None of the apps enquired about risk factors, triggers, or protective factors, and only one checked past history of suicide. Only 11 apps included all safety plan steps as developed by Stanley and Brown [ 41 ].
In seven apps, the safety plan was one component in a more comprehensive suicide prevention strategy that included educational articles, mood and suicidality assessment, and access to support network and crisis helplines. The information in 49 apps was specific for one or several countries, limiting its global usability.
In 15 apps, including two depression management apps and 13 suicide prevention apps, this functionality was included in a safety plan. All but one app were developed by public institutions or non-governmental organizations NGOs.
Three apps specifically targeted veterans and three apps, university students. In general, there were marked variations regarding compliance with HONcode principles Table 5.
Depression management apps were significantly more compliant than suicide prevention apps in indicating the qualifications of people involved in app development, and backing up effectiveness claims with evidence published in peer-reviewed journals or claimed to be in the process of analyzing research data.
Three additional apps two iOS and one Android app offered fixed, predetermined advice using a chatbot-style format and were not included in our analysis. In two of these apps, the chatbot was one of the features offered by the app, while in the other six apps the chatbot was the main component. All chatbots initiated a conversation reminding the user they should not use the app if they were feeling suicidal.
A systematic assessment of 69 depression management and suicide prevention apps revealed that only five apps offered all six evidence-based strategies for suicide prevention, with comprehensive and holistic support. Several studies appraising the quality of health apps consistently indicated that most apps do not provide evidence-based information or decision-support strategies and may not be safe to use [ 51 , 52 , 53 ]. Appraisals of mental health and suicide prevention apps showed similar results [ 34 , 54 ].
Larsen et al. Similarly, De la Torre et al. Most apps targeted only one aspect of suicide prevention, based on strategies recommended by evidence-based clinical guidelines [ 11 , 37 , 38 , 39 , 55 ], and hence, may be inadequate and potentially dangerous if used as a standalone intervention. Mobile apps could offer tools for real-time monitoring of at-risk persons and access to support whenever it is needed; however, apps should be seen as an addition to an ongoing patient-provider relationship and never as a replacement.
Six apps contained erroneous crisis helpline numbers, posing a potentially serious risk for users. Our findings show information may not be corroborated and clearly demonstrate the lack of self-regulation and self-monitoring of the industry.
Crisis helplines are readily available in a variety of platforms and can easily be verified by developers and app stores before apps are launched. The current review and approval processes established by the app stores prior to the launch of a new app do not prevent poor-quality apps from being released [ 57 , 58 ].
Furthermore, app developers seem to select an app category according to business models and marketing strategies, with no transparency or real oversight on such decisions. While this app development model may work best for less sensitive categories, health apps require appropriate evaluation of content alongside the technical aspects of the app.
There are currently no consequences for releasing health apps containing inaccurate or non-evidence-based information. At the same time, there are increasing calls to improve health app oversight, from independent expert assessments and app libraries [ 59 , 60 ], to higher standard of app development and quality assurance mechanisms, such as voluntary or compulsory certification or regulation prior to app release to the public [ 61 , 62 ].
App libraries, such as Psyberguide [ 59 ] or the new NHS Apps Library [ 63 ], provide a curated, although very limited collection of apps for users to choose from, while official regulatory bodies FDA and European CE marking directives have to date approved only eight mental health apps [ 64 ].
On the other hand, app assessment tools, such as the newly developed APA framework [ 60 ], place the onus of assessing app quality and efficacy on the app users or their healthcare providers. Although these are important steps toward improved app quality, they are post-launch assessments that do not prevent low-quality apps from reaching end users.
This study has several strengths. We followed rigorous systematic review methodology for app search and selection, using a specialized search engine to retrieve the maximum number of apps without country restrictions, increasing the generalizability of our findings. The search strategy retrieved apps available worldwide as well as apps restricted to specific countries.
We assessed the apps using a comprehensive set of criteria backed by evidence-based clinical guidelines, and trustworthiness of information by adapting HONcode principles. There were some limitations. By using stringent inclusion criteria, we might have missed apps targeting other mental health disorders providing suicide prevention strategies.
The search strategy was limited to four app store categories therefore we may have missed relevant apps available in other categories. Although we aimed to download all eligible apps, we were unable to do so for two Android apps. We did not assess the in-app paid additions offered by depression and mental health management apps as they appeared to be not relevant to suicide prevention and may have missed important pay walled features.
Our methods did not include a systematic literature review to identify apps. Therefore, we may have missed some apps developed and tested by research groups that have either not been published in app stores or were no longer available on app stores at the time of our study. There is a growing number of apps offering suicide prevention strategies to persons at risk, although few provide a comprehensive approach including all six strategies recommended by guidelines.
These apps should complement an ongoing patient-provider therapeutic relationship and not replace professional advice. Users should exercise caution when accessing crisis helplines using a suicide prevention app.
An effort involving government regulatory agencies, the app development industry, healthcare providers, and the public is urgently needed to create an improved and more transparent model for development and publication of health apps. All data generated or analyzed during this study are included in this published article and its supplementary information files. World Health Organization. Depression and other common mental disorders: global health estimates.
Accessed 3 Jan Naghavi M. Global, regional, and national burden of suicide mortality to systematic analysis for the Global Burden of Disease Study Article PubMed Google Scholar. Matthay EC. Suicide falls by a third globally. Cross-national prevalence and risk factors for suicidal ideation, plans and attempts. Br J Psychiatry. Screening for suicide risk in adults: a summary of the evidence for the U.
Preventive Services Task Force. Ann Intern Med. Suicide attempt as a risk factor for completed suicide: even more lethal than we knew. Am J Psychiatry. Article Google Scholar. Risk factors for suicide in individuals with depression: a systematic review. J Affect Disord. Suicide prevention strategies: a systematic review.
Suicide prevention strategies revisited: year systematic review. Lancet Psychiatry. An evaluation of crisis hotline outcomes. Part 2: Suicidal callers. Suicide Life Threat Behav. Some subtypes have five tiers of coverage. Others have four tiers, three tiers or two tiers. This search will use the five-tier subtype. It will show you whether a drug is covered or not covered, but the tier information may not be the same as it is for your specific plan.
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Utilization management. Update provider data. While "A Friend Asks" focuses on training users to recognize the signs of suicide ideation in others, MY3 Android, iOS is targeted squarely at those who are depressed or suicidal themselves.
MY3 aims to keep you connected to your core network, asking you to choose three close contacts, such as friends, family, loved ones or your therapist, that you feel comfortable reaching out to whenever you feel down. In addition, MY3 helps you build your own Safety Plan, asking you to think through and list your own warning signs, coping strategies and support network, so that you can easily act when you recognize your warning signs. In addition, the app includes a wealth of suicide prevention resources and contact information for the National Suicide Prevention Lifeline.
In addition, the app includes helpful links to more info, a quick dial function for the National Suicide Prevention Lifeline, a variety of Texas-based hotlines and sections for Veteran's and LGBTQ resources. In addition, the app comes with a dialer to the National Suicide Prevention Lifeline and a link to the QPR Institute, which offers suicide prevention training. Territories for mental and substance use disorders. Ellos escuchan. They Hear You. Subsite Title Publications and Digital Products.
Store Navigation Start a New Search. Share Buttons. Page title Suicide Safe Mobile App. Main page content. App Features.
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