Digital Narrative Bibliotherapy as a Scalable Intervention for Suicidal Thoughts

April 25, 2022 updated by: Peter Franz, Harvard University

Digital Narrative Bibliotherapy as a Scalable Intervention for Suicidal Thoughts: A Randomized Controlled Trial (Testing Whether Selected Blog Posts Can Improve Well-being)

The goal of this study was to determine whether reading about others' experiences with suicide can help reduce suicidal thoughts. To investigate this issue, the investigators recruited users from an internet support community. The investigators randomized participants to two separate groups: a Treatment group and a Control group. Participants in the treatment group read one first-person narrative about suicide each day for 14 days, and answered questions before and after reading the narrative. Participants in the Control group answered questions once per day during the 14-day trial period and did not receive the narrative intervention until after the initial study ended. All participants completed a follow-up questionnaire two weeks after the end of the 14-day trial period.

Study Overview

Status

Completed

Conditions

Intervention / Treatment

Detailed Description

BACKGROUND In the US, suicide is the 10th leading cause of death among all age groups, and the second leading cause of death of individuals 14 to 34. Despite the enormity of this public health concern, scientific progress has not led to lasting reductions in the suicide rate, which in 2019 was nearly identical to that in the US 100 years prior. Looking beyond the scope of traditional medicine and psychotherapy to identify novel treatments may be critical for improving our ability to ameliorate the problem of suicide.

Scholars have discussed the act of reading as an effective treatment for psychiatric concerns, a concept within narrative therapy known as bibliotherapy, for centuries. Studies investigating the effectiveness of bibliotherapy have found that reading about others' experiences with struggles can be therapeutic. For example, bibliotherapy has been shown to improve hopefulness, reduce symptoms of anxiety, and reduce depressive symptoms. Only a small number of studies have examined narrative-based bibliotherapy as a therapeutic tool to help those struggling with suicidal thoughts, and of these sample sizes are small. However, one such study found that bibliotherapy significantly reduced the number of suicide attempts and nonsuicidal self-harm episodes among adolescents and adults who had recently received treatment for these behaviors. Another such study found that bibliotherapy conducted adjunctively with traditional psychotherapy for depressed adults significantly reduced suicidal ideation for three months following the intervention.

Bibliotherapy has numerous practical benefits when compared with traditional psychotherapies. It is low-cost, brief, and can be conducted easily when face-to-face interventions are not plausible, such as during the current COVID-19 pandemic. The positive effects of bibliotherapy are also generally long-lasting, persisting for anywhere between 3 months and 3 years. Further, bibliotherapy has been shown to be as effective as face-to-face psychotherapy for reducing depression and anxiety symptoms in one large systematic review. Finally, bibliotherapy is shown to normalize the experience of mental health struggles, thereby reducing stigma and allowing patients to feel that they are not alone. Due to the lack of large-scale randomized controlled trials examining the effectiveness of bibliotherapy, there may be additional unknown benefits to this practice, perhaps especially in easily-scalable, online peer-to-peer modalities, as with the present study.

Three key aspects of suicide-related narrative bibliotherapy may be particularly beneficial to those struggling with suicidal thoughts. For one, the first-person perspective of narrative content conveys experiential knowledge about a subject area that is not often discussed openly. By sharing a first-hand experience with challenges, the author of the narrative can communicate specific challenges to be overcome, identify gaps in the reader's knowledge, propose strategies that were beneficial, and provide the reader with a plan for recovery. In doing so, suicide narratives, especially those that showcase recovery-related behaviors and activities (e.g., seeking support), could help people by illustrating the possibility of recovery. Indeed, inspiring optimism is shown to be a key benefit of narrative-sharing for individuals experiencing psychological distress.

Second, suicide narratives may lead to improvements in mental health and wellbeing by increasing social connectedness to a broader community. This may be especially important for suicidal people who face stigma and social isolation that may further exacerbate distress. Moreover, improving connectedness may be critical in remediating problems associated with social isolation caused by the COVID-19 pandemic.

Third, narratives are implicitly engaging and naturally constructed to make sense of complex circumstances and emotions. Narrative-based bibliotherapy may therefore hold particular value in healthcare communications and in interventions for which patients are expected to learn and apply new knowledge, skills, or behavioral strategies. Likewise, bibliotherapy may be able to support patients' abilities to verbalize their thoughts and feelings by helping these individuals develop a semantic representation of complex psychological processes.

Recently, a growing number of studies have revealed therapeutic benefits of digital mental health resources for people at risk for suicide. Such resources include peer-to-peer internet support networks, web-based individual psychotherapy platforms, and smartphone apps designed to improve the user's sense of self worth. The internet may be a fruitful domain for the development of new suicide interventions, as people with suicidal thoughts may be more likely to seek support online to avoid stigma, readily available methods for the detection of suicide-related discussions online have been validated, and digital interventions can reach a broader population more easily than traditional psychotherapies, including those unable or unwilling to attend in-person appointments. In short, society is in need of effective suicide interventions that are low-cost, engaging, and highly scalable, and internet-based resources seem poised to host such interventions.

Social media platforms provide an opportunity for users to discuss their experiences with mental health difficulties and allow other users to read, comment on, and share these stories with others at no monetary cost. People with suicidal thoughts, behaviors, and related self-injurious concerns tend to utilize social media platforms as a way to communicate and find information about these concerns. The content posted on these platforms, therefore, represents an opportunity to explore whether this form of digital bibliotherapy can help people struggling with suicide. Several recent studies have provided preliminary evidence that digital bibliotherapies can be beneficial for suicidal thoughts. However, many of these studies are qualitative in nature, all examined small sample sizes, and none to our knowledge have employed a randomized controlled design to systematically examine the influence of narrative bibliotherapy on suicidal thoughts.

In the present study, the investigators aimed to fill this gap in the field's knowledge by testing whether reading user-generated stories about suicide posted to a digital social media platform leads to a reduction in the suicidal thoughts of at-risk individuals. The investigators further aimed to test whether such stories are beneficial for people experiencing suicidal thoughts by helping these individuals feel more optimistic (less hopeless) and more connected to others (less isolated).

PARTICIPANTS & RECRUITMENT

Participants were recruited from the web platform, The Mighty, an online community dedicated to supporting those who face health challenges. Users of The Mighty can subscribe to content posted within sub-communities organized by specific challenges. Website moderators placed a "popup" advertisement for this study on pages that featured content about and related to suicide. Interested users, who had already established a user account with The Mighty, completed an online screening questionnaire that assessed age, race/ethnicity, history of suicidal thoughts, and current intent to act on suicidal thoughts. Participants qualified if they were age 18 or above, reported English as their primary language, thought about suicide in the past year, and reported current suicidal intent of six or lower on a 10-point scale. Eight hundred sixty-four participants met screening criteria and provided informed consent. Of this group, a final sample of 528 participants completed at least one survey including the main outcome of interest, desire to die, during the trial period. Participants were randomized into one of two study groups after providing informed consent, a Treatment condition and a Control condition.

TRIAL PROCEDURES All trial procedures were approved by the Harvard University Institutional Review Board. Qualified participants received instructions about all study procedures by email prior to beginning the trial. Participants randomized to the Treatment condition received one email each day during a 14-day trial period. The email contained a link, which first asked participants to complete a three-item survey assessing self-reported feelings of (a) connectedness, (b) hopefulness, and (c) desire to die. Treatment condition participants were then instructed to read a single user-generated narrative about suicide, confirm the narrative was read, and finally complete the same three-item survey again. Participants in the Control condition received one email each day during the 14-day trial period that contained the three-item survey assessing connectedness, hopefulness, and desire to die only. Participants responded to all survey items using an 10-point Likert-type scale ranging from 1 ("not at all") to 10 ("definitely").

Two weeks after the conclusion of the 14-day trial period, participants in both the Treatment and Control conditions were asked to complete the three-item survey assessing connectedness, hopefulness, and desire to die. After completing the follow-up survey, participants in the Control condition received the same suicide narrative bibliotherapy intervention provided to those in the Treatment condition.

The 14 narratives provided to participants in the Treatment condition each described first-hand experiences with suicidal thoughts and behaviors and highlighted a range of issues related to the authors' struggles. This set of 14 narratives was selected based on pilot research suggesting that they were associated with reductions in suicidal thoughts, included a positive conclusion (e.g., the author discussed recovery), and described the experience of struggle in a relatable way (e.g., "feeling this way is common").

HYPOTHESES The authors tested four a priori hypotheses. First, the authors hypothesized that participants receiving the digital bibliotherapy intervention (treatment condition) would report lower desire to die over the course of the trial period than participants on the waitlist (control condition). Second, the authors hypothesized that the effect of the treatment would be maintained at the 2-week follow-up period. Third, the authors hypothesized that participants assigned to the treatment condition who completed more days of the trial would report lower desire to die (i.e., dose response effect). Fourth, the authors hypothesized that reductions in suicidal thoughts for participants who received the digital bibliotherapy intervention (treatment condition) would be mediated by increased perceptions of connectedness and increased feelings of optimism.

Study Type

Interventional

Enrollment (Actual)

864

Phase

  • Not Applicable

Contacts and Locations

This section provides the contact details for those conducting the study, and information on where this study is being conducted.

Study Locations

  • United States
    • Massachusetts
      • Cambridge, Massachusetts, United States, 02138
        • Harvard University

Participation Criteria

Researchers look for people who fit a certain description, called eligibility criteria. Some examples of these criteria are a person's general health condition or prior treatments.

Eligibility Criteria

Ages Eligible for Study

18 years and older (Adult, Older Adult)

Accepts Healthy Volunteers

Yes

Genders Eligible for Study

All

Description

Inclusion Criteria:

  • Age 18 or above
  • English as primary language
  • Having thought about suicide in the past 12 months

Exclusion Criteria:

  • a high level of suicide intent (as indicated by a 7 or greater on a 10-point scale of intent to act on suicidal thoughts)

Study Plan

This section provides details of the study plan, including how the study is designed and what the study is measuring.

How is the study designed?

Design Details

  • Primary Purpose: Treatment
  • Allocation: Randomized
  • Interventional Model: Factorial Assignment
  • Masking: None (Open Label)

Arms and Interventions

Participant Group / Arm
Intervention / Treatment
Active Comparator: Treatment
Participants in the Treatment arm were assigned to read one each day during the two-week trial period. These articles described a personal experience suicide from a first-person perspective, and included positive messages. Before and after reading these articles, participants in the Treatment arm answered brief questions assessing current suicidal thoughts and other constructs. Participants in the Treatment group were administered follow-up questionnaires 14 days after the completion of the trial period to assess suicidal thoughts and other constructs.
Behavioral: Treatment
Once per day for a 14-day trial period, participants in the Treatment group were assigned to read a first-person narrative about a past issue with suicidal thoughts or behaviors. These narratives each contained positive elements, such as providing details about how the author had overcome issues with suicide, suggesting that people with suicidal thought are "not alone," or encouraging people with suicidal thoughts/behaviors to have hope.
No Intervention: Control
Participants in the Control arm answered questionnaires one time per day assessing suicidal thoughts and among other constructs (the same items as the Treatment group) during the two-week trial. Control participants did not receive the positive suicide related stories during the two-week trial period. Participants in the control group completed follow-up questionnaires 14 days after the completion of the trial period to assess suicidal thoughts and other constructs (the same items as the Treatment group). After the follow-up phase was complete, participants in the Control group received the same intervention as those in the Treatment group.

What is the study measuring?

Primary Outcome Measures

Outcome Measure
Measure Description
Time Frame
Suicidal Thoughts
Time Frame: 14-day trial period with a follow-up assessment two weeks later
Participants self-reported their current desire to die on a Likert-type scale. Responses were made using a 9-point Likert-type scale ranging from 1 (not at all) to 10 (definitely). Higher scores indicate higher feelings of suicidal thoughts.
14-day trial period with a follow-up assessment two weeks later

Secondary Outcome Measures

Outcome Measure
Measure Description
Time Frame
Optimism
Time Frame: 14-day trial period with a follow-up assessment two weeks later
Participants self-reported their feelings of optimism (like the problems they have might get better). Responses were made using a 9-point Likert-type scale ranging from 1 (not at all) to 10 (definitely). Higher scores indicate higher feelings of optimism.
14-day trial period with a follow-up assessment two weeks later
Connectedness
Time Frame: 14-day trial period with a follow-up assessment two weeks later
Participants self-reported their feelings of being connected to others (like they are not the only ones with their problems). Responses were made using a 9-point Likert-type scale ranging from 1 (not at all) to 10 (definitely). Higher scores indicate higher feelings of connectedness.
14-day trial period with a follow-up assessment two weeks later

Collaborators and Investigators

This is where you will find people and organizations involved with this study.

Sponsor

Harvard University

Publications and helpful links

The person responsible for entering information about the study voluntarily provides these publications. These may be about anything related to the study.

General Publications

Study record dates

These dates track the progress of study record and summary results submissions to ClinicalTrials.gov. Study records and reported results are reviewed by the National Library of Medicine (NLM) to make sure they meet specific quality control standards before being posted on the public website.

Study Major Dates

Study Start (Actual)

November 20, 2020

Primary Completion (Actual)

March 14, 2021

Study Completion (Actual)

March 14, 2021

Study Registration Dates

First Submitted

January 11, 2022

First Submitted That Met QC Criteria

April 25, 2022

First Posted (Actual)

April 28, 2022

Study Record Updates

Last Update Posted (Actual)

April 28, 2022

Last Update Submitted That Met QC Criteria

April 25, 2022

Last Verified

April 1, 2022

More Information

Terms related to this study

Keywords

Additional Relevant MeSH Terms

Other Study ID Numbers

  • IRB19-0843

Plan for Individual participant data (IPD)

Plan to Share Individual Participant Data (IPD)?

YES

IPD Plan Description

Because data were collected with the help of a private organization, authors will make a determination about sharing of data on a case-by-case basis, in consultation with the organization

IPD Sharing Time Frame

Data will be available from the time of first publication for at least 5 years

IPD Sharing Access Criteria

Researchers affiliated with not-for-profit institutions, and who are interested in this study's data can contact the principal investigator to request access.

IPD Sharing Supporting Information Type

  • STUDY_PROTOCOL
  • SAP
  • ICF
  • ANALYTIC_CODE
  • CSR

Drug and device information, study documents

Studies a U.S. FDA-regulated drug product

No

Studies a U.S. FDA-regulated device product

No

This information was retrieved directly from the website clinicaltrials.gov without any changes. If you have any requests to change, remove or update your study details, please contact register@clinicaltrials.gov. As soon as a change is implemented on clinicaltrials.gov, this will be updated automatically on our website as well.

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