The ‘Werther effect’ suggests that a spike in deaths by suicide is often observed when a death by suicide (often that of a celebrity) is widely publicised (WHO, 2017). A report on Suicide Prevention by WHO (2017) proposed explanations including social learning and modelling, wherein the death is inadvertently glamorised through the photos of the deceased or the language used to describe the event alongside with the associated circumstances. It is suggested that vulnerable individuals may identify with the deceased and have an increase likelihood of engaging in a similar act. The capability to engage in suicidal behaviours is particularly increased when information about the method of suicide is reported.
On the other hand, a “Papageno effect” is also proposed wherein coverage of effective coping mechanisms highlighting alternative paths (e.g. stories of hope and recovery) may have a protective effect against death by suicide.
Niederkrotenthaler and Till (2019) develop a strong rationale for their research. Whilst the Werther effect has been more marked amongst those with prior suicidal thoughts and behaviours, the Papageno effect has only been studied across the general population, as opposed to focusing on those who are vulnerable. Individuals with suicidal ideation would be the primary focus for suicide prevention initiatives, therefore there is a need to examine the phenomenon within this group.
The authors also note the need to study possible effects of who the intervention is delivered by, e.g. a person with lived experience of suicidality vs. a mental health professional. They suggest that interventions delivered by individuals with lived experience may resonate more closely with these vulnerable individuals. This resonates with current evidence around the values of peer-assisted interventions for those with depression, with some suggesting that the involvement of professionals may compromise efficacy (APA, 2018, Bellamy, Schmutte & Davidson, 2017, Bryan & Arkowitz, 2015, Fuhr et al., 2014).
Overall, they conclude that this is the first study to assess whether these educative messages actually serve to reduce suicide risk among those who are already at risk for suicidal behaviour. Secondly, their research is the first to consider the potential influences dependant on who delivers the message.
Can educational interventions by those with lived experience play a role in suicide prevention?
Methods
The study used a double-blind randomised controlled trial design, inviting German speaking participants. There were 266 participants.
The study involved three interventions:
- Positive educational intervention from a person with lived experience: participants read an article headlined ‘Coping with suicidal crisis’, wherein an individual describes the development of her suicidal crisis, and how she sought help prior to a planned attempt and developed a safety plan in association with a counsellor (n=89)
- Positive educational intervention from a suicide prevention expert: a mental health expert outlined the development of suicidal crisis and how to seek help and develop a safety plan (n=90)
- Control group: an educational intervention unrelated to suicide prevention. The number of a crisis helpline was in the heading, but the article was on unrelated content (n=90).
The following measures were used at baseline and the end of the study wave (one week later): Survival and Coping Beliefs subscale of the Reasons for Living Inventory for suicide risk, selected items from the Revised Facts on Suicide Quiz for suicide prevention related knowledge, and Affective State Scale for mood.
Listen to Thomas Niederkrotenthaler speaking about this study and his wider work at the #IASP2019 conference in Derry last year:
Results
Intervention involving individual with lived experience of suicidal ideation
- Unlike the control group, this group demonstrated a small but statistically significant decrease in suicide risk both immediately after the intervention and at the end of the study
- The effects were more pronounced in participants with a recent suicide attempt
- Better suicide-prevention related knowledge was reported at the end of the study compared to the control group, which was primarily due to better knowledge in the subgroup of people with a recent suicide attempt
- Their mood did not differ significantly from that of the control group.
Intervention involving mental health expert
- This group showed no significant change in suicide risk
- Their change in suicide risk was not significantly different to that of the control group
- Their levels of suicide-prevention related knowledge and mood at the end of the study were not significantly different to that of the control group.
The control group
- This group experienced a short-term increase in suicide risk, which was small but statistically significant
- It was most pronounced in those with a recent suicide attempt, and was not maintained until the study end-point.
- The change in their suicide risk was significantly different from that observed in the group whose intervention was delivered by a person with lived experience of suicidal thoughts and behaviours, but not significantly different from the group whose intervention was delivered by a mental health expert.
Educational interventions delivered by those with lived experience bring small but significant reductions in suicide risk.
Conclusions
The authors conclude that their results support a reduction in suicidal ideation among vulnerable individuals. However, this was only when the media intervention was delivered by an individual with lived experience, and remained evident at the endpoint of the study which was one-week later. The authors themselves note that the effect size was statistically small. It is important to note that because the intervention was only brief, the small effect size observed is still likely to have practical implications from a public health perspective.
The increased short-term suicide risk that was observed in the control group is also discussed. It is proposed that it may be due to the fact that their participants and may have found it burdensome to engage in research, which was not tailored to their needs. This of course has important implications for the ethics and design of future research in this area.
Media based educational interventions by those with lived experience most likely have practical public health implications for suicide prevention initiatives.
Strengths and limitations
The authors present several strengths of the study e.g. (i) extending the research design to those with some degree of vulnerability to suicide, as indicated by recent suicidal ideation or suicide attempt, and (ii) the use of a follow-up period of 1 week, which goes beyond earlier studies that tested immediate effects only. An example limitation noted is the use of a convenience online sample not representative of the general population in terms of age, gender and education, with younger, female and higher educated individuals being over-represented. They also note the use of an online anonymous survey method, which of course brings both strengths and limitations.
One further issue that I would note is that a measure of suicide risk is used as the main outcome, however risk assessment scales are unable to predict with any level of accuracy who will engage in suicidal behaviour (Steeg et al., 2018; Quinlivan et al., 2016; Quinlivan et al., 2017). Also, whilst participants were followed up at the end of the week, further longitudinal research is necessary. It is possible to prevent suicidal behaviours (Zalsman et al., 2016), but states of suicidal crisis can fluctuate for individuals (Kleiman et al., 2017) and variability in suicidal ideation predicts future attempts (Witte et al., 2005).
New research suggest that messages with a clear personal narrative of recovery are safe for use with individuals with recent suicide attempts, and reduce their short-term suicide risk.
Implications for practice
Public health interventions need evidence bases for the safety and efficacy for various suicide prevention initiatives (WHO, 2017). These results support the Papageno effect and may offer a framework for suicide prevention initiatives. They highlight that messages with a clear personal narrative of recovery are safe for use with individuals with recent suicide attempts, and reduce their short-term suicide risk.
Media discussions have implications for how people respond to crises (NICE, 2018; WHO, 2017). The focus must be on adopting constructive coping strategies in adverse circumstances (Niederkrotenthaler et al., 2010). Further research is necessary to examine how best the media and educational interventions can promote actual help-seeking within such vulnerable groups, so that in accordance with best practice, they can develop safety plans (NICE, 2011; Stanley & Brown, 2012).
The Papageno effect appears to offer a framework for suicide prevention initiatives, particularly when they are delivered by those with lived experience of suicidal thoughts and behaviours.
Statement of interests
None.
Links
Primary paper
Niederkrotenthaler, T. & Till B. (2019). Effects of suicide awareness materials on individuals with recent suicidal ideation or attempt: online randomised controlled trial. The British Journal of Psychiatry, 1-8. doi: 10.1192/bjp.2019.259
Other references
APA (2018). Position Statement on Peer Support Services. Available from; https://www.psychiatry.org/File%20Library/About-APA/Organization-Documents-Policies/Policies/Position-2018-Peer-Support-Services.pdf. Accessed May 1, 2019
Bellamy C, Schmutte T, Davidson L. An update on the growing evidence base for peer support. Mental Health and Social Inclusion. 2017;21(3):161-167.
Bryan, A.E.B. & Arkowitz, H. (2015). Meta-analysis of the effects of peer-administered psychosocial interventions on symptoms of depression. American Journal of Community Psychology, 55(3-4), 455-471
Fuhr DC, Salisbury TT, De Silva M, et al. (2014). Effectiveness of peer-delivered interventions for severe mental illness and depression on clinical and psychosocial outcomes: a systematic review and meta-analysis. Soc Psychiatry Psychiatr Epidemiol., 49, 1691-1702
Kleiman, E.M., Turner, B.J., Fedor, S., et al. (2016). Examination of real-time fluctuations in suicidal ideation and its risk factors: Results from two ecological momentary assessment studies. Journal of Abnormal Psychology, 126(6), 726-738.
NICE (2018). Preventing suicide in community and custodial settings, NICE guideline (NG105), September 2018. Available from; https://www.nice.org.uk/guidance/ng105 (accessed 4/11/2019).
NICE (2011). Self-harm in over 8s: long-term management (Clinical Guidance [CG133]). Retrieved from; https://www.nice.org.uk/guidance/cg133 (accessed 25th November 2019).
Niederkrotenthaler T, Voracek M, Herberth A, et al. (2010). The role of media reports in completed and prevented suicide—Werther versus Papageno effects. Br J Psychiatry, 197, 234-43.
Quinlivan, L., Cooper, J., Meehan, D., et al. (2017). The predictive accuracy of risk scales following self-harm: multicentre, prospective cohort study. The British Journal of Psychiatry, 210(6), 429-436.
Stanley, B. & Brown, G.K. (2012). Safety planning intervention: a brief intervention to mitigate suicide risk. Cogn Behav Pract., 19(2), 256–64.
Steeg, S., Quinlivan, L., Nowland, R., et al. (2018). Accuracy of risk scales for predicting repeat self-harm and suicide: a multicentre, population-level cohort study using routine clinical data. BMC Psychiatry, 18, 113.
WHO (2017). Preventing suicide: a resource for media professionals – update 2017. Available from: http://www.who.int/mental_health/suicide-prevention/resource_booklet_2017/en/
Witte, T.K., Fitzpatrick, K.K., Joiner, T.E., et al. (2005). Variability in suicidal ideation: A better predictor of suicide attempts than intensity or duration of ideation? Journal of Affective Disorders, 88 (2), 131-136
Zalsman, G., Hawton, K., Wasserman, D., et al. (2016). Suicide prevention strategies revisited: 10-year systematic review. Lancet Psychiatry, 3(7), 646-659.
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