal reattempt

and their relationship with

demographic characteris-

tics of patients

Patients who attempted

suicide Intoxication emergency

services, Noor Hospital,

Isfahan

In-patient

Psychiatry last-year resident

Muscara et al., 2020 [128] Australia Pilot/Feasibility trial -Assess the feasibility and

acceptability of a combina-

tion 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 Mel-

bourne, Australia

In-patient

Not reported

Nuij et al., 2018 [129]

(Protocol) Netherlands Pilot/Feasibility trial TMF:

Integrated Motivational-

Volitional (IMV) model of

suicidal behaviour

-Evaluate the feasibility

of mobile safety plan-

ning and daily mobile

self-monitoring in routine

care treatment for suicidal

patients, and to conduct

fundamental research on

suicidal processes

Patient with main diag-

nosis of major depressive

disorder or dysthymia and

current suicidal ideation

3 Mental health organiza-

tions

Out-patient

Not reported

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Table 2 (continued)

Author, Year Country of origin Study design Research aim/objectives/

questions Patient population Clinical setting and type Clinician characteristics

O’Keefe et al., 2019 [81]

(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 Reserva-

tion in Eastern Arizona

Mixture

Trained Apache Community

mental health specialists

O’Toole et al., 2019 [82] Denmark Experimental -Compare the eﬀect

between treatment as usual

(TAU) with (TAU + APP) and

without (TAU) the assis-

tance of the mobile app

on individuals referred to

outpatient suicide preven-

tion treatment

Patients with suicidal idea-

tion or suicide attempt A specialized outpatient

suicide prevention clinic

located at a psychiatric uni-

versity hospital in Denmark.

The clinic provides psycho-

social therapy for people

at risk of suicide, typically

presenting with adjust-

ment disorders and mild to

moderate depression

Out-patient

Therapists

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Table 2 (continued)

Author, Year Country of origin Study design Research aim/objectives/

questions Patient population Clinical setting and type Clinician characteristics

O’Connor et al., 2019 [135]

(Protocol) United Kingdom Pilot/Feasibility trial TMF:

Medical Research Council,

Process evaluation frame-

work for analysis

-Determine whether a

safety planning interven-

tion (SPI) with follow-up tel-

ephone 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 accept-

ability of the intervention.-

Investigate trial recruitment,

retention and other trial

processes including data

collection.-Explore the bar-

riers and facilitators to inter-

vention 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

Olsen et al., 2021 [130]

(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 Men-

tal Health Service

Patients with non-suicidal

self-injury Child and Adolescent Men-

tal Health Services in capital

Region of Denmark

Out-patient

Therapists

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Table 2 (continued)

Author, Year Country of origin Study design Research aim/objectives/

questions Patient population Clinical setting and type Clinician characteristics

Owens and Charles, 2016

[131]United Kingdom Pilot/Feasibility trial TMF:

Normalisation Process

Theory

-Test and reﬁne 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

Canady 2018 [104] United States Other: Quality improve-

ment -Describe steps in develop-

ing 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 [132] United States Pilot/Feasibility trial -Determine the feasibility of

implementing a self-admin-

istered 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 [133] United Kingdom Pilot/Feasibility trial -Determine the acceptabil-

ity and feasibility of carrying

out an RCT of remotely

delivered (video-calling or

mobile phone) problem-

solving cognitive behaviour

therapy (PSCBT) plus treat-

ment as usual (TAU) versus

TAU in adolescents and

young adults with depres-

sion who self-harm

Patients with self-harm Adult or child and adoles-

cent mental health services

that assess people in emer-

gency 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

Seong et al., 2021 [99] Korea Observational -Investigate the eﬀects

of Mobile Messenger

Counseling on the post-

discharge case manage-

ment 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

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Table 2 (continued)

Author, Year Country of origin Study design Research aim/objectives/

questions Patient population Clinical setting and type Clinician characteristics

Simon et al., 2016 [63]

(Protocol)

Simon et al., 2022 [83]

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

deﬁned member/patient

populations

Out-patient

Care managers, Skills coach

(Master’s-prepared mental

health professional)

Stallard et al., 2016 [64]

(Protocol)

Stallard et al., 2018 [84]

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 second-

ary outcomes of psycho-

logical functioning

Patients with self-harm Specialist child and adoles-

cent mental health services

provided by Oxford Health

NHS Foundation Trust. The

Trust serves a wide geo-

graphical area that includes

Bath and North East Som-

erset, Buckinghamshire,

Oxfordshire, Swindon, and

Wiltshire

Out-patient

A total of 37 clinicians: Child

psychiatrists, clinical psy-

chologists, family therapists,

child psychotherapists,

occupational therapists,

and community psychiatric

nurses

Stevens et al., 2019 [85]

(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): Toxicol-

ogy Centers, Psychiatric

Emergency Care Centers,

and Mental Health Triage

and Assessment Centers

Out-patient

Psychiatrists, clinical nurse

consultants, registered

nurses, psychiatry registrars

Vaiva et al., 2006 [87] 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 treat-

ment

Patients who attempted

suicide 13 EDs from north of France

Out-patient Psychiatrists with at least ﬁve

years’ experience in manag-

ing suicidal crises

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Table 2 (continued)

Author, Year Country of origin Study design Research aim/objectives/

questions Patient population Clinical setting and type Clinician characteristics

Vaiva et al., 2011 [65]

(Protocol)

Vaiva et al., 2018 [86]

France Experimental -Assess the eﬀectiveness

of a decision-making algo-

rithm for suicide prevention

(ALGOS) combining existing

Brief Contact Interven-

tions 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 [134] United States Pilot/Feasibility trial -Verify methods for assess-

ing adolescents and young

adults who had signs or

symptoms of depression

or suicide ideation and

for training profession-

als to implement mental

health interventions using

telehealth devices

Teenage and young adult

patients prescribed lifelong

home parental nutrition

(HPN) infusions

University of Kansas Medi-

cal Center

Out-patient

A total of 4 profession-

als. 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, ED Emergency department

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Table 3 Characteristics of included ICTs

Target

age

ICT

intervention

References Suicide Prevention Intervention Category MHCC Typology WHO category

Screening

and

Assessment

Safety

Planning

Lethal

Means

Restrictions

and/or

Counselling

Discharge

or Post‑

Discharge

Follow‑Up

Therapy Resources Other Computerized

interventions,

resources, and

applications

Telehealth

and

telemedicine

Wearable

computing

and

monitoring

Virtual

reality

Peer support

through

social media

and other

technologies

Robots Universal Selective Indicated

Total

counts

(n)

66 75 22 20 3 27 4 18 12 55 16 1 2 2 1 4 10 53

Adult Addiction

Comprehen-

sive Health

Enhancement

Support

System

(ACHESS)

Mackie

et al., 2017

[102]

✓ ✓ ✓ ✓ ✓ ✓ ✓

16-25yrs Aﬃnity Bailey et al.,

2020 [67]

✓ ✓ ✓ ✓ ✓

Adult ALGOrithm

for Suicide

prevention

(ALGOS)

Telephone

contact

Vaiva et al.,

2018 [86]

✓ ✓ ✓

Vaiva et al.,

2011[65]

Youth As Safe as Pos-

sible (ASAP)

Kennard

et al.,

2018[121]

✓ ✓ ✓ ✓ ✓

BRITE (SMS) ✓ ✓ ✓ ✓ ✓

Youth Ask Suicide

Screening

Questions

(ASQ) via

tablet

Pickett et al.,

2021[132]

✓ ✓ ✓

Adult BackUp Nuij et al.,

2018[129]

✓ ✓ ✓

mEMA app ✓ ✓ ✓

Youth Be Safe App Gregory

et al., 2017

[93]

✓ ✓ ✓

Adult BEACON

(Smartphone

assisted prob-

lem solving

therapy)

Hatcher

et al., 2020

[74]

✓ ✓ ✓ ✓

Youth BeyondNow

app

Muscara

et al., 2020

[128]

✓ ✓ ✓ ✓

≥ 16yrs Melvin et al.,

2019 [126]

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Table 3 (continued)

Target

age

ICT

intervention

References Suicide Prevention Intervention Category MHCC Typology WHO category

Screening

and

Assessment

Safety

Planning

Lethal

Means

Restrictions

and/or

Counselling

Discharge

or Post‑

Discharge

Follow‑Up

Therapy Resources Other Computerized

interventions,

resources, and

applications

Telehealth

and

telemedicine

Wearable

computing

and

monitoring

Virtual

reality

Peer support

through

social media

and other

technologies

Robots Universal Selective Indicated

Youth BlueIce Stallard

et al., 2018

[84]

✓ ✓ ✓

Stellard

et al., 2016

[64]

Grist et al.,

2018 [101]

Muscara

et al., 2020

[128]

≤ 19yrs Brake of My

Mind (BoMM)

Jeong et al.,

2020 [119]

✓ ✓ ✓

≥ 15yrs Brief Mobile

Treatment

(BMT) (SMS)

Marasinghe

et al., 2012

[79]

✓ ✓ ✓ ✓

Adult Care

management

intervention

Simon et al.,

2016 [63]

✓ ✓ ✓ ✓ ✓

Skills training

intervention

✓ ✓ ✓

Adult Caring con-

tacts via text

message

Comtois

et al., 2019

[71]

✓ ✓ ✓ ✓

Adult Caring letters

(email)

Luxton et al.,

2012 [124]

✓ ✓ ✓ ✓

Luxton et al.,

2014 [62]

Luxton et al.,

2020 [78]

Youth Child Health

Improvement

through

Computer

Automation

(CHICA)

system

Etter et al.,

2018 [90]

✓ ✓ ✓ ✓

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Table 3 (continued)

Target

age

ICT

intervention

References Suicide Prevention Intervention Category MHCC Typology WHO category

Screening

and

Assessment

Safety

Planning

Lethal

Means

Restrictions

and/or

Counselling

Discharge

or Post‑

Discharge

Follow‑Up

Therapy Resources Other Computerized

interventions,

resources, and

applications

Telehealth

and

telemedicine

Wearable

computing

and

monitoring

Virtual

reality

Peer support

through

social media

and other

technologies

Robots Universal Selective Indicated

Adult Computer

interview/

self-rating

modiﬁca-

tion of the

Hamilton Rat-

ing Scale for

Depression

Levine et al.,

1989 [97]

✓ ✓ ✓

Adult Computerized

Self-Reported

patient-

reported

outcome

(PRO) Assess-

ment

Lawrence

et al., 2010

[96]

✓ ✓ ✓

Youth

and

their

parents

Crisis Care

(Web-based)

McManama

O’Brien

et al., 2017

[125]

✓ ✓ ✓ ✓

≥ 16yrs e-DASH

(electronic—

Depression

and Self-

Harm)

Sayal et al.,

2019 [133]

✓ ✓ ✓ ✓

Youth Emotion

regulation

individual

therapy for

adolescents

(ERITA)

Morthorst

et al., 2021

[127]

✓ ✓ ✓ ✓

Youth Empatica E4

(Empatica Srl)

Kleiman

et al., 2019

[122]

✓ ✓ ✓

Adult Enhanced

electronic

suicidality

alert system

Madan et al.,

2015 [98]

✓ ✓ ✓

Youth Internet-

based

Emotion

Regulation

Individual

Therapy for

Adolescent

(ERITA)

Olsen et al.,

2021[130]

✓ ✓ ✓

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Table 3 (continued)

Target

age

ICT

intervention

References Suicide Prevention Intervention Category MHCC Typology WHO category

Screening

and

Assessment

Safety

Planning

Lethal

Means

Restrictions

and/or

Counselling

Discharge

or Post‑

Discharge

Follow‑Up

Therapy Resources Other Computerized

interventions,

resources, and

applications

Telehealth

and

telemedicine

Wearable

computing

and

monitoring

Virtual

reality

Peer support

through

social media

and other

technologies

Robots Universal Selective Indicated

Adult Jaspr Health Dimeﬀ et al.,

2021 [115]

✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓

Adult LifeApp’tite

Mobile App

O’Toole

et al., 2019

[82]

✓ ✓ ✓ ✓ ✓ ✓

Adult Lock to Live

(L2L)

Betz et al.,

2020 [106]

✓ ✓ ✓

Youth MEDIACON-

NEX (SMS)

Ligier et al.,

2016 [77]

✓ ✓ ✓

Youth MI-SafeCope Czyz et al.,

2021[113]

✓ ✓ ✓

Post discharge

text-based

support

(Texts)

✓ ✓ ✓

Adult Mobile

Messenger

Counselling

Services

(MMC)

Seong et al.,

2021 [99]

✓ ✓ ✓

Adult Mobile

telephone

message

interventions

Chen et al.,

2010 [111]

✓ ✓ ✓

Adult

and

Youth

MyPlan Andreasson

et al., 2017

[66]

✓ ✓ ✓ ✓

Buus et al.,

2020 [100]

✓

10-24yrs New Hope O’Keefe

et al., 2019

[81]

✓ ✓ ✓

Optimized

Care Manage-

ment

✓ ✓ ✓

Adult Online

assessment of

suicidality in

patients with

cancer

Kolva et al.,

2020 [94]

✓ ✓ ✓

Adult Online dialec-

tical behavior

therapy skills

Simon 2022

[83]

✓ ✓ ✓ ✓ ✓

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Table 3 (continued)

Target

age

ICT

intervention

References Suicide Prevention Intervention Category MHCC Typology WHO category

Screening

and

Assessment

Safety

Planning

Lethal

Means

Restrictions

and/or

Counselling

Discharge

or Post‑

Discharge

Follow‑Up

Therapy Resources Other Computerized

interventions,

resources, and

applications

Telehealth

and

telemedicine

Wearable

computing

and

monitoring

Virtual

reality

Peer support

through

social media

and other

technologies

Robots Universal Selective Indicated

14-25yrs Online tool

for self-

monitoring

of depression

and suicidal

ideation

Hetrick et al.,

2017[117]

✓ ✓ ✓

Adult Post-acute

crisis text

messaging

outreach,

Suicide

intervention

assisted by

messages

(SIAM)

Berrouiguet

and Gravey

et al., 2014

[105]

✓ ✓ ✓ ✓

Berrouiguet

and Alavi

et al., 2014

[61]

HUGOPSYN-

etwork et al.,

2018 [68]

Adult Project Life

Force Safety

Planning

Mobile Apps

Goodman

et al., 2020

[73]

✓ ✓ ✓

Adult SAFETEL O’Connor

2019 [135]

✓ ✓ ✓ ✓ ✓

Adult SafeTy and

Recovery

Therapy

(START)

-Follow up

Telephone

Coaching and

Mobile aug-

mentation

Depp et al.,

2021 [114]

✓ ✓ ✓ ✓ ✓ ✓ ✓

≥ 16yrs SMS Text Mes-

saging- SMS

SOS Study

Stevens

et al., 2019

[85]

✓ ✓ ✓

Not

reported

Stop Depres-

sion platform

Cassola

et al., 2017

[110]

✓ ✓ ✓ ✓

Adult Strength

Within Me

(SWiM)

Bruen et al.,

2020 [108]

✓ ✓ ✓ ✓

Adult Suicide inter-

vention via

home-based

telehealth

Gros et al.,

2011[103]

✓ ✓ ✓ ✓

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Table 3 (continued)

Target

age

ICT

intervention

References Suicide Prevention Intervention Category MHCC Typology WHO category

Screening

and

Assessment

Safety

Planning

Lethal

Means

Restrictions

and/or

Counselling

Discharge

or Post‑

Discharge

Follow‑Up

Therapy Resources Other Computerized

interventions,

resources, and

applications

Telehealth

and

telemedicine

Wearable

computing

and

monitoring

Virtual

reality

Peer support

through

social media

and other

technologies

Robots Universal Selective Indicated

Adult Suicide inter-

ventions sent

via mobile

phone text

messaging

technologies

Kodama

et al., 2016

[123]

✓ ✓ ✓

Youth Suicide risk

detected via

adolescent

depression

screening

Davis et al.,

2021 [89]

✓ ✓ ✓

Youth TeenTEXT Owens et al.,

2016 [131]

✓ ✓ ✓

Youth

and

young

adults

Telehealth dis-

tance health

care

Wright et al.,

2021 [134]

✓ ✓ ✓ ✓

Adult Telehealth

monitoring

system using

Health Buddy

Kasckow

et al., 2015

[76]

✓ ✓ ✓ ✓

Adult Kasckow

et al.,2016

[120]

Adult Telephone

contact

Vaiva et al.,

2006 [87]

✓ ✓ ✓

≥ 15yrs Telephone

follow up

Mousavi

et al., 2014

[80]

✓ ✓ ✓

All ages Telephone

management

programme

Cebrià

2013[70]

✓ ✓ ✓

Youth TextIt Czyz et al.,

2020 [112]

✓ ✓ ✓ ✓ ✓

Adult The Parkland

Health & Hos-

pital System

(PHHS) Uni-

versal Suicide

Screening

Program

Canady

2018 [104]

✓ ✓ ✓

Youth The Safety

Planning

Assistant

Hill et al.,

2020 [118]

✓ ✓ ✓

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Table 3 (continued)

Target

age

ICT

intervention

References Suicide Prevention Intervention Category MHCC Typology WHO category

Screening

and

Assessment

Safety

Planning

Lethal

Means

Restrictions

and/or

Counselling

Discharge

or Post‑

Discharge

Follow‑Up

Therapy Resources Other Computerized

interventions,

resources, and

applications

Telehealth

and

telemedicine

Wearable

computing

and

monitoring

Virtual

reality

Peer support

through

social media

and other

technologies

Robots Universal Selective Indicated

Adult The tailored

Men and

Providers

Prevent-

ing Suicide

(MAPS)

program

Jerant et al.,

2020 [75]

✓ ✓ ✓

Adult True Colours

online

questionnaire

(digital self-

monitoring

component)

Brand et al.,

2021[107]

✓ ✓ ✓

Adult Virtual Col-

laborative

Assessment

and Manage-

ment of Suici-

dality System

(V-CAMS)

Dimeﬀ et al.,

2020 [116]

✓ ✓ ✓ ✓ ✓ ✓

Adult VigilanS

(renamed

after ALGOS)

Duhem

et al., 2018

[72]

✓ ✓ ✓

Fossi

Djembi

et al., 2020

[91]

Fossi et al.,

2021[92]

Adult Virtual Hope

Box (VHB)

Bush et al.,

2015 [109]

✓ ✓ ✓ ✓

Bush et al.,

2017 [69]

✓

Chen et al.,

2018 [88]

Adult Virtual Moni-

toring

Kroll et al.,

2020 [95]

✓ ✓ ✓

Adult: Above 18, Youth: Below 18

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[101] and simulation methods for training [115]. Educa-

tional 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 [73, 74, 84, 93, 101,

104, 108, 114, 126, 128, 131, 135]. Education or training

were sometimes accompanied by educational materials

(e.g., written handouts or supportive tools like a pocket

guide) (n = 6) [64, 73, 101, 110, 114, 131]. 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 clini-

cians, Information Technology (IT) consultants, ministry,

institutions and/or managers [74, 91, 94, 95, 114, 123,

124, 128]. For example, collaboratives initiatives involved

nominating site staﬀ as co-principal investigators [74],

or consulting key stakeholders before the start of the

study [123]. Six reported providing ongoing supervision

for using the ICT [63, 67, 71, 72, 104, 127], of which one

study speciﬁcally conducted audits and provided daily

reports to unit managers and nursing leaders [104]. ree

studies provided opportunities for clinicians to partici-

pate in discussion for improvement in the implementa-

tion of the ICT, contributing to iterative changes in the

implementation process during the study [67, 95, 114].

Two studies reported tailored approaches to implemen-

tation; one created a new clinical workﬂow to ensure that

the implementation was seamless and minimized inter-

ruptions by leveraging existing staﬀ roles and processes

as much as possible [132], and the other provided site-

speciﬁc training [62]. Lastly, one study provided onsite

technical IT support [104].

What are thereportedbarriers andfacilitators

toimplementing these ICT‑based interventions?

Overall, there was a general lack of reporting on barri-

ers and facilitators to implementation. Nineteen studies

reported several barriers and/or facilitators with a vary-

ing level of detail. Barriers and facilitators that were most

frequently reported by identiﬁed studies were associ-

ated 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 inﬂuences, such as norms and cultural factors

[51]. Internet instability [134], limited telephone lines

[103], lack of patients’ access to smart devices [107],

time limited nature of clinical settings [76, 82, 102, 131],

and no access to research teams to troubleshoot techno-

logical issues [108] 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 [93]. erefore, 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 dis-

charge. is not only speaks to physical barriers (i.e., hos-

pital policy), but also reﬂects social barriers of limiting

ICT related interactions with patients [93]. Other barri-

ers 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 [128,

131, 132]. Some of the facilitators were the direct oppo-

site of barriers. In contrast to lack of engagement with

clinicians, positive working collaborations between clini-

cians and the research team facilitated the implementa-

tion process [62, 104, 108, 131]. For example, one study

had a hospital staﬀ member in the role of principal inves-

tigator at each study site [62]. Furthermore, leadership

engagement, such as manager approvals for implementa-

tion, facilitated ICT implementation, and some managers

insisted on circulating implementation information to

clinicians via e-mail [131].

Reﬂective (n = 14) and automatic (n = 3) motivations

were the next commonly coded barriers and facilita-

tors in this review. Motivation encompasses all brain

processes that direct behaviour [49]. is includes not

just reﬂective motivation, such as goals, analytical and

conscious decision-making that leads to behaviour, but

it also includes autonomic motivation like habits and

emotional responses [49]. Reﬂective motivation includes

TDF domains of professional roles and identities, beliefs

about consequences, beliefs about capabilities, optimism,

intentions and goals [51]. Deﬁning roles and responsibil-

ity attributes [108], perceived burdens, and uncertain-

ties associated with ICTs [76, 82, 131] were examples of

barriers noted among the reﬂective motivation category.

For example, clinicians were worried about ICT devices

being stolen or broken [108] and perceived that that the

ICT may have a better ﬁt in other, non-clinical settings

such as schools [131]. Clinicians also did not appreciate

the perceived burdens of implementing ICTs because

introducing new ICTs possibly created new tasks, tak-

ing extra time in their usual clinical ﬂow [76, 82]. When

clinical settings included multi-disciplinary teams, cli-

nicians were concerned about who should be responsi-

ble for the ICT, but identifying appropriate professional

roles and having designated staﬀ for the new ICT were

reported facilitators [78, 104, 108]. For example, one

study implemented caring emails as post-discharge fol-

low-up care for suicide prevention and reported that the

new task associated with this ICT could be reasonably

done by existing hospital staﬀ rather than hiring new staﬀ

[78]. Additionally, they reported minimal requirements

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Shinetal. BMC Health Services Research (2023) 23:281

for clinicians to manage the new ICT, which facilitated

implementation [78]. In contrast to uncertainties around

ICTs, perceived beneﬁts and usefulness of ICTs were

facilitators [102, 109]. Automatic motivation refers to the

TDF domain of emotion [51]. Negative (“technophobia”)

or positive outlook about the ICTs [102, 116, 131] were

identiﬁed as barriers or facilitators.

Implementation barriers and facilitators related to psy-

chological (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]. Identiﬁed papers reported bar-

riers and facilitators related to the knowledge and skills

about ICTs, awareness of necessary resources, and cli-

nicians’ cognitive load. For example, having no manual

or guidelines to instruct clinicians on how ICTs should

be introduced to patients and used for suicide preven-

tion treatment was a barrier [82, 107]. In contrast, train-

ing resources and education sessions were facilitators

that helped to build clinicians’ psychological capabili-

ties [104, 109, 116, 134]. Additionally, a few ICTs helped

to decrease clinicians’ cognitive burden [116, 131]. 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 ﬁle4.

What are thereported measures andoutcomes ofthese

ICT‑based interventions?

As shown in Fig.2, studies reported PRO (n = 55), PRE

outcomes (n = 31), and patient health outcomes (e.g.,

mortality) (n = 10). Examples of PRO included assess-

ing patients’ suicide ideation, suicide risk, coping ability,

depressive symptoms, and health-related quality of life

using validated tools such as Beck Scale for Suicide Idea-

tion, Patient Health Questionnaires, Columbia Suicide

Severity Rating Scale, and Beck Depression Inventory.

Examples of PRE outcomes included assessing overall

experiences and perceptions of ICTs, patient satisfaction,

engagement with ICTs using open-ended survey ques-

tions, Likert-scale surveys, written feedback, or inter-

views. Patient health outcomes such as mortality and

adverse events often came from health administrative

data, electronic health records, or insurance claim data.

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. irteen studies

reported health system-level outcomes such as readmis-

sion rates and medical costs. Additionally, eight studies

speciﬁed usage data as an outcome of interest.

Following Proctor’s deﬁnitions for implementation

outcomes [56], studies reported feasibility (n = 20),

acceptability (n = 14), ﬁdelity (n = 10), and penetra-

tion (n = 1) of the ICTs. Feasibility outcomes included

perceived compatibility of ICTs in the clinical set-

tings or practicality of ICTs assessed by surveys, open-

ended questionnaires, interviews or measuring the time

required to complete the ICT-related module. Accept-

ability of ICTs was evaluated by user experience, per-

ception, agreeableness, or satisfaction using surveys,

open-ended questionnaires, or interviews. Fidelity

outcomes included the completion of follow-ups and/

or adherence to treatments using chart reviews or self-

reported data. Penetration was measured by the propor-

tion of people who attempted suicide and were enrolled

in an ICT-based intervention (i.e., VigilanS) relative

to all included samples of people who attempted sui-

cide regardless of their enrollment. None of the studies

reported adoption, appropriateness, implementation

cost, or sustainability outcomes of implementation. See

Table5 for summaries of the outcomes of interest, out-

come measures, measurement tools, and key results of

the 70 included studies.

Discussion

Summary ofevidence

is scoping review describes characteristics of ICT-

based interventions for suicide prevention implemented

in clinical settings. In this review, we identiﬁed 75

papers that described 70 studies and 66 ICTs. Overall,

the review ﬁndings provide detailed characteristics of

the existing ICTs for suicide prevention implemented in

clinical settings. We also identiﬁed common strategies

for implementing these ICTs, related barriers and facili-

tators, as well as reported measures and outcomes of the

included ICTs. e ﬁndings oﬀer insights into how to

better support the implementation of ICTs and highlight

the important role of collaborative initiatives in providing

both technical and social support to facilitate implemen-

tation of ICTs in clinical settings.

Characteristics ofincluded studies

Most of the included studies were experimental designs

and feasibility trials, and there were 18 protocols, indicat-

ing that many studies are currently underway. Despite the

growing evidence in this ﬁeld, we found a lack of qualita-

tive evidence. is 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. is is because clini-

cal practice within hospitals is an example of a complex

adaptive system [26, 27]. Evaluating and understanding

implementation of ICTs in complex systems will beneﬁt

from using qualitative or mixed-methods designs because

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Table 4 Barriers and facilitators to implementing ICTs

COM‑B TDF Domains Denitions Frequency

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 proﬁciency 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 deﬁnitive

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 partici-

pants who were in crisis (Facilitator)

Optimism The conﬁdence 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 out-

comes of a behaviour in a given situation 5 • Uncertainty about how well the mobile app was incorpo-

rated 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 beneﬁt 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 ﬁt with

schools and universal youth services (Barrier)

Emotion A complex reaction pattern, involving experiential, behav-

ioural, and physiological elements, by which the individual

attempts to deal with a personally signiﬁcant matter or

event

3 • Perceived burdensomeness and technophobia (Barrier)

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Table 4 (continued)

COM‑B TDF Domains Denitions Frequency

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 adap-

tive 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 consum-

ing (Barrier)

• No access to the research team available in participating

wards to troubleshoot technological issues in a timely man-

ner (Barrier)

• Patients’ lack of access to the technology (e.g., smart

phones) (Barrier)

• Inexpensive ICT (Facilitator)

Social inﬂuences 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 ﬂow 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)

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quantitative methods alone cannot capture the complex-

ity inherent within the phenomenon nor can it unpack

interplay of contextual characteristics that inﬂuence

implementation and impact of ICTs. Eﬀorts are needed

to move beyond traditional eﬀectiveness trials and bet-

ter understand how and why innovations bring change

in what context [136]. Qualitative research designs can

facilitate beneﬁts of unpacking contextual factors (e.g.,

barriers and facilitators) at multiple levels (e.g., individ-

ual, system) and answering complex questions [137] that

are integral to moving ICTs forward. Moreover, qualita-

tive methods alone or in mixed-methods designs can

conﬁrm, complement, or extend quantitative evaluation

of eﬀectiveness, providing explanatory knowledge [138].

Based on the paucity of TMFs identiﬁed in the include

studies, future research should consider using 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 theo-

retical foundations and rigour in research for implemen-

tation [23]. Future research can beneﬁt from leveraging

TMFs and qualitative and/or mixed methods designs

to unpack the complexity and contribute to building a

rich evidence base. Beneﬁts of using established TMFs

in research have been well documented. For example,

TMFs can help researchers consider comprehensive list

implementation outcomes [139–141]. Furthermore,

TMFs can help researchers consider a complete list of

determinants for implementation during the planning

phase to maximize implementation success [139–141].

Implementation is a known determinant of interven-

tion eﬀectiveness [56], and as we continue to face chal-

lenges in moving ICTs beyond pilot trials, it is necessary

to leverage TMFs to guide careful and purposeful imple-

mentation that accounts for the complex contexts in

which ICTs are implemented [22]. is will ensure that

implementation strategies are systematically selected to

address barriers in the local context. However, it is dif-

ﬁcult to know whether authors of the included studies in

this review did not use TMFs or did not report TMFs. If

it is a reporting issue, then researchers need to improve

reporting on TMFs so we can learn how TMFs have been

applied, build knowledge base, and modify TMFs as

necessary.

Implementation ofICTs inclinical settings

irty-one studies reported implementation strategies

and 19 studies reported barriers and facilitator. Despite

the general lack of reporting details, useful insights about

implementation supports can be drawn. Of the reported

studies, education and training were the most commonly

reported implementation strategies for the ICTs. is is

Fig. 2 Reported outcome types

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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 [66] Suicide ideation, hopelessness, depressive

symptoms, and app/user satisfaction • Beck Suicide Ideation Scale

• Beck hopelessness scale

• Major depression inventory

• Client satisfaction questionnaire

Not Applicable—protocol

Bailey et al., 2020 [67] Suicidal ideation, depression, perceived burden-

someness 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 signiﬁ-

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 [61] (protocol)

HUGOPSY Network et al., 2018 [68]Suicide reattempt, suicide deaths, suicide idea-

tion, medical costs, and satisfaction • Columbia Suicide Severity Rating Scale

• Medico-economic questionnaire

Satisfaction questionnaire

• Mini-international neuropsychiatric interview

• Narrative description of circumstances associ-

ated 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 [105] Feasibility, acceptability • Text messages status reports and the transmis-

sion rates issued by the web server engine

• Standardized phone interview and question-

naire

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

Betz et al., 2020 [106] Feasibility, acceptability, suicide severity • Minutes for the patient to complete L2L and

the completion rate

• Ottawa acceptability scale

• Decisional conﬂict scale

• Columbia Suicide Severity Rating Scale

The L2L decision aid appears feasible and accept-

able for use among adults with suicide risk and

may be a useful adjunct to lethal means coun-

seling and other suicide prevention interventions

Brand and Hawton 2021 [107] 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 ﬁve nurses

who participated in the evaluation stated that

they found it easy to recruit patients and explain

the beneﬁts of True Colours to them. The remain-

ing nurse found registering a patient onto the

True Colours system challenging. All the nurses

who used True Colours found it useful

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Table 5 (continued)

Author, Year Outcomes of interest Outcome measures and measurement tools Key results

Bruen et al., 2020 [108] 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 par-

ticipants 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 [109] 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 beneﬁcial,

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 [69] Coping, suicide ideation, reasons for living • Coping self-eﬃcacy scale

• Beck Scale for Suicidal Ideation

• Brief reasons for living inventory

VHB users reported signiﬁcantly greater ability to

cope with unpleasant emotions and thoughts at

three and 12 weeks compared with the control

group. No signiﬁcant advantage was found on

other outcome measures for treatment aug-

mented by the VHB

Buus et al., 2020 [100] 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 ﬁnding per-

sonalized problem-solving strategies. This study

indicates that there were huge variations in users’

engagement and use of MYPLAN

Cassola et al., 2017 [110]

(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. Qualiﬁed users

considered the platform to be straightforward

and with a low learning curve, having felt conﬁ-

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 applica-

tion of a telephone management programme to

patients discharged from an emergency room

for suicide attempts signiﬁcantly delays further

attempts and decreases the rates of reattempts in

the context of a general reduction

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Table 5 (continued)

Author, Year Outcomes of interest Outcome measures and measurement tools Key results

Chen et al., 2010 [111] 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 con-

tacts, most of them thought it was acceptable

and said they would like to receive the messages

for a longer time

Chen et al., 2018 [88] Suicide ideation, coping, app usage • App usage logs

• Beck Scale for Suicidal Ideation

• Coping self-eﬃcacy 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 ﬁnd-

ings suggested a potential association between

usage and eﬃcacy for stopping negative

thoughts. Usage was associated with increased

eﬃcacy for stopping negative thoughts, though

this relationship was attenuated among partici-

pants 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 signiﬁcant eﬀect on the likelihood

or severity of current suicidal ideation or likeli-

hood 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 [112] 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 [113] Suicide ideation, self-eﬃcacy, coping, suicide

attempt, suicide injury, safety plan use • Eﬃcacy to cope with suicidal

parental self-eﬃcacy 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

speciﬁc intervention components and sequences

inﬂuenced key mechanisms of change and have

potential to reduce risk of suicidal behavior

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Table 5 (continued)

Author, Year Outcomes of interest Outcome measures and measurement tools Key results

Davis et al., 2021[89] Suicide risk, ﬁdelity of screening process • Patient Health Questionnaire (PHQ) – modiﬁed

for teens

• Columbia diagnostic interview

• Schedule for children-depression scale

• Manual chart review

The study results indicated the high degree of

ﬁdelity to the follow-up suicide risk questions.

Follow-up: suicide-speciﬁc follow-up actions

were relatively sparse in the year following PHQ-

9-M screening per a retrospective manual chart

review

Depp et al., 2021[114] Suicide ideation, suicide behaviour, satisfaction,

service utilization, acceptability, adherence, and

ﬁdelity

• 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

Not Applicable—protocol

Dimeﬀ et al., 2020 [116] Feasibility • Semi structured interview

• Usability satisfaction and acceptability ques-

tionnaire ratings

• Open ended qualitative data from Dr. Dave

(Artiﬁcial Intelligence avatar)

Technology tools including a patient-facing ava-

tar 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 [115] 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 [72] Professional knowledge about suicide, suicide

attempt, health care pathway, acceptability,

ﬁdelity

• Regional suicide mortality data

• Penetrance rate

• Quantitative appraisal (digital survey)

• Qualitative appraisal (semi structured inter-

views)

• Two-step medico economic assessment of the

programme

• Crisis card measures

Not Applicable—protocol

Etter et al., 2018 [90] Provider follow-up action, suicide risk, depres-

sion, substance use • A single question based on American Acad-

emy 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

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Table 5 (continued)

Author, Year Outcomes of interest Outcome measures and measurement tools Key results

Fossi Djembi et al., 2020 [91] 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

signiﬁcant relationship was identiﬁed, showing a

sharp decrease in suicide attempt as a function

of penetrance

Fossi et al., 2021 [92] Suicide reattempt • Second entry in VigilanS Findings suggests the eﬀectiveness of VigilanS on

suicide reattempt, from the ﬁrst entry into Vigi-

lanS. Maintaining contact is of great importance

for the patient’s future

Goodman et al., 2020 [73] Suicide behaviour, depression, hopelessness,

coping and treatment utilization • Medical record abstraction

• Brief safety plan scoring form

• Columbia Suicide Severity Rating Scale

Not Applicable—protocol

Gregory et al., 2017 [93] 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, ﬁve patients reported

that they still intended to download the Be Safe

app later. Of the 50 patients who owned a smart-

phone, nine downloaded the Be Safe app in hos-

pital. 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 ﬁrst admission to hospital

Grist et al., 2018 [101] Usability, acceptability, safety • Interview 6 key themes emerged: (1) appraisal of BlueIce,(2)

usability of BlueIce, (3) safety (4) beneﬁts 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 [103] Eﬃcacy and symptoms • Beck’s depression inventory -2

• Beck anxiety inventory

• Post-traumatic stress disorder (PTSD) checklist

– military version

The preliminary ﬁndings in the present case

support the use of telehealth in the identiﬁcation

and intervention of suicidality at home

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Table 5 (continued)

Author, Year Outcomes of interest Outcome measures and measurement tools Key results

Hatcher et al., 2020 [74] 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 identiﬁcation test

• Drug abuse screening test

• Administrative health data

• Smartphone application usage data

• Interviews

Not Applicable—protocol

Hetrick et al., 2017 [117] Feasibility, acceptability, perceived usefulness,

depression • Questionnaire about acceptability and useful-

ness including open-end-ed questions

• Suicidal Ideation Questionnaire – junior

• Patient Health Questionaries—9

The e tool was feasible to implement. Young peo-

ple and clinicians found the tool acceptable and

useful for understanding symptoms and risk

Hill et al., 2020 [118] 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 sui-

cide attempt. The average time to complete the

adolescent safety plan module was 48.13 min.

Data support the preliminary feasibility of admin-

istering safety planning using the web-based

tool and the acceptability of the Safety Planning

Assistant

Jeong et al., 2020 [119] 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

Jerant et al., 2020 [75] Whether the topic of suicide was discussed dur-

ing the visit, suicidal thought, suicide risk • Beck Scale for Suicide Ideation

• Patient Health Questionnaire

• Primary care PTSD screen

• Alcohol use disorder identiﬁcation 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 signiﬁcant

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Table 5 (continued)

Author, Year Outcomes of interest Outcome measures and measurement tools Key results

Kasckow et al., 2015 [76] Suicide ideation, depression, feasibility • Suicide severity interview

• Beck Scale for Suicide Ideation

• Calgary depression rating scale

• Percentage of days active participants down-

loaded 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 signiﬁcant

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 [120] 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 ﬁndings 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 [121] 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 question-

naire

• Client satisfaction questionnaire-8

Results show acceptability and feasibility of the

As Safe as Possible (ASAP) intervention and sup-

porting 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 [122] 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 18 h a day and reported that

despite sometimes ﬁnding the monitor uncom-

fortable, they did not mind wearing it

Kodama et al., 2016 [123] 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 com-

mitted self-harm during the previous 6 months

at baseline accounted for 27.6% of the sample

(n = 8), whereas the proportion at 6 months

signiﬁcantly decreased. Further, the intensity of

suicidal ideation was signiﬁcantly reduced after

the intervention period

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Table 5 (continued)

Author, Year Outcomes of interest Outcome measures and measurement tools Key results

Kolva et al., 2020 [94] 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 idea-

tion as identiﬁed 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 [95] 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 signiﬁcant diﬀer-

ences in favourability of virtual monitoring or 1:1

between nurses who did and did not care for

patients

Lawrence et al., 2010 [96] Suicide ideation • Patient Health Questionnaire—9

• Alcohol Use Disorders Identiﬁcation 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 asso-

ciated with lower risk. Our experience supports

the use of novel technologies and user-friendly

interfaces (i.e., touchscreens or tablet comput-

ers) to facilitate the collection of self-reported

information in high volume clinical settings

Levine et al., 1989 [97] Self-harm, suicide ideation • Hamilton rating scale for depression

• Suicidal Ideation Questionnaire Study result suggests that not only is the com-

puter interview acceptable to most patients, but

the data suggest that the patients are prepared

to conﬁde information to the computer that they

may be unwilling to tell the clinician. Further, the

data also suggest a signiﬁcant pathoplastic eﬀect

of the personality of the patient on the percep-

tion of the psychopathology by the clinician. The

computer appeared to be a better predictor of

suicidality than the interview by the clinician

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Table 5 (continued)

Author, Year Outcomes of interest Outcome measures and measurement tools Key results

Ligier et al., 2016 [77] 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

Not Applicable—protocol

Luxton et al., 2012 [124] 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

Luxton et al., 2014 [62]

(Protocol)

Luxton et al., 2020 [78]

Suicide mortality, depression, suicide ideation,

coping, belongingness, perceived burdensome-

ness, capability for lethal self-injury, positive

aspects in a person’s life, suicide behaviour,

medical/psychiatric treatment utilization

• Positive assets search semi-structured inter-

view tool

• Acquired Capability for Suicide Scale

• Patient Health Questionnaire -9

• Lifetime Parasuicide Count

• Interpersonal Needs Questionnaire

• Acquired Capability for Suicide Scale

• Death certiﬁcates recorded in the Centers for

Disease Control and prevention

• National Death Index Plus

• Rudd suicide ideation scale

• Survey (phone interview)

• Health administrative data

No ﬁrm conclusions about the eﬃcacy 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 [102] 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 identiﬁed were of trust and

connection. Participants attended 85% of their

appointments

Madan et al., 2015 [98] Depression, suicide ideation and behaviour • Patient Health Questionnaire -9 (PHQ-9)

• Columbia Suicide Severity Rating Scale (CSSR-

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

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Table 5 (continued)

Author, Year Outcomes of interest Outcome measures and measurement tools Key results

Marasinghe et al., 2012 [79] 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 identiﬁcation test

• Drug check problem list

There were no signiﬁcant 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 [125] 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 interven-

tions, such as Crisis Care, as an adjunct to treat-

ment for suicidal adolescents and their parents

following discharge from acute care settings

Melvin et al., 2019 [126] 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 signiﬁcantly. No signiﬁcant changes

were observed in suicide resilience

Morthorst et al., 2021[127] Feasibility, clinical outcomes including NSSI,

quality of life, sick days • Phone interviews

• Completion of follow-up, compliance (comple-

tion of modules)

• deliberate self-harm inventory – youth version

• Health-related quality of life questionnaire

(kidscreen-10)

• Depression anxiety stress scale

• Number of sick days

• Diﬃculties 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 diﬃculties questionnaire

• Working alliance inventory, short version

Not Applicable—protocol

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Table 5 (continued)

Author, Year Outcomes of interest Outcome measures and measurement tools Key results

Mousavi 2014 [80] 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 signiﬁcant

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 signiﬁcant diﬀerence for

the compliance to treatments after 6 months of

follow up

Muscara et al., 2020 [128] 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 man-

age 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 satisﬁed with

the apps. Most participants did not believe that

they would use the apps in the future. A signiﬁ-

cant improvement was found on the Emotional

Stability Scale

Nuij et al., 2018 [129] Feasibility, level of explorative power of the

model, suicide behaviour • System usability scale

• Client satisfaction questionnaire 8

• Survey comprised of scale and question-

naires operationalised within the Integrated

Motivational-Volitional model

Not Applicable—protocol

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Table 5 (continued)

Author, Year Outcomes of interest Outcome measures and measurement tools Key results

O’Keefe et al., 2019 [81] Suicide ideation, resilience, depression, anxiety,

impulsivity, self-eﬃcacy, 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

Not Applicable—protocol

O’Toole et al., 2019 [82] 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 signiﬁcant main eﬀect of time on SSF was

found across the whole intervention period,

where self-reported suicide risk decreased. Con-

cerning MDI, the main eﬀect of time across the

whole intervention period was signiﬁcant, show-

ing 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 signiﬁcant at either post-treatment. The total

number of methods used was not signiﬁcantly

associated with the eﬀect

O’Connor 2019 [135] Feasibility, acceptability, intervention adher-

ence, 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

Not Applicable—protocol

Olsen et al., 2021 [130] Feasibility, NSSI, quality of life, depression, anxi-

ety, and stress • Deliberate self-harm inventory–youth version

• Kidscreen-10

• Depression anxiety stress scale

• Proportion of sick days during the last month

• Diﬃculties in emotion regulation scale

• Borderline symptom list

• Columbia Suicide Severity Rating Scale

• Coping with children’s negative emotions

scale

• Negative eﬀects questionnaire

Not Applicable—protocol

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Table 5 (continued)

Author, Year Outcomes of interest Outcome measures and measurement tools Key results

Owens and Charles 2016 [131] Feasibility, clinician and patient experience • Interview Clinicians all understood the purpose of the

intervention and recognised that it could be valu-

able 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

Canady 2018 [104] Suicide risk • Columbia Suicide Severity Rating Scale

• Clinical practice screener-recent In the ED, 6.3 percent of the screens were posi-

tive, as were 1.6 percent in the inpatient units,

and 2.1 percent in the outpatient clinics

Pickett et al., 2021[132] Feasibility, rate of screening, suicide risk • Ask suicide screening questions Suicide screening increased from 1.0% to 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

Sayal et al., 2019 [133] Depression, suicide severity, anxiety, hopeless-

ness, 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 presenta-

tions 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 [99] Successful case management rate • Case management database of the hospital The rate of patients who connected with their

local psychiatric healthcare center showed a

signiﬁcant diﬀerence between the Mobile Mes-

senger 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 psychiat-

ric healthcare center

Simon et al., 2016 [63](protocol)

Simon 2022 [83]Self-harm, mortality

suicide attempt • Electronic health record data

• Death certiﬁcate

• Insurance claim data

Risk of fatal or nonfatal self-harm over 18 months

did not diﬀer signiﬁcantly between the care

management and usual care groups but was

signiﬁcantly higher in the skills training group

than in usual care

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Table 5 (continued)

Author, Year Outcomes of interest Outcome measures and measurement tools Key results

Stallard et al., 2016 [64] protocol

Stallard et al., 2018 [84]Depression, anxiety, suicide behaviour, safety,

acceptability, and self-harm, usability, feasibility • Mood and feelings questionnaire

• Revised child anxiety and depression scale

• Strengths and diﬃculties questionnaire

• Rating questionnaires

• Semi-structured interviews

• Referral pathways

No safety issues were identiﬁed 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 signiﬁcant mean diﬀerence on post

use symptoms of depression and symptoms

of anxiety, which was evident across all anxiety

subscales. Ratings of app acceptability and use-

fulness were high

Stevens et al., 2019 [85] Hospitalization, mortality • Routinely collected data sources through New

South Wales (NSW) health, other government

agencies, and the centre for health record

linkage

Not Applicable—protocol

Vaiva et al., 2006 [87] 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 signiﬁcantly

for proportion with an adverse outcome. The

number of participants contacted at one month

who reattempted suicide was signiﬁcantly lower

than that of controls. For participants contacted

at three months, the number who attempted

further suicide was not signiﬁcantly lower than

that of controls. Participants in the intervention

groups talked about their attempted suicide with

their general practitioner more often than the

controls

Vaiva et al., 2011 [65] (protocol)

Vaiva et al., 2018 [86]Suicide reattempt, adverse events such death

by suicide • Mini-international neuropsychiatric interview

• Phone survey After 6 months, 58 participants in the interven-

tion group reattempted suicide compared with

77 in the control group. The diﬀerence between

groups was not signiﬁcant

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Table 5 (continued)

Author, Year Outcomes of interest Outcome measures and measurement tools Key results

Wright et al., 2021 [134] Depression, suicidality, and patient experience • Beck depression inventory-II

• Questions/observations during sessions (gen-

eral 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 con-

cerned 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 support-

ive interactions were observed among the group

participants, including aﬃrmations, humor, and

emotional and in-formational support

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consistent with the current literature for implementa-

tion practice and knowledge translation [142, 143]. Edu-

cational meetings and training workshops are less costly

and more accessible to support implementation than

complex strategies requiring organizational-level change

[144]. erefore, 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 [145]. erefore, we recommend strategically

considering diverse types of implementation strategies,

other than education and training, to target both clini-

cian- and external-level barriers for a given context. Sec-

ondly, collaborative initiatives were the next commonly

reported strategy for implementation identiﬁed 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 [146]. is is not true; researchers

can co-create changes in the workﬂow to support imple-

mentation [147]. We encourage researchers to continue

to leverage collaborative initiatives within their studies as

they can foster important relationships between knowl-

edge users and researchers. is will allow researchers to

focus on real-world needs and facilitating implementa-

tion eﬀorts [148, 149].

Researchers need to consider the complex contexts in

which apps are being implemented [22]. As such, report-

ing details of implementation plans are strongly encour-

aged to advance our understanding of implementation

processes and context. During implementation, the inﬂu-

ence 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 varia-

tions in outcomes across studies [150, 151]. Furthermore,

implementation is a known determinant of intervention

eﬀectiveness, and barriers can signiﬁcantly reduce the

eﬀectiveness of an intervention [56]. Not knowing con-

textual inﬂuences may limit the generalizability of study

ﬁndings to diﬀerent settings. In response to the general

lack of reporting details identiﬁed in this review, we

encourage future studies to consider Proctor’s recom-

mendations for specifying and reporting implementation

strategies [152] and the Expert Recommendations for

Implementing Change (ERIC) taxonomy for implementa-

tion strategies [153]. Furthermore, considering the itera-

tive 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 Modiﬁcations–Enhanced

(FRAME) to guide the reporting of adaptations and

modiﬁcations to the design or delivery of an intervention

[154].

It has been reported that researchers are faced with

challenges of selecting implementation strategies [155].

Furthermore, implementation strategies have often been

mismatched to existing barriers [156, 157]. 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 [156]. Similarly, the current review identi-

ﬁed that the three most reported categories of barriers

were related to physical opportunity, social opportunity

and reﬂective 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. is 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 identiﬁed in this

review. To overcome physical opportunity, Training,

Enablement, Environment Restructuring, or Restriction

are recommended [49]. To overcome social opportunity,

Restriction, Environment Restructuring, Modelling, or

Enablement are suggested [49]. e use of evidenced-

based theories like the BCW can improve the selection of

implementation strategies and subsequent integration of

ICTs in clinical settings [139, 141]. Additionally, clinical

practice within health systems as well as human behav-

iour are complex; it is not individual factors that facilitate

implementation of a new innovation, but the dynamic

interaction between them [28, 158]. Nonetheless, the

BCW accounts for interactions between both internal

(i.e., capability, motivation) and external (i.e., opportu-

nity) factors that inﬂuence behaviour change [49]. Use of

behaviour change theories will not downgrade the com-

plexity, but rather it can help researchers organize com-

plex 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.

Consistent with the current review ﬁndings, other

external barriers associated with implementing ICTs are

related to limited access to ICTs and internet, and digi-

tal literacy skills [159]. Despite the widespread use of

mobile phones, a phenomenon called the ‘digital divide’

can occur due to social equity factors such as educa-

tion, income, age, and urban/rural residence [160–162].

Digital divide refers to inequities in accessing and using

ICTs as well as associated outcomes of using ICTs [162].

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To prevent digital divide ampliﬁcation and to avoid

unintended harm, implementation eﬀorts for new inno-

vations must account for digital equity considerations

[163]. However, very few included studies considered

equity concerns and provided patients with ICT devices

[74, 101, 114, 134], free data plans [111], or options

for alternative ICTs (e.g., email instead of texts) as per

patients’ preferences [71, 133]. In contrast, several stud-

ies made ownership of ICT devices as one of the inclu-

sion criteria [61, 69, 78, 82, 85, 88, 102, 105, 111, 113, 120,

128, 129, 131, 135], and one study excluded participants

who reported diﬃculty using a computer [117]. is is

a critical area of future eﬀorts for minimizing the digital

divide. Van Dijk [164, 165], and Selwyn [166] 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-

ﬁed a lack of attention to equity-related considerations in

the current literature. is highlights a critical direction

for future research, as eﬀorts are needed to prevent digi-

tal divide ampliﬁcation and avoid unintended harm while

advancing ICT use.

Reported measures andoutcomes

We identiﬁed that studies of ICT-based interventions for

suicide prevention reported implementation outcomes

and/or interventions’ impact on patients, clinicians,

and/or health systems. Most studies reported patient-

level outcomes, such as suicide risk and behaviours, and

implementation outcomes of feasibility. However, no

studies reported long-term outcomes of implementation

such as sustainability. is is a gap in the current litera-

ture, and future research should consider assessing long-

term outcomes, or at least should consider sustainability

potential beyond feasibility. e end goal of implement-

ing new innovations in clinical settings is routinization,

achieving seamless integration of ICT use in routine clin-

ical ﬂow [167]. Despite the promising clinical beneﬁts of

ICTs for suicide prevention, clinical integration remains

limited [22–24]. is problem is consistent across ICTs

in general. It has been repeatedly reported that ICTs are

not fully implemented, not moving beyond pilot trials,

or being abandoned [25, 168]. To move beyond initial

adoption of useful ICTs, we encourage future research

to consider sustainability outcomes early on. Proctor’s

Implementation Outcomes Framework [56] and the

Reach, Eﬀectiveness, Adoption, Implementation Main-

tenance (RE-AIM) [169] are example tools to guide

outcome selections related to implementation and sus-

tainability of interventions. Several studies included in

this review measured both intervention outcomes and

implementation outcomes in one study [67, 76, 80, 84, 89,

91, 101, 106, 114, 115, 117, 118, 120, 122, 124, 126–132,

135]. Similarly, future research can beneﬁt from lever-

aging eﬀectiveness-implementation hybrid designs that

have a dual focus of evaluating intervention eﬀectiveness

and implementation outcomes simultaneously [170, 171].

Hybrid designs are encouraged to move interventions

to the real-world more rapidly because the traditional

research approach of keeping eﬃcacy, eﬀectiveness, and

implementation research separate and sequential slows

down the process and overlooks complex contexts inher-

ent within [170, 171].

Limitations

Several limitations may aﬀect the interpretation and use

of our review ﬁndings. 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, and we report the frequency counts of these

barriers and facilitators. However, this may not be a com-

plete list of barrier and facilitators to implementation.

Additionally, 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 underlin-

ing assumptions of the human behaviour [49].

Secondly, our search strategy was limited to papers

published in English. is may partly explain our ﬁnd-

ing 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 also acknowledge

that our search strategies may not have captured stud-

ies conducted in low and middle-income countries. As

a result, this review does not reﬂect evidence of ICTs

for suicide prevention written in non-English languages

or low- and middle-income countries, possibly result-

ing in underrepresentation and/or underreporting of the

authorship and the amount of literature.

ird, we did not include ICT-based interven-

tions in non-clinical settings such as schools. ere

are many other ICT-based interventions for suicide

prevention that exist beyond what is included in this

review. Lastly, despite our comprehensive search strat-

egy, which included varied terms to describe ICTs, it

is possible that relevant literature was not captured.

To mitigate this limitation, we used Google search as

a complementary to locate additional studies that our

search strategy might have missed. We believe that our

ﬁnal search strategies were sensitive enough to pro-

vide full coverage of relevant literature because many

papers identiﬁed during the second step of Google

search were already captured by our main database

searches. It is also important to recognize the inherent

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Shinetal. BMC Health Services Research (2023) 23:281

limitation of Google searches related to reproducibility

of results [172]. A researcher from a diﬀerent country

may receive diﬀerent results with the same steps, which

is why Google search was complementary to full search

strategies and not used alone.

Conclusions

is scoping review provides a comprehensive over-

view of published literature on the ICTs for suicide pre-

vention implemented in clinical settings. e ﬁndings

revealed the most common types of ICTs for suicide

prevention, including apps, text messages, and telemed-

icine. ese 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 ﬁndings revealed that the most com-

mon strategies for implementing these ICTs included

education, training, and collaborative initiatives. How-

ever, barriers collectively inﬂuenced clinicians’ capabil-

ity, opportunity, and motivation to implement ICTs for

suicide prevention. erefore, implementation strate-

gies must be tailored and multi-faceted to target spe-

ciﬁc 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 ﬁeld,

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 iden-

tiﬁed in included studies encourages the use of estab-

lished TMFs to guide future work. Lastly, the absence

of sustainability outcomes and digital equity consid-

erations identiﬁed in the current literature highlights a

critical direction for future research.

Abbreviations

ICT Information and communication technology

BCW Behaviour change wheel

COM-B Capability opportunity motivation – behaviour

TDF Theoretical domains framework

JBI Joanna Briggs Institute

TMF Theory, model, framework

Supplementary Information

The online version contains supplementary material available at https:// doi.

org/ 10. 1186/ s12913- 023- 09254-5.

Additional le1.

Additional le2.

Additional le3.

Additional le4.

Acknowledgements

We wish to thank the librarians for generating and peer-reviewing compre-

hensive search strategies in this review.

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 veriﬁed analyzed data.

HDS wrote the ﬁrst draft of the manuscript and worked on revisions. GS

supervised all phases of the work. All authors (HDS, KD, LS, JZ, JT, GS) critically

reviewed and provided feedback on the manuscript. The author(s) read and

approved the ﬁnal manuscript.

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.

Availability of data and materials

All data generated or analysed during this study are included in this published

article [and its Additional ﬁles].

Declarations

Ethics approval and consent to participate

Not applicable.

Consent for publication

Not applicable.

Competing interests

The authors declare that they have no competing interests.

Author details

1 Institute of Health Policy, Management and Evaluation, University of Toronto,

Toronto, Ontario, Canada. 2 Campbell Family Mental Health Research Institute,

Centre for Addiction and Mental Health, Toronto, Ontario, Canada. 3 Arthur

Labatt Family School of Nursing, Western University, London, Ontario, Canada.

4 School of Health, Community Service & Creative Design, Lambton College,

Sarnia, Ontario, Canada. 5 Health Outcomes and Performance Evaluation

(HOPE) Research Unit, Institute for Mental Health Policy Research, Centre

for Addiction and Mental Health, Toronto, Ontario, Canada. 6 Gerald Sheﬀ

and Shanitha Kachan Emergency Department, Centre for Addiction and Men-

tal Health, Toronto, Ontario, Canada. 7 Department of Psychiatry, University

of Toronto, Toronto, Ontario, Canada. 8 Department of Psychiatry, Beth Israel

Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts,

USA.

Received: 29 July 2022 Accepted: 7 March 2023

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Implementation of suicide bereavement support: a scoping review

Article

Full-text available

Nov 2024

Introduction Approximately one in five people will experience a death by suicide during their lifetime. Struggling to understand their experiences, people bereaved by suicide often require formal support including support groups, online resources and discussion forums. While previous research has focused on examining experiences of grief, little is known about the implementation of support programs for people bereaved by suicide. Methods Adhering to PRISMA-ScR guidelines, eight databases were searched for peer-reviewed studies that focused on the strategies or evaluation of the implementation of suicide postvention programs. Results Sixteen studies met the eligibility criteria. A narrative synthesis of study findings mapped to the Proctor implementation framework shows that a variety of implementation outcomes have been assessed by different studies; however, there is limited use of formal implementation frameworks to guide analysis. Discussion Recommendations from this review indicate the need for consistent terminology and better utilisation of implementation frameworks to guide postvention research and provide a well-rounded view of implementation. Increasing the use of reliable and validated tools to measure implementation outcomes will also increase the rigour of implementation research in this field. Systematic review registration https://doi.org/10.17605/OSF.IO/4RB92.

Characteristics of suicide prevention apps: a content analysis of apps available in Canada and the UK

Article

Full-text available

Jan 2025

Objectives We aimed to examine the characteristics, features and content of suicide prevention mobile apps available in app stores in Canada and the UK. Design Suicide prevention apps were identified from Apple and Android app stores between March and April 2023. Apps were screened against predefined inclusion criteria, and duplicate apps were removed. Data were then extracted based on descriptive (eg, genre, app developer), security (eg, password protection) and design features (eg, personalisation options). Content of apps was assessed using the Essential Features Framework. Extracted data were analysed using a content analysis approach including narrative frequencies and descriptive statistics. Data sources Apple and Android app stores between March and April 2023. Eligibility criteria Identified apps were eligible for inclusion if they were: (a) free, (b) developed in the English language, (c) could be downloaded on an Apple or Android device in England or Canada, (d) the focus of the app was suicide prevention and (e) the target users of the app were individuals experiencing suicide-related thoughts and/or behaviours. Data extraction and synthesis Apps were assessed on basic descriptive data (eg, name, genre, developer of the app), alongside security (eg, whether password protection was available) and design features (eg, whether the app could be personalised). App content was examined using the Essential Features Framework. Results 52 suicide prevention apps were included within the review. Most were tailored for the general population and were in English language only. One app had the option to increase app accessibility by offering content presented using sign language. Many apps allowed some form of personalisation by adding text content, however most did not facilitate further customisation such as the ability to upload photo and audio content. All identified apps included content from at least one of the domains of the Essential Features Framework. The most commonly included domains were sources of suicide prevention support, and information about suicide. The domain least frequently included was screening tools followed by wellness content. No identified apps had the ability to be linked to patient medical records. Conclusions The findings of this research present implications for the development of future suicide prevention apps. Development of a co-produced suicide prevention app which is accessible, allows for personalisation and can be integrated into clinical care may present an opportunity to enhance suicide prevention support for individuals experiencing suicidal thoughts and behaviours.

Contextual factors influencing the use of digital health by patients and physicians in primary care: a scoping review protocol

Article

Full-text available

Dec 2024

Introduction Integrating digital health technologies to improve the overall performance of healthcare systems counts among the top priorities of the WHO. As evidenced in recent research, there are specific factors that may decisively determine the effective implementation and development of innovative digital health solutions. This review attempts to recognise and map the existing body of research and evidence to identify the determinants that either favour or hinder the deployment and use of digital health technologies by patients and physicians in primary care. Methods and analysis The scoping review will be conducted in accordance with the JBI Manual for Evidence Synthesis (2024 edition introducing nine stages) and with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews checklist. Search strategy will be conducted in PubMed, Embase, Cochrane Database of Systematic Reviews and Scopus in November 2024. The review will include quantitative, qualitative, mixed-methods studies, systematic, scoping or umbrella reviews, as well as text and opinion papers. The study selection process will be conducted by two researchers using Rayyan. The data will be analysed using MAXQDA and extracted into a tool prepared by the researchers. This review will summarise the existing data and will help create a list of potential and determinant barriers and facilitators that may be useful in conducting empirical research on embedding new digital health solutions and sustaining their use. Ethics and dissemination As no primary data will be collected for the purposes of this study, no formal ethical approval is required. Results will be published in a peer-reviewed journal. The findings will be used to conduct further research (HORIZON.2.1;grant:101095424) on the determinants of digital health implementation in primary care at the national level and to prepare recommendations for key stakeholders, as well as to develop recommendations on health policy in the European Union.

Evaluating an App-Based Intervention for Preventing Firearm Violence and Substance Use in Young Black Boys and Men: Usability Evaluation Study

Article

Full-text available

Nov 2024

Background Young Black male individuals are 24 times more likely to be impacted by firearm injuries and homicides but encounter significant barriers to care and service disengagement, even in program-rich cities across the United States, leaving them worryingly underserved. Existing community-based interventions focus on secondary and tertiary prevention after firearm violence has occurred and are typically deployed in emergency settings. To address these service and uptake issues, we developed BrotherlyACT—a nurse-led, culturally tailored, multicomponent app—to reduce the risk and effects of firearm injuries and homicides and to improve access to precrisis and mental health resources for young Black male individuals (aged 15-24 years) in low-resource and high-violence settings. Grounded in Acceptance and Commitment Therapy, the app provides life skills coaching, safety planning, artificial intelligence–powered talk therapy, and zip code–based service connections directly to young Black male individuals at risk for violence and substance use. Objective The primary aim of this study is to evaluate the usability, engagement, and satisfaction of BrotherlyACT among target young Black male users and mobile health (mHealth) experts, using a combination of formative usability testing (UT) and heuristic evaluation (HE). Methods Using a convergent mixed methods approach, we evaluated the BrotherlyACT app using HE by 8 mHealth specialists and conducted UT with 23 participants, comprising 15 young Black male users (aged 15-24 years), alongside 4 adult internal team testers and 4 high school students who were part of our youth advisory board. UT included the System Usability Scale and thematic analysis of think-aloud interviews and cognitive walkthroughs. HE involved mHealth experts applying the Nielsen severity rating scale (score 0-3, with 3 indicating a major issue). All testing was conducted via REDCap (Research Electronic Data Capture) and Zoom or in person. Results Qualitative usability issues were categorized into 8 thematic groups, revealing only minor usability concerns. The app achieved an average System Usability Scale score of 79, equivalent to an A-minus grade and placing it in the 85th percentile, indicating near-excellent usability. Similarly, the HE by testers identified minor and cosmetic usability issues, with a median severity score of 1 across various heuristics (on a scale of 0-3), indicating minimal impact on user experience. Overall, minor adjustments were recommended to enhance navigation, customization, and guidance for app users, while the app’s visual and functional design was generally well received. Conclusions BrotherlyACT was considered highly usable and acceptable. Testers in the UT stage gave the app a positive overall rating and emphasized that several key improvements were made. Findings from our UT prompted revisions to the app prototype. Moving forward, a pilot study with a pretest-posttest design will evaluate the app’s efficacy in community health and emergency care settings. International Registered Report Identifier (IRRID) RR2-10.2196/43842

Help-Seeking Needs Related to Suicide Prevention for Individuals in Contact With Mental Health Services: A Rapid Scoping Review

Article

Full-text available

Sep 2024
J PSYCHIATR MENT HLT

Introduction Prior mental healthcare utilisation presents an important window of opportunity for providing suicide prevention interventions. To date, no reviews have consolidated the help‐seeking needs of individuals in contact with mental health services. This warrants further attention given this group may have different needs for interventions compared with the general population who have not sought help previously. Aim The purpose of this rapid scoping review was to summarise the available literature on help‐seeking needs related to suicide prevention among individuals in contact with mental health services from healthcare settings. Method Cochrane rapid review and Joanna Briggs Institute scoping review methodologies were adapted, and databases, including MEDLINE, Scopus, CINAHL, PsycInfo and EMBASE, were searched. Results A total of 42 primary studies were included in analysis. Reported barriers and facilitators to help‐seeking behaviours identified within studies were mapped onto the socio‐ecological model. Barriers and facilitators identified included knowledge and attitudes towards healthcare utilisation, family and peer support, interactions with healthcare professionals, provision of holistic care, and the creation of a supportive atmosphere and safe space to promote open discussions of suicide‐related concerns. Discussion The findings of this review offer valuable insights into areas for improvement in addressing help‐seeking needs for individuals who are in contact with health services related to suicide prevention. Implication for Research The findings serve as a foundation for shaping mental health initiatives informing approaches and care delivery tailored towards individuals who are in contact with health services. The reported barriers and facilitators offer insights to inform the development of mental health support tools to enhance care and considerations for evaluations.

Pediatric Primary Care Provider Perspectives on Universal Suicide Screening

Article

Full-text available

Aug 2024

Introduction Given the increase in youth mental health concerns, the American Academy of Pediatrics (AAP) recommends universal suicide screening for ages 12 and older, with positive screens followed by a brief suicide risk assessment. However, it is unclear how pediatric clinicians incorporate this recommendation into practice. Therefore, the objective of this qualitative study was to identify pediatric clinicians’ current practice, attitudes, and barriers to implement the updated universal suicide screening recommendation in primary care. Methods Community-based pediatric primary care providers (PCPs) in the St. Louis Metropolitan area who by self-report provide mental health care for patients participated. Participants completed a 30-minute semi-structured interview with invitations extended through an electronic listserv in a local Pediatric PCP Learning Collaborative. Interviews were transcribed and analyzed using consensual deductive and inductive approaches until data saturation. Results Eighteen PCPs participated in the interviews. Interviews described themes related to acceptability of the recommendations, PCPs’ current screening practices, and perceived barriers for implementing the recommendations. Overall, PCPs agreed with, but expressed hesitancy about, the recommendation. Frequently mentioned barriers to suicide screening included time, training, and inadequate access to resources for follow-up care for at-risk patients. Yet, PCPs were optimistic they could learn with support and were interested in working in this subject area through quality improvement interventions. Conclusions PCPs agree with the AAP recommendation about suicide screening but need support to implement into practice. Specifically, PCPs need time sensitive strategies, resources, training, and practice change support to assist these efforts.

Prevenir en suicidio. ¿Oportunidad o utopía? Revisión pragmática sobre el estado de la cuestión.

Article

Feb 2025

Changes in suicidal behaviors and predictors of suicidal behaviors among middle-aged single-person households in South Korea: Analysis of the 2013 Korean Community Health Survey and 2021 Korean Community Health Survey

Article

Dec 2024

Young-Ran Hwang

Synchronous remote-based interventions for suicidal behaviour prevention: a systematic review and meta-analyses of clinical trials

Preprint

Full-text available

Mar 2025

Objectives Suicide is a leading cause of preventable death worldwide. Evidence supports the impact of providing active contact for individuals who have attempted suicide. The current systematic review and meta-analyses aim to investigate the effects of suicide prevention strategies implemented through remote and synchronous technology-based interventions. Design Systematic review, narrative synthesis, and meta-analysis. Data sources Electronic databases (PubMed, PsycInfo, Scopus, and Web of Science) and grey literature sources (ClinicalTrials.gov and Google Scholar) were searched until December 2024. Eligibility criteria Eligible articles assessed suicide prevention interventions for participants over 12 years with prior suicidal behaviour. Eligible study design included randomised control trials and non-randomised clinical trials published in English or Spanish. Data extraction and synthesis Screening, selection process, data extraction, and risk of bias assessment were performed independently by two reviewers. Data on suicide-related factors and adherence to treatment were extracted. Meta-analyses were conducted to determine effect sizes (Hedges’ g) for suicidal ideation, risk ratios (RR) for suicide attempts, and Peto odds ratios (OR) for suicide. Heterogeneity was assessed using the Cochrane’s Q test, tau2 statistic, and I2 value. Publication bias was investigated employing funnel plots and Egger's test. Results A total of 28 studies, comprising 10,015 participants in the intervention group and 10,726 in the comparison group, were included in the systematic review and meta-analyses. Synchronous remote-based interventions were effective in preventing repeated suicide attempts at 1 month (RR 0.73, 95% CI 0.62 to 0.85), 6 months (RR 0.56, 95% CI 0.34 to 0.95), and 12 months (RR 0.68, 95% CI 0.49 to 0.96). Additionally, these interventions were associated with a reduction in suicide-related deaths at 18 months (Peto OR 0.18, 95% CI 0.08 to 0.44). Conclusions Synchronous remote-based interventions demonstrate moderate effectiveness in preventing suicidal behaviour and may serve as an adjunct to usual treatment; however, there is no strong evidence that such effects were cognitively mediated by a reduction in suicidal ideation. The observed heterogeneity warrants caution when interpreting these findings. Future research should prioritise methodological enhancements to improve the quality and consistency of evidence, as well as investigate the mediating processes underlying their effectiveness in reducing suicidal behaviour. PROSPERO registration number CRD42021275044. Keywords Suicide, Telemedicine, Preventive Medicine. STRENGTHS AND LIMITATIONS OF THIS STUDY ● The current study examined the evidence for the effectiveness of synchronous remote-based interventions in the prevention of suicidal behaviours, including suicidal ideation, suicide attempts, and death by suicide. ● Data extraction, synthesis, and quality assessment were conducted using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA-2020) criteria. ● The systematic review and meta-analyses used a comprehensive search strategy to avoid missing published articles. ● Heterogeneity in the methods makes it difficult to draw definitive conclusions about the effectiveness of interventions. ● The heterogeneity of the interventions also makes it difficult to synthesize the results.

Barriers and Facilitators to Using an App-Based Tool for Suicide Safety Planning in a Psychiatric Emergency Department: A Qualitative Descriptive Study Using the Theoretical Domains Framework and COM-B Model

Preprint

Full-text available

May 2024

Background Emergency departments (ED) play a crucial role in suicide prevention, with evidenced-based safety planning interventions (SPI) playing an important role. Traditional safety plans, which are often paper based, come with challenges (i.e., not easily accessible, or easy to misplace). Digital safety planning tools offer an alternative mode of intervention delivery, but clinical implementation remains limited. Using behavioural change frameworks, we aim to provide insights into the factors influencing app adoption. These insights will be used as a knowledge base to design behavior change strategies to promote the implementation of a SPI app in a psychiatric ED. Methods We used a qualitative descriptive design to conduct semi-structured interviews with clinicians in a psychiatric ED in Toronto, Canada. Participants encompassed all ED staff, irrespective of their SPI app usage. The semi-structured interview guide was developed using the Theoretical Domains Framework (TDF) and the capability (C), opportunity (O), motivation (M) and behavior (B) (COM-B) model. We then used directed content analysis, identifying findings within the TDF and COM-B domains as barriers, facilitators, or both. Findings A total of 29 ED clinicians were interviewed, including nurses, psychiatrists, social workers, program assistants, and a pharmacist. The majority had not used the app. We observed strong motivation among clinicians across all disciplines to use the app, and they considered SPI as a high-priority ED care strategy closely linked to their professional identity and responsibility. Anticipated barriers regarding the app as a new mode of SPI delivery in routine practice included: documentation, communication, care efficiency, and patient access to smartphones. Some barriers were attributable to the lack of interoperability between the app and the electronic health record and documentation infrastructure for the app. Conclusion We identified key behavioral factors influencing the implementation of the SPI app in the psychiatric ED. We found that tailored strategies are essential to address barriers, while leveraging facilitators can sustain implementation. Additionally, ongoing monitoring and adaptation of strategies are necessary, as new barriers may arise or facilitators may weaken over time, impacting the sustained use of the app in the ED. We will use these findings to inform the next phase of this work, which involves co-designing targeted and tailored implementation strategies.

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

Article

Full-text available

Jan 2022

Introduction: There is a surplus of information and communication technology (ICT)-based interventions for suicide prevention. However, it is unclear which of these ICT-based interventions for suicide prevention have been implemented in clinical settings. Furthermore, evidence shows that implementation strategies have often been mismatched to existing barriers. In response, the authors recognise the critical need for prospectively assessing the barriers and facilitators and then strategically developing implementation strategies. This review is part of a multiphase project to develop and test tailored implementation strategies for mobile app-based suicide prevention in clinical settings. The overall objective of this scoping review is to identify and characterise ICT-based interventions for all levels of suicide prevention in clinical settings. Additionally, this review will identify and characterise the barriers and facilitators to implementing these ICT-based interventions as well as reported measures and outcomes. The findings will directly inform the subsequent phase to maximise implementation and inform future efforts for implementing other types of ICT-based interventions related to suicide prevention in clinical settings. Methods and analysis: This review will adhere to the methods described by the Joanna Briggs Institute for conducting scoping reviews. The reporting will follow the Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for scoping review checklist. The following databases will be searched: Medline, PsycInfo, Embase, Cumulative Index to Nursing & Allied Health Literature (CINAHL), Web of Science and Library, Information Science & Technology Abstracts (LISTA). Two reviewers will independently screen the articles and extract data using a standardised data collection tool. Then, authors will characterise extracted data using frameworks, typology and taxonomies to address the proposed review questions. Ethics and dissemination: Ethics approval is not required for this scoping review. Authors will share the results in a peer-reviewed, open access publication and conference presentations. Furthermore, the findings will be shared with relevant health organisations through lay language summaries and informal presentations.

Mitigating unintended consequences of co‐design in health care

Article

Full-text available

Aug 2021
HEALTH EXPECT

Background Co‐design and associated terms are increasingly being used to facilitate values‐based approaches to health‐care improvement. It is messy and complex, involving diverse actors. Methods We explore the notion that initiatives have outcomes other than initially planned is neither new nor novel but is overlooked when thinking about co‐design. We explore some of the unintended consequences and outline some optimal conditions that can mitigate challenges. Discussion Although co‐design approaches are being applied in health care, questions remain regarding its ability to produce gains in health outcomes. Little is known about determining whether co‐design is the most suitable approach to achieve the given project goals, the levels of involvement required to realize the benefits of co‐design or the potential unintended consequences. There is a risk of further marginalizing or adding burden to under‐represented populations and/or over‐researched populations. Conclusion Undertaking a co‐design approach without the optimal conditions for inclusive involvement by all may not result in an equal partnership or improve health or care quality outcomes. Co‐design requires on‐going reflective discussions and deliberative thinking to remove any power imbalances. However, without adequate resources, a focus on implementation and support from senior leaders, it is a tough ask to achieve. Patient or Public Contribution This viewpoint article was written by two academics who have undertaken a significant amount of PPI and co‐design work with members of the public and patient's right across the health system. Our work guided the focus of this viewpoint as we reflected on our experiences.

An Internet-based emotion regulation intervention versus no intervention for non-suicidal self-injury in adolescents: a statistical analysis plan for a feasibility randomised clinical trial

Article

Full-text available

Jul 2021
TRIALS

Background Non-suicidal self-injury (NSSI) has a lifetime prevalence of 17% in adolescents in the general population and up to 74% in adolescents with psychiatric disorders. NSSI is one of the most important predictors of later suicidal behaviour and death by suicide. The TEENS feasibility trial was initiated to assess the feasibility and safety of Internet-based Emotion Regulation Individual Therapy for Adolescents (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 Services. Methods The TEENS feasibility trial is a randomised clinical trial with a parallel-group design. The trial intervention is an 11-week online therapy which is tested as an add-on to treatment as usual versus treatment as usual. The primary feasibility outcomes are the fraction of participants who (1) completed 12 weeks of follow-up interview or assessment, (2) consented to inclusion and randomisation out of all eligible participants, and (3) were compliant with the experimental intervention, assessed as completion of at least six out of eleven modules in the programme. Since this is a feasibility trial, we did not predefine a required sample size. The exploratory clinical outcome, the frequency of NSSI episodes, assessed using Deliberate Self-Harm Inventory – Youth version (DSHI-Y), at the end of intervention, is planned to be the future primary outcome in a larger pragmatic definitive randomised clinical trial. After completion of the feasibility trial, blinded data will be analysed by two independent statisticians blinded to the intervention, where ‘A’ and ‘B’ refer to the two groups. A third party will compare these reports, and discrepancies will be discussed. The statistical report with the analyses chosen for the manuscript is being tracked using a version control system, and both statistical reports will be published as a supplementary material. Based on the final statistical report, two blinded conclusions will be drawn by the steering group. Discussion We present a pre-defined statistical analysis plan for the TEENS feasibility trial, which limits bias, p-hacking, data-driven interpretations. This statistical analysis plan is accompanied by a pre-programmed version-controlled statistical report with simulated data, which increases transparency and reproducibility. Trial registration ClinicalTrials.gov NCT04243603 . Registered on 28 January 2020

Suicide reattempt in a population-wide brief contact intervention to prevent suicide attempts: The VigilanS program, France

Article

Full-text available

Jul 2021

Objective: Among the postcrisis suicide prevention programmes, brief contact interventions (BCIs) have been proven to be efficient. VigilanS generalizes to a whole French region a BCI combining resource cards, telephone calls, and sending postcards, according to a predefined algorithm. However, a major problem in suicide prevention is the suicide reattempt, which can lead to final suicide. Here, we analyze the suicide reattempt in VigilanS. Methods: The study concerned patients included in VigilanS over the period from January 1, 2015 to December 31, 2018, with an end of follow-up on July 1, 2019. We performed a series of descriptive analyses, survival curves, and regressions. The outcome was the suicide reattempt, and the predictive variables were the characteristics of the patient at entry and during follow-up in VigilanS. Age and sex were considered as adjustment variables. Results: A total of 11,879 inclusions occurred during the study period, corresponding to 10,666 different patients, among which 905 reattempted suicide. More than half were primary suicide attempters (53.4%). A significant relationship with suicide reattempt was identified for the following characteristics: being a non-primary suicide attempter, having attempted suicide by voluntary drug intoxication and phlebotomy, alcohol consumption among primary suicide attempters, and having no companion at the emergency room visit among non-primary suicide attempters. Hanging (as suicide method), having made no call to VigilanS were protective factors. Conclusion: This study provides us with a valuable insight into the profiles of patients repeating a suicide attempts, which is important for suicide prevention in general.

Effects of mobile messenger counseling on case management success for individuals engaging in self-harm or suicide attempts who were discharged from emergency departments

Article

Full-text available

Mar 2021

Objective: Postdischarge case management for self-harm or suicide attempters often fails; therefore, this study aimed to investigate the effects of mobile messenger counseling (MMC) on the postdischarge case management results among this patient group. Methods: A retrospective analysis was done with data collected from March 2015 to February 2020 that included self-harm or suicide attempters who had visited a Korean emergency department and were discharged. If patients consented, postdischarge case management and MMC were conducted from March 2017. The primary outcome was the rate of successful case management, which reflects the patients either connecting to a local psychiatric healthcare center or undergoing a follow-up at a neuropsychiatric outpatient department at least once following discharge. Using univariate and multivariate logistic regression analyses, we evaluated MMC's effects on these patients' postdischarge case management. Results: Of 913 patients, 604 participated in this study. In terms of successful case management, the MMC group showed a significantly higher rate than the non-MMC one (28.3% vs. 16.1%, P=0.001). A multivariate analysis demonstrated that access to postdischarge MMC (odds ratio, 2.149; 95% confidence interval, 1.357-3.403; P=0.001) and giving consent for case management while in the emergency department were significantly associated with successful case management (odds ratio, 8.917; 95% confidence interval, 5.610-14.173; P<0.001). Conclusion: The use of MMC for self-harm or suicide attempters is associated with higher case management success rates by increasing their chances of connecting to a psychiatric healthcare center or a neuropsychiatric outpatient department.

Information and communications technology use in suicide prevention: A scoping review (Preprint)

Article

Full-text available

Oct 2020
J MED INTERNET RES

Background: The use of information and communications technology (ICT) in suicide prevention has progressed rapidly over the past decade. ICT plays a major role in suicide prevention but research regarding best and promising practices has lagged behind. Objective: The aim of this paper is to scope the existing literature on ICT use in suicide prevention in order to answer the following question: What are the best and promising ICT practices for suicide prevention? Methods: A scoping search was conducted in the following databases: PubMed, PsycInfo, Sociological Abstracts, and IEEE Xplore. These were searched for articles published from January 1, 2013, to December 31, 2018. Five stages were followed: (1) identify research question, (2) target relevant studies, (3) select studies, (4) chart data, and (5) collate, summarize and report results. The World Health Organisation suicide prevention model was used according to the continuum of universal, selective and indicated prevention [1]. Results: Of 3848 studies found, 115 were selected. Of these, 10 regarded the use of ICT in universal suicide prevention, 53 referred to the use of ICT in selective suicide prevention and 52 dealt with the use of ICT in indicated suicide prevention. Conclusions: The use of ICT plays a major role in suicide prevention and many promising programs were identified through this scoping review. However, larger-scaled evaluation studies are needed to further examine the effectiveness of these programs and strategies. Also, safety and ethics protocols for ICT-based interventions are recommended. Clinicaltrial:

Using digital monitoring alongside psychosocial interventions in patients who self-harm

Article

Sep 2021

Effect of Offering Care Management or Online Dialectical Behavior Therapy Skills Training vs Usual Care on Self-harm Among Adult Outpatients With Suicidal Ideation: A Randomized Clinical Trial

Article

Feb 2022

Importance: People at risk of self-harm or suicidal behavior can be accurately identified, but effective prevention will require effective scalable interventions. Objective: To compare 2 low-intensity outreach programs with usual care for prevention of suicidal behavior among outpatients who report recent frequent suicidal thoughts. Design, setting, and participants: Pragmatic randomized clinical trial including outpatients reporting frequent suicidal thoughts identified using routine Patient Health Questionnaire depression screening at 4 US integrated health systems. A total of 18 882 patients were randomized between March 2015 and September 2018, and ascertainment of outcomes continued through March 2020. Interventions: Patients were randomized to a care management intervention (n = 6230) that included systematic outreach and care, a skills training intervention (n = 6227) that introduced 4 dialectical behavior therapy skills (mindfulness, mindfulness of current emotion, opposite action, and paced breathing), or usual care (n = 6187). Interventions, lasting up to 12 months, were delivered primarily through electronic health record online messaging and were intended to supplement ongoing mental health care. Main outcomes and measures: The primary outcome was time to first nonfatal or fatal self-harm. Nonfatal self-harm was ascertained from health system records, and fatal self-harm was ascertained from state mortality data. Secondary outcomes included more severe self-harm (leading to death or hospitalization) and a broader definition of self-harm (selected injuries and poisonings not originally coded as self-harm). Results: A total of 18 644 patients (9009 [48%] aged 45 years or older; 12 543 [67%] female; 9222 [50%] from mental health specialty clinics and the remainder from primary care) contributed at least 1 day of follow-up data and were included in analyses. Thirty-one percent of participants offered care management and 39% offered skills training actively engaged in intervention programs. A total of 540 participants had a self-harm event (including 45 deaths attributed to self-harm and 495 nonfatal self-harm events) over 18 months following randomization: 172 (3.27%) in care management, 206 (3.92%) in skills training, and 162 (3.27%) in usual care. Risk of fatal or nonfatal self-harm over 18 months did not differ significantly between the care management and usual care groups (hazard ratio [HR], 1.07; 97.5% CI, 0.84-1.37) but was significantly higher in the skills training group than in usual care (HR, 1.29; 97.5% CI, 1.02-1.64). For severe self-harm, care management vs usual care had an HR of 1.03 (97.5% CI, 0.71-1.51); skills training vs usual care had an HR of 1.34 (97.5% CI, 0.94-1.91). For the broader self-harm definition, care management vs usual care had an HR of 1.10 (97.5% CI, 0.92-1.33); skills training vs usual care had an HR of 1.17 (97.5% CI, 0.97-1.41). Conclusions and relevance: Among adult outpatients with frequent suicidal ideation, offering care management did not significantly reduce risk of self-harm, and offering brief dialectical behavior therapy skills training significantly increased risk of self-harm, compared with usual care. These findings do not support implementation of the programs tested in this study. Trial registration: ClinicalTrials.gov Identifier: NCT02326883.

Implementing and evaluating co-designed change in health

Article

Jan 2022

Interventions to change clinicians’ behavior related to suicide-prevention care in the emergency department: a scoping review

Article

Dec 2021

Objective: The objective of this scoping review was to explore, characterize, and map the literature on interventions and intervention components implemented to change emergency department clinicians' behavior related to suicide prevention using the Behaviour Change Wheel as a guiding theoretical framework. Introduction: An emergency department is a critical place for suicide prevention, yet patients are often discharged without proper suicide risk assessments and/or referrals. In response, we must support emergency department clinicians' behavior change to follow evidence-based suicide prevention strategies. However, reviews to date have yet to systematically and theoretically examine interventions' functional characteristics and how they can influence emergency department clinicians' behaviors related to suicide-prevention care. Inclusion criteria: This review considered interventions that targeted emergency department clinicians' behavior change related to suicide prevention. Behavior change referred to observable practice changes as well as proxy measures of behavior change, including changes in knowledge and attitude. Methods: This review followed JBI methodology for scoping reviews. Searches included PubMed, PsycINFO, CINAHL, Embase, and gray literature, including targeted Google searches for relevant organizations/websites, ProQuest Dissertations and Theses Global, and Scopus conference papers (using a specific filter). This review did not apply any date limits, but our search was limited to the English language. Data extraction was undertaken using a charting table developed specifically for the review objective. Narrative descriptions of interventions were coded using the Behavior Change Wheel's intervention functions. Reported outcome measures were categorized. Findings are tabulated and synthesized narratively. Results: Forty-one studies were included from the database searches, representing a mixture of experimental (n = 2), quasi-experimental (n = 24), non-experimental (n = 12), qualitative (n = 1), and mixed methods (n = 2) approaches. An additional 29 citations were included from gray literature searches. One was a pilot mixed methods study, and the rest were interventions. In summary, this review included a total of 70 citations, describing 66 different interventions. Identified interventions comprised a wide range of Behaviour Change Wheel intervention functions to change clinicians' behavior: education (n = 48), training (n = 40), enablement (n = 36), persuasion (n = 21), environmental restructuring (n = 18), modeling (n = 7), and incentivisation (n = 2). Based on the Behaviour Change Wheel analysis, many interventions targeted more than one determinant of behavior change, often employing education and training to improve clinicians' knowledge and skills simultaneously. Among the 42 studies that reported outcome measures, effectiveness was measured at clinician (n = 38), patient (n = 4), and/or organization levels (n = 6). Few studies reported implementation outcomes, such as measures of reach (n = 4), adoption (n = 5), or fidelity (n = 1). There were no evaluation data reported on the interventions identified through Google searches. Conclusions: Interventions included in this review were diverse and leveraged a range of mechanisms to change emergency department clinicians' behavior. However, most interventions relied solely on education and/or training to improve clinicians' knowledge and/or skills. Future research should consider diverse intervention functions to target both individual- and/or organization-level barriers for a given context. Secondly, the ultimate goal for changing emergency department clinicians' behavior is to improve patient health outcomes related to suicide-related thoughts and behaviors, but current research has most commonly evaluated clinicians' behavior in isolation of patient outcomes. Future studies should consider reporting patient-level outcomes alongside clinician-level outcomes.

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

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