Priorities for suicide prevention: balancing the risks and opportunities of internet use
Minimising the risks of the internet while harnessing its potential for good is one of the most significant emerging challenges for suicide prevention. This research explored how people with suicidal feelings use the internet, and its impact on their suicidal behaviour.
About the research
Many cases of internet-related suicide have been reported in the popular and academic press. These highlight the existence of pro-suicide discussions and online information about methods, leading to concern that the internet can promote suicide. At the same time, there has been speculation about the potential to use the internet as a way of reaching vulnerable people through online help sites, peer-support, and as a means of delivering mental health interventions.
However, little is known about how many people use the internet when they are feeling suicidal, why they do this and how they interpret the material that they view. Understanding when, how and for whom the internet is a positive or negative resource is paramount.
This research gathered the experiences of over 1,000 people who had used the internet for suicide-related purposes or knew someone who had used the internet when planning suicide. This was achieved by surveying 8000 young people in their 20s and over 1500 people of all ages who were hospitalized following suicide attempts; and by interviewing over 60 people, including those who had used the internet in the context of suicidal feelings or self-harm, as well as bereaved family or friends. Clinicians were also interviewed about their experiences of asking patients about internet use when making assessments of suicide risk.
There is an urgent need to further develop regulation, policy and best practice around internet use and internet curatorship. This policy report recommends a number of strategies ranging from working with search engine companies, transforming online help provision, and encouraging clinicians to explore patients’ internet use and support those at risk. There is also an urgent need to encourage and promote responsible practice by all internet users.
How the evidence informs policy and practice
Some clinicians were unaware that individuals used Wikipedia and medical sites to obtain information about methods; their knowledge of chatrooms and social media was also limited. While they found it acceptable to ask patients about suicide-related internet use, at times they avoided asking this directly and several were worried that asking could ‘put ideas into a patient’s head’. However, clinicians may be in a unique position to guide internet use, and knowing about internet activity could help to identify high risk patients and contribute to clinical decision-making so that patients receive better support.
‘When you actually read what [helpsites] have to say, its signposting, suggesting your GP. These are not what I would consider to be crisis interventions. When you’re two hours away from taking those pills, make an appointment with your GP – it’s not thought through…’ Participant
Summary of findings
In a population survey of 21 year olds, of the 248 participants who had made suicide attempts (6% of the overall sample), almost three quarters reported some kind of suicide-related internet use at some point in their lives. One in five had accessed sites giving information on how to hurt or kill yourself, though most of these had also visited help-sites.
In a clinical sample of over 1500 patients who presented to hospital following a suicide attempt, 8% said they had used the internet in connection with their attempt. This percentage was higher for younger patients (12% of those aged 16-24 years) and those who had self-harmed with high suicidal intent (24%).
For most of those interviewed in the clinical sample, the main purpose for going online was to research methods of suicide, sometimes in great depth. While this did not always lead to action, it made individuals vulnerable by validating their feelings, legitimising suicide as a course of action, and providing knowledge about methods of suicide. Half of those interviewed in the clinical sample planned and carried out a suicide method, based on their online research; some had purchased materials online. However, in some instances, information about methods discovered online was found to be ‘off putting’, causing some individuals to rule out particular methods of suicide.
There is currently a large unrealised potential to deliver help to suicidal and distressed individuals online. Users at lower levels of severity wanted solutions and frequently looked for these; some simultaneously checked suicide methods and help material, the two apparently competing. There is a strong presence of formal help organisations online, and yet help provision only engaged and met the preferences of a small group of study participants.
Implications for the internet industry
- The internet industry should continue to work with regulators and the Government to explore ways of restricting access to sites that primarily exist to promote suicide or self-harm (pro-suicide content) and especially pro-suicide chatrooms.
- Wikipedia should review its policies and guidelines to cover regulation of potentially harmful suicide related content.
- Hosts and moderators of blog sites and discussion forums should ensure policies and guidelines are in place to cover potentially harmful suicide-related content.
- Ongoing dialogue within the internet industry should be encouraged so as to develop joined-up approaches, such as putting in place preventative strategies based on search algorithms and predictive searching, or structuring search data to optimise supportive sites where suicide-related search terms are entered.
- While all internet users should be encouraged to adopt safe practices, the internet industry has a particular responsibility for developing and promoting safe internet use. This could be achieved through moderators of online community forums ensuring that harmful suicide related content is prohibited in their rules for contributors and that there are processes by which users can report harmful content to be considered for removal. Strategies should also involve raising awareness around the availability of controls that can be used to block access to suiciderelated material.
Summary of Key Findings
- The internet is often used by people who self-harm and/or attempt suicide to explore possible methods and read others’ personal accounts of suicidal feelings and behaviour.
- Material that is or can be harmful is abundant and easily accessed, including from popular information sites (such as the highly accessed ‘Wikipedia’), general and specialist medical sites, question and answer sites; and through social media channels.
- The internet is also used as a forum for seeking help. While some individuals derive peer support from some sites, considerable dissatisfaction was expressed with formal online help. Information online can both increase and decrease an individual’s risk of suicide.
- This research lends weight to previous suggestions that the internet may pose a particular threat to young people. Suicide-related use was more prevalent amongst young people and more often included the use of social media.
Biddle L, Derges J, Mars B, Heron J, Donovan J, Potokar J, Piper M, Wyllie C, Gunnell D. Suicide and the Internet: Changes in the accessibility of suicide-related information between 2007 and 2014. Journal of Affective Disorders, 2016. 190 p 370-375.
Mars B, Heron J, Biddle L, Donovan J, Holley R, Piper M, Potokar J, Wyllie C, Gunnell D. Exposure to, and searching for, information about suicide and self-harm on the Internet: Prevalence and predictors in a population based cohort of young adults. Journal of Affective Disorders, 2015. 185 p 239-245.
Gunnell D, Derges J, Chang S-S, Biddle L. Searching for suicide methods. Crisis, 2015. 36(5): 325-331.
Prof Jenny Donovan, Dr Jon Heron, Dr Becky Mars, Dr Prianka Padmanathan, Dr John Potokar (University of Bristol); Dr Carlie Goldsmith (Samaritans); Mr Martyn Piper (PAPYRUS Prevention of Young Suicide); Mr Chris O’Sullivan, Dr Rachel Holley (advisers); the Liaison Psychiatry teams at Bristol Royal Infirmary and Southmead Hospital, Bristol; and the Avon Longitudinal Study of Parents and Children (ALSPAC).
All material presented is drawn from independent research commissioned and funded by the Department of Health Policy Research Programme (“Exploring the use of the internet in relation to suicidal behaviour: identifying priorities for prevention”: PRP023/0163). The views expressed are those of the authors and not necessarily those of the Department of Health.
Implications for providers of online help
- A review and redesign of formal online help provision is required. Online help provision should:
- be tailored to the population who seek it (bearing in mind why some individuals may seek virtual rather than real world help) and not simply a rolling out of offline services.
- place less emphasis on signposting initially, focussing also on providing more immediate responses/ solutions within the online environment. (These may include opportunities for self-help including self-directed therapy, assistance with crisis planning, interactive online chat with a trained advisor, or brief clickable online crisis interventions.)
- provide age-appropriate material for young adults.
- Providers of online help forums, discussion groups and blogs should ensure that site moderation is in place to safeguard the benefits of peer support and the ‘safe spaces’ provided by these communities.
- Providers should seek to develop new online help approaches that will effectively engage those in active suicidal crisis, who typically avoid help at this time.
- All moderators of online community forums should be made aware of the National Suicide Prevention Alliance guidance for online moderators, recognising that users may express suicidal feelings not only on “help” forums but on any online forum.
Implications for clinicians and providers of clinical practice guidelines
- Training should be provided to clinicians to increase their understanding of the online environment and the nature and impact of suicide-related internet use. This should include awareness of the potential for harm and for benefit, the types of sites accessed, and guidance about how and when to respond to disclosures of suicide-related internet use.
- Clinicians could better support patients to recognise how and when their internet use is harmful, and to develop personalized online safety practices as part of their crisis planning. This could be supported by technology, e.g. purpose built blocking apps.
- Internet use is a marker of severity and suicidal intent. Clinicians should therefore explore an individual’s internet use as part of a ‘suicide risk assessment’, in order to identify ‘at risk’ individuals and develop appropriate treatment plans.
- There are obvious risks associated with medical sites and open access research containing information on suicide methods. Site curators/moderators should consider strategies to reduce these risks, such as producing publication guidelines for researchers, and increasing the use of registration details (particularly on professional medical sites) to access certain content.
Policy Report 07: 2016
Contact the researchers
Dr Lucy Biddle
Senior Lecturer in Medical Sociology, University of Bristol:
Dr Lucy Biddle, Dr Jane Derges, Prof David Gunnell (University of Bristol)
Dr Stephanie Stace, Jacqui Morrissey (Samaritans)