Social media and suicide prevention: findings from a stakeholder survey.

BACKGROUND: Suicide is a leading cause of death, particularly among young adults. The rapid growth of social media and its heavy use by young adults presents new challenges and opportunities for suicide prevention. Social media sites are commonly used for communicating about suicide-related behavior with others, which raises the possibility of using social media to help prevent suicide. However, the use of social media varies widely between different suicide prevention advocates. The role this type of intervention should play in a community's overall suicide prevention strategy remains a matter of debate. AIM: Explore the ways in which stakeholders use social media for suicide prevention and assess their views about the potential utility of social media as a suicide prevention tool.
METHODS: A 12-week stakeholder consultation that involved the online administration and completion of surveys by 10 individuals who conduct research about suicide and social media, 13 organizations that use social media for suicide prevention purposes, and 64 users of social media.
RESULTS: Social media was seen as a useful means of delivering a range of suicide prevention activities. Respondents reported that the key benefits of social media were the opportunity to obtain emotional support from others, to express one's feelings, to talk to others with similar problems, and to provide help to others. The social media site believed to hold most potential for delivering suicide prevention activities was Facebook. There were concerns about potential risks of social media, but respondents felt the potential benefits outweighed the risks.
CONCLUSIONS: Social media was recognized by different types of stakeholders as holding potential for delivering suicide prevention activities. More research is required to establish the efficacy and safety of potential social media-based interventions and ethical standards and protocols to ensure that such interventions are delivered safely need to be developed and implemented.

Introduction

Suicide is a leading cause of death,particularly among young people. The prevalence of non-fatal suicide-related behavior - one of the most important risk factor for death by suicide - may be up to 20 times higher than fatal suicidal behavior; globally an estimated 10 to 20 million non-fatal attempted suicides occur each year.[1] Preventing suicide is an important public health objective for all countries.

Different types of media can potentially play an important role in the prevention of suicide-related behaviors.[2] Over the last decade the internet had become increasingly influential in the lives of the world’s citizens,particularly young adults in high- and middle-income countries. Internet users now access social media platforms to create and exchange their own content.[3,4] These platforms include collaborative projects (e.g. Wikipedia), blogs and microblogs (e.g. Twitter),content communities (e.g. YouTube), social networking sites (e.g. Facebook), virtual game worlds (e.g. World of Warcraft), and virtual social worlds (e.g. Second Life).

The growth of social media presents a new set of challenges for the field of suicide prevention. Young people often express their suicidal feelings on social networking sites and blogs, and they occasionally use these media to find out about suicidal methods or to make suicide pacts with like-minded individuals.[5] This raises a series of questions about the potential use of social media to help in the effort to prevent suicide.[6] The aims of this study were to explore the ways in which stakeholders use social media for suicide prevention and to assess the potential utility of social media as a suicide prevention tool.

Methods

This was a 12-week stakeholder consultation that involved the online administration of surveys to three classes of respondents: (a) individuals who conduct research about suicide and social media; (b) organizations and agencies that use social media for suicide prevention purposes; and (c) users of social media.

Partiipant recruitment

The identification of survey participants is shown in Figure 1. Researchers and organizations were identified using a snowball sampling technique. An initial list of stakeholders was identified from a search of the peer-reviewed literature[5] and an internet search.[7] Each of these stakeholders received a direct email inviting them to participate in the survey and asking them to identify other individuals or organizations who had conducted research about suicide and the media or used social media as a vehicle for suicide prevention activities. These recommended individuals and organizations were also asked to complete the survey. In total 44 researchers and 69 organizations were identified and invited to participate in the survey.

Individual users of social media were identified using a two-stage respondent-driven sampling (RDS) process[8] that has been shown to have the capacity to reach large numbers of social media users.[9] The survey was advertised on the website, Facebook page, and Twitter feed of the Orygen Youth Health network and its partner organizations, which primarily serve Australian youth. Respondents were then asked to re-post the survey using any form of social media that they normally use. As an incentive, participants were given the option of entering a draw to win an iPad.

Research questinnaires

The survey is composed of three separate online questionnaires that were specifically developed for this study. These questionnaires have been described in detail elsewhere,[10] and are available at the following link: http://www.youngandwellcrc.org.au/wp-content/uploads/2014/07/Robinson_2014_Suicide-and-Social-Media-Report-of-the-Stakeholder-Consultation.pdf. The first questionnaire was designed for people who conduct research about suicide and social media; it includes 31 items (6 dichotomous, 13 multiple choice, 7 using a 5-point Likert scale, and 5 open-ended) about demographic characteristics, about the nature of their research, and about their views on conducting research about suicide and the media. The second questionnaire was focused on organizations and agencies that use social media for suicide prevention; it included 40 items (6 dichotomous, 13 multiple-choice, 13 using 5-point or 6-point Likert scales, and 8 open-ended) about the nature and purpose of the organization, about the ways the organization employs social media for suicide prevention, and about their perceived utility of using social media for suicide prevention. The third questionnaire was for the users of social media; it included 34 items (11 dichotomous, 9 multiple-choice, 12 using 5-point or 6-point Likert scales, and 2 open-ended) which asked respondents about their demographic characteristics, about their use of social media, about the reasons they use social media (e.g. obtaining information, emotional support, or for seeking professional help), about the ways they have used social media to help others, and about their own help-seeking offline (if any). Each group was asked about their views on social media and suicide, about which types of social media they considered to hold the most potential for preventing suicide, and about the potential risks and benefits of using social media as a suicide prevention tool.

Statitial methods

Data were entered into SPSS and frequency tables generated for each variable. Percentages are reported to the nearest whole number.

Results

Response rates

Of the 44 questionnaires sent out to researchers, 11 were returned and 10 (23%) of them were sufficiently complete to be included in the analysis; this included responses from three researchers based in Australia,two in the United States,and one each in Belgium, Hong Kong, Israel, the Netherlands, and the United Kingdom. Of the 69 questionnaires distributed to organizations, 13 (19%) were returned and included in the analysis; this included responses from five organizations in Australia,three in the United States, two in the United Kingdom, and one each in India, Ireland, and Norway. Seventy-six questionnaires were returned by users of social media, 64 of which were sufficiently complete to include in the analysis (though the number of respondents who answered each set of questions varied); almost all of these respondents were living in Australia.

Views of researchers

Of the ten researchers that completed questionnaires, nine indicated that the primary focus of their work was on suicide and the media, including social media. Eight reported having previously conducted research into suicide and social media, six reported that they were currently conducting research into suicide and social media, and six reported that they were planning to conduct this type of research in the future. Twitter was the most frequently used social media platform; seven respondents reported that they used Twitter in their suicide prevention work ‘quite often’ or ‘frequently’. This was followed by Facebook and YouTube; six of the 10 researcher respondents indicated that they used these social media platforms ‘quite often’ or ‘frequently’.

All respondents indicated that there is currently insufficient research about the effects of social media-based interventions on suicide risk and about the ways in which social media can be used to support people bereaved by suicide. The most commonly cited barriers thought to contribute to this lack of research included methodological and ethical issues. The following topics were rated as being either a ‘high priority’ or a ‘very high priority’ for future research about suicide and the media:

• Examining the relationship between suicide and social media (9 of the 10 respondents).

• Examining the ways people use social media to talk about their experiences of feeling suicidal (8 respondents).

• Examining the effects of social media-based intervention on suicide risk (8 respondents).

• Examining the ethics or safety of delivering suicide prevention programs via social media (8 respondents).

• Examining the ways in which people use social media to talk about the experience of being bereaved by suicide (7 respondents).

• Intervention studies examining the ways social media can be used to support people bereaved by suicide (6 respondents).

Views of organizations

Of the thirteen organizations that returned questionnaires,one was government-based and the remaining twelve described themselves as ‘not-for-profit’. Ten organizations stated that their primary purpose was suicide prevention, two stated that their primary purpose was the prevention or treatment of depression, and one described its primary purpose as ‘education’.

Facebook and Twitter were the most commonly used social media platforms by these organizations. All thirteen organizations reported using social media for raising awareness about suicide, five used social media for advocacy purposes, four provided online counselling, and three facilitated online peer support. Six organizations reported hosting online activities or discussion forums specifically about suicide and its prevention, five reported hosting blogs discussing suicide prevention, four reported hosting discussion forums about other mental health issues, and four reported hosting blogs about other mental health issues. None of the organizations hosted virtual game sites.

Seven of the thirteen organizations employed a marketing professional to promote their social media site,three used marketing professionals to keep their site up to date,and another three used a trained volunteer for this purpose. In most cases the organization’s social media site was updated daily. All but one of the organizations reported having a mental health professional moderate their social media sites; in 11 of these 12 organizations the site was moderated at least once a day by a trained staff member or volunteer.

Ten of the organizations reported that their social media page prominently displayed details of a crisis line and/or other information regarding emergency services in the host country; four reported having a prominent link that directly connected site visitors with crisis response services. Six organizations reported having a disclaimer indicating that they do not provide assistance 24 hours per day and that they are not a counselling site. Five organizations had clear protocols of safe and respectful online behaviour which indicate what action will be taken if a user does not comply with these guidelines (usually deleting posts or blocking a user from the site). And three sites had a code of ethics about acceptable behaviour of site users.

Respondents from the organizations were asked how beneficial they considered their social media site(s) to be. Of the eleven organizations that responded to these questions, all reported social media to be either ‘somewhat beneficial’ or ‘very beneficial’ to both their organization and to the target audience; ten of them considered the site ‘somewhat beneficial’ or ‘very beneficial’ to people at risk of suicide.

Views of social media users

The most commonly used social media site among respondents was Facebook,followed by Twitter. Forty-seven media user respondents provided information about their demographic characteristics: 66% were female, 53% were aged 30 or under, 57% were engaged in either full-time or part-time work, 28% were full-time students, and 15% were unemployed.

Fifty-six media users provided information about mental health issues: 71% reported having felt suicidal at some time in the past, 79% had sought help from a friend for an emotional or mental health problem, 71% had received professional help for an emotional problem, 41% had called a telephone helpline, 88% had encouraged a friend or peer to seek professional help for a mental health problem,and 70% reported having supported someone who had been suicidal or bereaved by suicide at some time in the past.

Thirty-seven per cent (22/59) reported having used social media for an emotional problem related to suicide. Among these 22 individuals, the reported benefits of social media included its ability to provide a platform for them to express their feelings (91%), receiving emotional support from others (82%), talking to others with a similar problem (73%), and helping others (73%).

Asked how often they used different social media sites to obtain professional help for an emotional problem, none of these 22 respondents reported ‘quite often’ or ‘frequently’; 7 (32%) reported ‘almost never’ or ‘occasionally/sometimes’; and 15 (68%) reported never using social media to obtain professional mental health services. Of the 7 who had used social media to access professional help, the platforms most commonly used for this purpose were Facebook and Twitter.

Overall, 64% (14/22) of users reported feeling better after posting their feelings on social media, 35% (20/57) reported encounters with sites that they found unhelpful or harmful, and 25% (14/57) reported negative experiences when using social media for help-seeking or sharing their feelings.

Comparison across groups

Table 1 shows the responses of the three groups of respondents to questions about the role of social media in suicide prevention.

As shown in Table 1A and 1B,all three groups of respondents consider Facebook, Twitter, and YouTube potentially useful tools for preventing suicide and for helping persons bereaved by suicide.

As shown in Table 1C, there were differences in the perceived importance of social media for different types of suicide prevention activities both within each group of respondents and between the three groups of respondents. All groups rated social media as highly important in the provision of information and promotion of activities but the groups differed in their opinions about the usefulness of social media for other types of suicide prevention activities. Social media users emphasized the value of social media as a source of risk assessment tools and mutual support; organizational respondents highlighted the use of social media for providing mutual support and sharing of experiences; and researchers emphasized the use of social media for advocacy and awareness raising. Overall,social media were considered somewhat less useful as a means of fund-raising, sharing inspirational messages, volunteer recruitment, and providing professional support.

As shown in Table 1D, respondents in all three groups expressed concerns about the potential risks of social media-based suicide prevention efforts. There were differences in the level of concern between the three groups, though in most cases these differences did not reach statistical significance due to the small sample sizes. All three groups expressed concerns regarding the ability of site administrators to operate safe and effective interventions online.

Finally, researchers and organizational respondents were also asked to rate how strongly they agreed with the statement that ‘the potential benefits of using social media for suicide prevention outweigh the risks’. Sixty per cent of researchers agreed or strongly agreed with this statement, compared with 73% of the organizational respondents. Social media users were asked a parallel (reversely worded) question about the extent they agreed or disagreed with the statement ‘the risks of using social media for suicide prevention outweigh the potential benefits’; of the people who responded to this question,44% (21/48) either disagreed or strongly disagreed versus 27% (13/48) who agreed or strongly agreed.

Discussion

Main findings

This study reported on the findings from a small-scale survey that sought the views of researchers, organizations, and social media users regarding the potential for social media as a platform for suicide prevention. All three groups believed that social media, in particular social networking sites such as Facebook, held significant potential in this regard. Whilst possible risks were highlighted,each group believed that the potential benefits outweighed the risks.

Perceived benefits of social media

The benefits identified by the current study centred on the ability of people to use social media to express their feelings in a safe and supportive environment and to receive support from others who have had similar experiences. Respondents also highlighted the value of social media not just as a platform to seek help, but also as a platform to provide help to others, a finding that supports the results of a previous study, which reported that social media users found the ability to help others to be of therapeutic value in and of itself.[11] Thus social media seems to provide the opportunity for a beneficial dynamic exchange of roles that is not possible with face-to-face therapy.

The majority of the user respondents reported having sought help from professionals for an emotional problem,but they did not report using social media in this way. Given the lack of representativeness of our sample it is hard to generalize this finding,but it may help dispel concerns that young people are turning to online sources of help instead of seeking face-to-face assistance from professionals. Social media may have the potential of providing a useful adjunct to traditional treatment. Health professionals need to look for ways to engage in a dialogue with people who use suicide and self-harm websites so that professional expertise and electronic media can be appropriately integrated.[11,12,13]

A final benefit identified by respondents was the potential to intervene promptly if someone expressed suicidal feelings or posted a suicide note online. Two previous studies cited this as a unique benefit of social media.[14,15] One of these reports[14] described a successful intervention in a suicide attempt following the posting of a suicide note on Twitter.

Perceived risks of social media

Although respondents considered the benefits of using social media for suicide prevention to outweigh the risks, the potential risks still need to be taken seriously. Previously reported concerns about the potential for contagion or ‘copy cat’ events[16,17] were not the most significant concerns raised by the stakeholders in this study. Rather, respondents were more concerned that site moderators were not sufficiently skilled to deliver effective and appropriate support to people at risk. Most organizations that facilitated user-user interaction via their social media sites had trained moderators in situ; however, few had clear safety protocols or a code of ethics underpinning their work.

The need for clear protocols and ethical standards for suicide prevention activities using social media platforms has been emphasised before.[18] Work is currently underway to develop guidelines, both in Australia[19] and in the United States.[20] The subsequent implementation of these guidelines will be an important step towards enhancing the safe delivery of suicide prevention initiatives using the internet.

Implications for research

The need for further research in this area was clearly articulated by the researchers who responded to the survey. Future priorities included the need for intervention studies for both people at risk and people bereaved by suicide, and for research examining the ethics and safety of delivering interventions via social media.

The fact that little intervention research appears to have been conducted is disappointing,but not surprising. Indeed, there is a lack of intervention research in suicide prevention generally,[21,22] including research that examines the effects of internet-based interventions on suicide risk. To the best of our knowledge,only one study has assessed the effects of an Internet-based intervention on suicide risk among adults,[23] and two studies (recently published by our research group) that examined the safety,acceptability,and efficacy of an internet-based program for suicidal adolescents.[24,25] These studies reported that using the internet for suicide prevention purposes can be both safe and effective. However, none of these studies utilised a social media platform, so the potential value of social media-based suicide prevention interventions remains uncertain.

The amorphous and anonymous nature of social media presents both methodological and ethical challenges for researchers,a problem that was reflected in the responses given by survey respondents. The development of new methodologies that can be rigorously applied to research that utilizes social media platforms is a necessary next step. This problem is similar to the problem described above of developing service-related guidelines[19,20] to ensure the acceptability, utility, efficacy, and ethical standards of social media-based suicide prevention services. Researchers need to work closely with organizations that use social media for the purpose of suicide prevention to help them improve the implementation of these protocols and guidelines.

Limitations

There are a number of limitations to be considered when interpreting the results from this study. Firstly, this was a small study and response rates for the researchers (23%) and institutional respondents (19%) were poor. Such low response rates are not unusual in survey-based research,[26] but the potential lack of representativeness of the respondents highlights the need to be cautious when interpreting the findings.

A related problem exists with regard to the user group. In order to recruit users of social media into the study we placed a link to the survey on the Orygen Youth Health Facebook page and Twitter feed (both of which primarily serve youth in Australia), and then used a respondent-driven sampling system. Whilst this method does have the capacity to reach large numbers of young respondents in Australia, it is not possible to determine how many people saw the link to the survey and, thus, we cannot calculate a response rate for this group. Another option would have been to use a voucher tracking system,[8] however this is expensive and more complex to implement. Finally, some questions were answered by too few respondents in the social media users group to provide meaningful results.

Despite these limitations, this study provides useful information about how social media is currently being used for suicide prevention and about the potential such platforms may hold for future suicide prevention activities.

Implications

Social media were recognised by three key groups of stakeholders as potentially useful platforms for delivering suicide prevention activities to people at risk of, and bereaved by, suicide. More research is required to establish the efficacy and safety of potential social media-based interventions. To help promote this research effort, there is a need to develop and implement rigorous methodologies and ethical standards to ensure that social media-based interventions are delivered carefully and safely.

Table 1.

Responses of different types of respondents to the items on the internet-administered survey instrument about use of social media in suicide prevention efforts

	Researchers(n=10)%	Organizations(n=10)%	Users%(n/N)
A. GENERAL ITEMS    (% who ‘agree’ or ‘strongly agree’)
Social media has the potential to be a useful tool for delivering suicide prevention activities	100%	82%	87%(47/54)
Social media is a useful way for people to communicate with others about their suicidal feelings	60%	73%	70%(38/54)
Social media provides an opportunity to intervene early if someone expresses suicidal thoughts or feelings	70%	82%	85%(46/54)
Social media is a useful way for people who have felt suicidal to support others	70%	73%	82%(44/54)
Social media is a useful way for people who have been bereaved by suicide to share their experiences	60%	82%	87%(47/54)
Social media is a useful way for people who have been bereaved by suicide to support others	60%	82%	85%(46/54)
Social media is a useful way for people who feel suicidal to seek/receive professional help	60%	64%	56%(30/54)
B. USE OF DIFFERENT SOCIAL MEDIA FOR SUICIDE PREVENTION    (% who believe media has ‘moderate’ or ‘high’ potential for suicide prevention)
Social networking sites (e.g. Facebook)	70%	100%	82%(41/50)
Blogs and micro-blogs (e.g. Twitter)	60%	91%	72%(36/50)
Content communities (e.g. YouTube)	50%	73%	66%(33/50)
Collaborative projects (e.g. Wikipedia)	20%	27%	34%(17/50)
Virtual game worlds (e.g. World of Warcraft)	40%	18%	16%(8/50)
Virtual social worlds (e.g. Second Life)	50%	18%	16%(8/50)
C. IMPORTANCE OF SOCIAL MEDIA FOR SUICIDE PREVENTION    (% who believe different social media are ‘important’ or ‘very important’)
To promote activities, services, events or training programs	100%	82%	86%(43/50)
Awareness raising	90%	73%	82%(41/50)
The provision of information/resources	100%	100%	94%(47/50)
The provision of tools for suicide prevention (e.g. risk assessment tools)	50%	64%	88%(44/50)
For advocacy purposes	90%	73%	76%(38/50)
To allow users to share experiences	60%	82%	67%(33/49)
To share inspirational quotes/messages	40%	46%	62%(31/50)
To allow users to support each other	70%	100%	80%(40/50)
For fundraising purposes	40%	55%	62%(31/50)
For volunteer recruitment	60%	36%	64%(32/50)
For the provision of professional support or treatment	50%	73%	64%(32/50)
D. POTENTIAL RISKS OF USING SOCIAL MEDIA FOR SUICIDE PREVENTION    (% who consider each possibility a ‘moderate risk’ or ‘high risk’)
Site visitors at risk of suicide may expect support that the organization is not able to provide via social media	60%	73%	79%(38/48)
Site visitors may inadvertently harm other visitors at risk of suicide	80%	46%	83%(40/48)
Site visitors may deliberately harm other visitors at risk of suicide	70%	46%	71%(34/48)
Site visitors may develop unhealthy relationships with other visitors to the site	60%	46%	69%(33/48)
Incorrect information related to suicide might be spread via the site	80%	46%	65%(31/48)
Interaction between people at risk of suicide via social media may normalise or encourage the behaviour	50%	36%	67%(32/48)
Site administrators lack the skills to operate safe and effective interventions online	80%	82%	73%(35/48)
People may use social media to seek information regarding methods of suicide	80%	64%	60%(29/48)