Original Title: Aplicaciones de software para la prevención e intervención en personas con riesgo de suicidio: efectividad, seguridad y coste-efectividad

Authors' objectives: • Assess the effectiveness and safety of mobile apps (such as smartphones and tablets) and desktop apps (web and desktop applications). • Analyze the cost-effectiveness of the apps from the perspective of health and social services. • Provide an estimate of the budgetary impact of integrating these apps into Spain's common portfolio of social networking services. • Consider ethical, patient, social, legal, organizational, and environmental issues related to technology. • Discuss the research needs of patients, caregivers, and healthcare professionals in relation to apps. • Identifying and evaluating the quality of suicide prevention apps in the Spanish context.

Authors' results and conclusions: Effectiveness/safety One SR and 13 RCTs (n = 2952) were included. No significant differences were found in deaths by suicide (3 studies, very low quality of evidence: ⨁◯◯◯) and suicide attempts (RR = 0.85, 95%CI: 0.48, 1.52; 9 studies, very low quality: ⨁◯ ◯◯). At the end of the intervention, small intensity significant reductions were obtained in suicidal ideation (g = -0.21, 95% CI: -0.35, -0.07; 12 studies, low quality ⨁⨁◯◯), hopelessness (g = -0.36, 95CI %: -0.52, -0.20; 4 studies, low quality ⨁⨁◯◯), depression (g = - 0.20, 95% CI: -0.35, -0.04; 9 studies, moderate quality: ⨁⨁⨁◯) and worry (g = -0.35, 95%CI: -0.46, -0.24; 3 studies, moderate quality: ⨁⨁⨁◯), while the reduction in anxiety was slightly above significance (g = -0.17, 95%CI: -0.34, 0.01; 5 studies, moderate quality: ⨁⨁⨁◯). In the follow-up (between 8-52 weeks) the number of studies is smaller and the evidence is even weaker. The results were significant except for depression and suicidal ideation (in the latter the effect was significant when the study with the longest follow-up of one year was excluded). Subgroup analyzes do not allow for stronger conclusions to be drawn. In terms of safety, there was no significant difference in the number of safety phone calls made to participants with a suicidal ideation score above a risk threshold (RR = 0.92, 95% CI: 0.61, 1.38; 5 studies, very low quality: ⨁◯◯◯). The study with the longest follow-up (1 year) had a significantly worse outcome for the intervention. Environmental, ethical, legal, organizational, patient and social considerations In order for apps to be well accepted and used by people at risk, they must be easy-to-use, attractive, highly customizable, low-demanding, and stress-free, provide professional and social support resources, and meet the necessary requirements. Security and confidentiality should be ensured. Cost-effectiveness A study conducted in the Netherlands, based on one of the included RCTs, showed that, from a societal perspective, the intervention was dominant (more effective and less expensive than usual treatment), with an incremental cost-effectiveness ratio of -€34,727 owing to an additional significant reduction in suicidal ideation. From the perspective of the healthcare system, the intervention would not be dominant but would add a cost of €663 per participant, resulting in an ICER of €4422 for an additional significant response. The study did not include the cost of developing the program, and the sensitivity analysis did not address the uncertainty of the data used, such as the effectiveness of the intervention, the prevalence of suicidal ideation, or direct and indirect costs. Budget impact analysis The gross Budget impact at 5 years would be €26,690, with no limitation on the number of app users. Conclusions • Evidence of the effectiveness of the apps evaluated in reducing suicide attempts and completed suicides is of very poor quality, and no conclusions can be drawn. For attempts, the overall point estimate offers a 21% reduction (when studies with high risk of bias are excluded), but the confidence interval includes a detrimental effect of 60% increase. • In the case of suicidal ideation, depression and hopelessness, the quality of the evidence is higher, between low and moderate, although the effects observed are of small intensity and therefore of uncertain clinical relevance. The subgroup analyzes show certain trends that suggest that these results could be influenced by methodological factors (type of comparator, metric and questionnaire used), but no firm conclusion can be drawn either. Anxiety and worry, considered important but not critical for decision-making, also showed significant results of low intensity. • The safety results (people with high suicidal ideation scores at some point in the study) are also subject to a significant level of uncertainty due to the scarcity, heterogeneity and imprecision of the results, so the same can be said of the risk balance/benefit. • The apps' acceptability and adherence are based on their nature as complementary resources to the usual health services, with a simple design and attractive functionality that allows personalized attention without being demanding, provides the possibility of professional/social contact and promotes strategies, psychology of emotional regulation and coping with stressful situations. • It is not possible to draw conclusions about the cost-effectiveness of these interventions, due to the existing uncertainty regarding the most important outcome variables (suicide attempts and deaths) and the lack of data on the use of resources in our country. • The cost and budgetary impact of implementing an exclusively self-guided suicide prevention app (without additional clinical care than usual) and without including promotion/dissemination costs, is relatively low.

Authors' recommendations: There is considerable uncertainty about the risk/benefit balance (i.e., uncertain benefits in critical variables, doubts about long-term safety) and about the cost-effectiveness of the intervention, which, combined with the existence of numerous ongoing studies whose results will be available in the coming years, suggests that the inclusion of these products in the portfolio should be postponed until more scientific evidence is available.

Authors' methods: • Three independent systematic reviews about: 1) Evaluation of effectiveness and safety (MEDLINE, EMBASE, CINAHL, and PsycINFO databases). Outcome variables: suicide; suicidal behavior; suicidal intent; suicidal ideation/thinking; selfperceived suicide risk; using/seeking mental health services; associated mental symptoms (eg, depression, anxiety, psychotic symptoms; impulsiveness; hopelessness; mental health-related quality of life; satisfaction of the user and the health professional; adverse events related to the app, as defined in the included studies. Studies that do not include suicidal behavior, intention, or ideation were excluded. Where available data allowed, a meta-analysis was conducted for each outcome variable. 2) Economic sstudies (same databases). 3) Ethical, patient, social, legal, organizational, and environmental issues related to technology (MEDLINE, EMBASE). • Costs analysis: The costs associated with developing and maintaining software for mobile devices and computers, aimed at preventing suicide among the population at risk, were estimated. Information was obtained from the "Más Caminos" mobile application, developed by the Regional Hospital of Malaga's Clinical Management Unit with the cooperation of Infobiotic and MediaDisplay Software (www.mascaminos.es). • Budget impact analysis: An analysis of the budgetary impacts of developing and maintaining software to prevent suicides was undertaken, with a 5-year time horizon, from the perspective of the health system.

Project Status: Completed

Year Published: 2023

URL for published report: https://sescs.es/wp-content/uploads/2015/09/66_SESCS_APPS_SUICIDIO_DEF_NIPO.pdf?x68814

Requestor: Ministry of Health

English language abstract: An English language summary is available

Publication Type: Full HTA

Country: Spain

Organisation Name: Canary Health Service

Contact Address: Dirección del Servicio. Servicio Canario de la Salud, Camino Candelaria 44, 1ª planta, 38109 El Rosario, Santa Cruz de Tenerife

Contact Name: sescs@sescs.es

Contact Email: sescs@sescs.es