Digital Interventions for Adolescents and Young Adults Experiencing Self-Injurious Thoughts and Behaviors

Abstract

Purpose of Review

To summarize literature on digital mental health interventions (DMHIs) for self-injurious thoughts and behaviors (SITBs) among adolescents and young adults. This includes studies evaluating DMHI efficacy in reducing SITBs, exploring the quality of these interventions, and describing the features, functionality, and psychological strategies of these interventions.

Recent Findings

Evidence for the efficacy of DMHIs for SITBs is limited but growing. The strongest support is for DMHIs with a cognitive-behavioral approach, those that target suicidality specifically, and those that target adults rather than adolescents. DMHIs vary in format and level of human support. Human support is commonly in the form of a clinician—peer support is infrequent. DMHIs facilitate safety planning, connect users with crisis support, teach users coping strategies, or encourage self-assessment. CBT-based approaches are the most frequent, but others include mindfulness and problem solving. While no DMHI for SITBs incorporate all evidence-based strategies for suicide prevention, many include several, with the most common being elements of safety planning.

Summary

DMHIs have promise to address high rates of SITBs among young people. We summarize the existing literature and offer suggestions for future research to improve trial methodology, optimize design of DMHIs, and translate DMHIs into practice.

Introduction

Rates of self-injurious thoughts and behaviors (SITBs) have reached unprecedented levels among adolescents and young adults (AYAs). In the USA, suicide is the second leading cause of death among those aged 15–34 [1]. Furthermore, rates of non-suicidal self-injury (NSSI; a leading risk factor for future suicide) are between 17 and 23% and between 13 and 22% in adolescents and young adults respectively [2, 3]. Addressing SITBs, inclusive of suicide and NSSI, among AYA is a public health priority [4].

Many AYAs do not access traditional mental health treatments. Barriers to traditional treatments are well-documented (e.g., cost, geography) [5–7], and specialized evidence-based treatments for SITBs (including dialectical behavior therapy [DBT], cognitive behavioral therapy [CBT] for suicide prevention and attachment-based family therapy) are time-intensive, costly, and trained providers are in limited supply. Consequently, interest has grown in how ubiquitous technologies can be leveraged to make evidence-based interventions more accessible and timely, while also upholding fidelity.

Digital mental health interventions (DMHIs) have promise for risk identification and increasing access to mental health and crisis resources for SITBs. This may be especially true for AYAs since they have high rates of smartphone use and digital literacy [8–10]. Existing research has shown that AYAs have interest in, and are generally satisfied with, digital interventions for SITBs [11•]. In this review, we will provide a summary of extant research focused on the use of technology to intervene in, and respond to, SITBs directly with AYAs. We note that technology-based interventions to support AYAs that are primarily delivered to parents or caregivers are beyond the scope of this review. We answer the following questions: What digital interventions exist? What evidence is there for their efficacy? What formats have these digital interventions taken? What features do they include? What psychological strategies are commonly used?

Summary of recent reviews

There have been a number of recent reviews focused on DMHIs for SITBs. In general, these reviews sought to (1) evaluate digital intervention efficacy in reducing SITBs, (2) explore the quality of these interventions, and/or (3) describe the features, functionality, and psychological strategies of these interventions. We review evidence for each of these lines of inquiry in the sections that follow.

Evidence for the efficacy of digital interventions for SITB

Although there are many commercially available apps for SITBs, most are still relatively early in their development and have not been subjected to rigorous, fully powered evaluations [11•, 12, 13]. In studies that have evaluated DMHIs for SITBs, evidence has been mixed. The strongest support is for the efficacy of CBT and CBT-informed interventions. Indeed, several reviews have shown that Internet-based CBT (iCBT) programs are associated with subsequent reductions in suicidal ideation post-intervention as well as at follow-up periods months later [14•, 15], and that these effects are not moderated by age [16]. There is less support for DMHIs that use other treatment models or individual components of evidence-based treatment models (i.e., mindfulness, problem solving) and for reductions in SITB outcomes beyond suicidal ideation, including self-harm, NSSI, and suicide plans or attempts [17, 18, 19•]. Of the studies focused on NSSI, most have been single-arm pilot trials of DMHIs, with just two randomized trials. In general, trials have shown reductions in NSSI [20, 21], as well as secondary targets (emotion dysregulation and depressive and anxiety symptoms) [20, 22]. However, these DMHIs vary in their duration, their approach, and their measure of NSSI, so it is difficult to make generalizable statements. While there is emerging evidence for small effects of DMHIs on suicide-related outcomes among broad adult populations, the few randomized trials of DMHIs for suicide-related outcomes among AYAs fail to demonstrate significant effects for reducing suicidal ideation [23]. Additionally, many DMHIs focused on suicide prevention do not directly target suicide-related outcomes. Research has shown, however, that DMHIs targeting suicidality directly outperform those that target depression or other comorbid conditions [23]. The effectiveness of DMHIs for NSSI has yet to be rigorously explored.

In summary, existing empirical work supports the efficacy of DMHIs with a CBT-informed approach, those that target suicidality specifically, and those that target adults rather than adolescents, but more work is needed. Studies that have been conducted to date have limitations: (1) The majority of evidence comes from studies with small sample sizes and short follow-up evaluations, making it unlikely for some SITB outcomes like suicide plans and behavior to occur. (2) SITB outcome measurement differs substantially across studies, making it difficult to aggregate evidence especially for outcomes that are often inconsistently defined (e.g., self-harm and NSSI). (3) Reviews of efficacy studies commonly include studies with both adult and adolescent populations, making it difficult to draw clear conclusions about DMHI effectiveness and acceptability [17, 18, 24]. (4) Trials of DMHIs for SITBs are characterized by high rates of dropout, making it impossible to generalize beyond what is likely a highly motivated subset of individuals that could benefit from DMHIs. (5) The majority of studies do not adequately account for diversity within intervention development and evaluation potentially leading to greater gaps in health equity [25, 26].

Features and functionalities of DMHIs

Formats

Digital interventions for SITBs have leveraged different technologies including smartphones, computers, virtual reality, and networked sensors. Formats have included apps, interactive videos, text messaging, games, and chatbots, among others. In general, most DMHIs require a smartphone, a computer, or a device capable of connecting to the internet (e.g., tablet). These interventions include call or text messaging programs [27–31], such as those focused on promoting help-seeking behavior or safety planning [32, 33], web-based programs such as those that provide psychoeducation on SITBs along with activities to reflect on and practice new strategies [20, 34], and mobile or app-based programs that facilitate the learning and practice of evidence-based strategies (e.g., DBT Coach [35]; MyPlan for safety planning [36]) [37–40]. Extant DMHIs have been structured as unidirectional psychoeducational messaging interventions, module-based programs with interactive features, and multimedia interventions involving audio and video. Supportive messages or phone calls are the most common type of digital intervention component for SITBs in the literature [19•]. Often, this messaging is coupled with other elements including psychoeducation, functionalities for learning and practicing skills, charting moods or symptoms, and connecting to crisis services.

Purpose

Several reviews have summarized the common objectives of DMHIs for SITBs [41•, 42, 43•]. For example, a 2021 review described that suicide prevention apps typically have one or more of the following aims: to facilitate safety planning, to connect users with helplines and support, to teach users coping strategies (such as distraction, mindfulness and stress management), and to encourage self-assessment (via mood tracking) [42]. Furthermore, apps often use strategies to facilitate engagement, e.g., through personalization, gamification, and notifications. Of the different functionalities and features, safety planning was most common—serving as the primary or secondary feature of most apps. All apps reviewed included a customizable list of emergency contacts, while 33% had a customizable list of coping strategies, and 20% had self-tracking capabilities (e.g., mood, ideation frequency, and severity).

A recent broad review evaluating the quality, features, functions, and prevention strategies of mobile apps for suicide and NSSI produced similar results [43•]. The authors categorized the purpose of the highest quality SITB mobile apps as follows: (1) providing information about SITBs or mental health, (2) providing emergency resources, and (3) management of urges/behavior. Safety planning was part of 54% of these apps and elements of safety planning such as emergency contacts (83%); education (78%) and suicide or NSSI urge management (63%) were also common. In addition to offering coping strategies like distraction, positive reminders, relaxation, mindfulness, grounding, and acceptance, users could enter their own strategies in most apps [43•].

Therapeutic approach

Digital interventions for SITBs have been informed by a variety of therapeutic approaches and principles. The most used approach follows a CBT model. These include both CBT- and DBT-informed interventions. For example, Blue-Ice is a CBT-based mobile app designed as an adjunct face-to-face therapy for young people who self-harm [22]. The app includes coping strategies rooted in CBT and DBT, including activities meant to improve mood, a mood diary, and safety checks. DBT Coach is also a smartphone app that focuses on DBT skills [35]. Other digital interventions use approaches like acceptance and commitment therapy or have other foci such as problem solving, mindfulness, and emotion regulation. There have also been interventions based on emerging approaches like therapeutic evaluative conditioning [44] and expressive writing [45]. For example, in a game-like app based on aversive conditioning, users are asked to pair self-related words (e.g., my, me) with positive images and images depicting self-injury and suicide with aversive images in 1–2-min sessions [44]. In sum, the most common therapeutic approach for SITB interventions is CBT, but there is significant variety among existing DMHIs for SITBs. At this point, there is insufficient data to compare DMHIs with specific therapeutic approaches and their overall efficacy.

Human support

The extent to which DMHIs for SITBs include human support varies significantly [19•]. Some DMHIs are adjunctive to traditional face-to-face treatments [22, 35, 40, 46, 47], whereas others provide some form of digital human support (e.g., clinician based messaging support) [20, 48, 49], or no human support at all [27, 44, 45]. Messaging-based interventions typically allow individuals to respond to, and interact with, a clinician or designated support person. Web- and app-based interventions [50–52] are commonly designed as unguided self-management tools, with only technical support. Of those that allow for communication, they typically allow for communication between the user and a therapist or trained clinician [43•]. Very few interventions for SITBs involve peers as supporters apart from the national suicide hotline and crisis text-line, where peers are trained to assess and provide specific types of support or assistance.

Though research on DMHIs for mental health more broadly have typically been more effective when they include human support, when considering interventions targeting specific symptoms or disorders, evidence for human support improving outcomes appears more mixed [53]. This may also be the case for DMHIs for SITBs in particular. Research has shown that individuals with SITB may be hesitant to disclose their behaviors with others, and this may translate as a preference for self-guided interventions [11•]. More research is needed to understand the role of human support in SITB-focused DMHIs.

Availability/accessibility

While DMHIs for SITBs are promising and appealing to AYAs, few are widely available for use. Some app-based interventions are locked behind paywalls, and others are available to providers only. Additionally, DMHIs developed and tested through academic research rarely make it to public consumption or do so after years of testing. One review [19•] found that 15% (5/34) of the apps reviewed were available to the public, while 12% (4/34) were available for purchase by users or clinicians. In sum, over half were not available to the public. Another review [43•] noted that most apps were developed by commercial entities, followed by non-governmental organizations (NGOs) and government entities, with substantially fewer developed by universities.

Quality of DMHIs for SITBs

Studies evaluating the quality of DMHIs for SITBs have primarily focused on whether interventions adhere to evidence-based guidelines for suicide prevention. While many DMHIs adhere to some of the suicide prevention best practices, most DMHIs do not adhere to all of the most widely regarded suicide prevention best practices [11•]. For example, in a review of 69 commercial apps (available via Google Play and Apple App Store) for suicide and depression [13], only five (7.2%) apps offered six evidence-based intervention strategies (self-tracking, activity recommendations, psychoeducation, access to social support, referrals to crisis support or helplines, and safety planning), and most targeted only one preventive strategy. Another study examining 66 commercially available suicide prevention apps found that no apps offered all five suicide prevention best practices (lethal means access, access to social support, referrals to crisis support or helplines, therapeutic orientation [e.g., CBT, DBT], and safety planning), and only four (6.1%) of apps incorporated four best practices [11•]. Similarly, in a review focused on the quality of mental health apps for suicidal ideation and NSSI in European commercial app stores, apps deemed to be of “high quality” (those scoring high on Mobile Application Rating System—a scale measuring the quality of mobile health apps by assessing engagement and interactivity, functionality, esthetics, and the quality of information [54, 55]) had at least three evidence-based preventive strategies. However, no apps included all 15 evidence-based strategies assessed. Apps most often provided information about SITBs, information about emergency resources, or facilitated management of crisis situations or behaviors [43•].

Reviews focused on the feasibility and acceptability of DMHIs for SITBs often suggest that there is promise for these resources. AYA feedback is usually evaluated through focus groups, field testing, interviews, and self-report questionnaires [41•]. In contrast to generally high acceptability, many trials of DMHIs for SITBs have high dropout rates. One recent meta-analysis found that 69% (11/16) studies had attrition rates at post-treatment or follow-up of 20% or greater.

Other ways technologies are being used to impact SITBs

While we have primarily focused on DMHIs meant to reduce SITB outcomes directly (or through targets), technology has played a role in facilitating screening and identifying risk. For example, there has been work focused on facilitating assessment on college campuses and during primary care or emergency department visits. The American Foundation for Suicide Prevention developed an online screening that was sent to university students through email to characterize individuals based on tiers of risk. Those that were high risk received personalized feedback and an option to follow up with a counselor. Those that dialogued with a counselor online were more likely to begin treatment, than those who did not [56, 57]. This suggests promise for online screening methods to increase access and promote treatment seeking [58]. Similar methods of screening, tiering, and feedback provision have been used in primary care and emergency departments [59–63]. For example, to reduce re-hospitalization following emergency department visits, researchers developed a conversational avatar system that administers the Virtual Collaborative Assessment and Management of Suicidality and asks clarifying questions [64]. This frees up physician time and enables a comprehensive assessment in a format that patients are comfortable with. A summary of the assessment results is then delivered to emergency department physicians and used to guide recommendations. There have also been efforts to utilize electronic health record data to aid in risk identification [65]. In general, these methods have had moderate success but are better at identifying some SITB outcomes, specifically NSSI and suicidal ideation, than others [66]. Other approaches that show promise include using smartphone or wearable sensors to identify periods of high risk [67–69]; often, these approaches are used to monitor individuals who are on or have been discharged from psychiatric inpatient settings.

Discussion and future work

In general, existing empirical work highlights the promise of DMHIs to reduce SITBs, but findings are mixed, and evidence for certain SITBs is more robust (e.g., suicidal ideation) than others (i.e., suicidal behavior, non-suicidal self-injury). DMHIs for SITBs exist across formats (i.e., web-apps, mobile apps, messaging, immersive technologies) and incorporate myriad psychological approaches (e.g., CBT, DBT, mindfulness, problem solving). We devote the remainder of the discussion to outlining opportunities for future work including suggestions for improving trial methodology, opportunities through design, and translating DMHIs into practice.

Improving trial methodology

One clear need in the SITB digital interventions space is to expand the efficacy literature to include higher risk populations and a broader range of SITB outcomes such as suicide attempts. It is common to exclude individuals at highest risk of suicide (e.g., those with recent suicidal behavior) in studies testing suicide prevention interventions; however, this limits our ability to assess efficacy and acceptability in the populations these interventions ultimately target. Relatedly, studies are needed with larger sample sizes and longer follow-up periods to appropriately capture rare events such as suicide attempts.

It is also necessary for researchers to consider the heterogeneity of target populations and inequities in access to DMHIs. Some young people do not have access to specific modalities for intervention delivery, such as smartphones or home computers [75]. Moreover, interventions may not be designed in the patient’s preferred language or may not be culturally appropriate. Further studies are needed to evaluate feasibility, acceptability, and effectiveness of interventions among specific population groups (e.g., minoritized racial and ethnic groups, youth who identify as sexual or gender minorities) and to adapt or culturally tailor interventions for specific groups [76]. To support studies that include more heterogeneous samples, it is necessary to recruit diverse users to participate in the design process, with attention to adequate inclusion of young people who hold marginalized identities. Specifically, this means prioritizing heterogeneity with regard to age, race and ethnicity, sexual orientation, gender identity, presence of neurodevelopmental disorders (such as autism spectrum disorder, which has been associated with increased suicide risk), firearm ownership and access, and other characteristics. These diverse users should be included in the design and implementation process to increase engagement [73, 74].

Additionally, researchers must carefully consider measurement and operationalization of the aspects of SITBs they want to evaluate. Across studies, researchers assess a wide variety of SITB attributes (e.g., types of behaviors, categories of thoughts, duration, quantity, frequency) and timescales (e.g., past month, past 5 min, current). The diversity of SITB-related attributes and timescales in AYA research means that measurements used across studies are, often, not directly comparable, limiting the field’s ability to make generalizable statements and provide recommendations.

Finally, trials capable of identifying active ingredients of interventions are needed. There are numerous eclectic interventions that blend approaches and evidence-based principles. The impact of specific intervention elements can be detected using modern study designs (e.g., sequential multiple assignment randomized or SMART trials, multiphase optimization strategy or MOST trials) or designs meant to dismantle effects for existing interventions that use a range of clinical approaches [71, 72].

Opportunities for design

Although trials have demonstrated feasibility and acceptability of DMHIs for SITBs, many have high dropout rates which may suggest a survivorship bias in acceptability results and demonstrates that additional design work may be needed to ensure DMHIs for SITBs are meeting the needs of AYAs. Design work should consider who should introduce interventions (e.g., primary care clinicians, mental health professionals, teachers, professional organization websites, social media), how interventions should optimally be introduced (e.g., scripting, infographics), and timing (e.g., at times when risk factors related to suicide are identified). Further work is needed to evaluate the power of brief interventions that do not require ongoing treatment engagement [80].

In addition to addressing dropout rates, the existing literature suggests that interventions targeting SITBs directly outperform those that target secondary outcomes. Thus, there is great potential in developing and testing interventions directly targeting specific SITBs (e.g., NSSI, suicide planning, means availability, capacity for suicide, suicidal ideation). Relatedly, designers should be intentional about selecting specific SITBs to target, because they frequently have different risk factors and available treatments.

An underexplored design area in research on DMHI for SITBs is how and when to integrate human support in SITB interventions. Typically, DMHIs that involve human support outperform those that do not; however, DMHIs with human support are less scalable than those without. Therefore, DMHIs with human support or those that are part of a treatment program in higher levels of care may be more difficult to access. To this end, artificial intelligence has been considered as a possible augmentation to self-guided DMHIs for SITBs, but the role of artificial intelligence also deserves careful consideration. Efforts are needed to address ethical and safety concerns that may arise from artificial intelligence-augmented DMHIs [79].

Translating DMHIs into practice

Moving interventions into practice spaces including clinics, healthcare systems, online and NGOs remains one of the biggest challenges in digital mental health. Research is needed to identify and test implementation strategies that increase uptake and engagement with effective DMHIs [77]. Researchers must consider how and where interventions will be sustained and continually optimized to support continued use and dissemination [78]. At a minimum, this should include studying the cost of intervention development, deployment, and maintenance. Sustainable sources of funding for clinical (non-research) use will need to be identified.

Finally, if research is to make an impact on SITB rates among AYA, increased collaboration is needed among academic researchers, clinicians, and industry in the development and implementation of these interventions. Leveraging expertise in commercialization pathways to bring health technologies to market for the AYAs who need them could increase access and availability to DMHIs for SITBs. However, this should work should recognize and appropriately address barriers to access (e.g., cost, technology access) and ethical and liability concerns associated with granting AYAs access to interventions focused on SITB risk.

Conclusion

In this brief review, we summarized the types of DMHIs that exist to address SITBs, the evidence for their efficacy, the formats taken by DMHIs for SITBs, their most common features, and the psychological strategies they commonly use. Based on the existing evidence base, we feel optimistic about the potential impact of DMHIs for SITBs and identify several areas of focus for future research.