[Simagery] Targeting repetitive intrusive suicidal images and thoughts: towards a new suicide prevention strategy

Suicide is a major public health problem, and it remains unclear which processes link suicidal plans to the act of suicide. Growing evidence shows that the majority of suicidal patients diagnosed with major depression or bipolar disorder report repetitive suicide-related images and thoughts. In addition, experimental and clinical studies show that vividness of negative as well as positive intrusive images may be reduced by Dual Task (e.g. eye movements) interventions taxing the working memory. We propose that the eye movements during image retrieval will also reduce intensity and frequency of suicidal imagery.



The current registration is for the pilot trial, a preliminary study set up to evaluate feasibility, potential adverse events, and implementation of the (EMDT) intervention, to inform a full-scale, definitive randomized controlled trial.



Study participants are 6 depressed adults (18 years and older) with suicidal ideation. Participants will receive (max.) 6 sessions of EMDT as an add-on treatment to their care-as-usual.



The main study parameter will be the feasibility (i.e. treatment adherence, data collection) of setting up a multi-center randomized controlled trial evaluating the add-on Eye Movement Dual Task (EMDT) treatment.

The pilot study has the following objectives associated to the preparations of a full-scale randomized controlled trial:

1. To evaluate the feasibility, acceptability, and implementation of the add-on Eye Movement Dual Task (EMDT) treatment

2. To test for potential adverse events and use this knowledge to create a safety protocol

Baseline (Intrusion Interview)

During treatment (max. 6 weeks)

Post-treatment

EMDT add-on treatment

The treatment will be an add-on module that addresses intrusive suicidal images and can be added to regular treatment. It will consist of max. six sessions each of approximately 1 hour, in the course of three to six weeks, delivered at the participants’ mental health care center.



Eligible suicidal intrusion

The flash-forward/suicidal intrusion eligible to be treated by the EMDT treatment must score high on burdensomeness as measured by the Intrusion Interview. If the suicidal intrusion is interpreted as positive, i.e. if it’s used as a coping strategy, it is no longer eligible. In other words, the image may not present a desired situation that is attractive to the patient.



Each session will consist of the following steps:

1. Selection of intrusive suicidal flash-forward target images with related ideation (as informed by the baseline intrusion interview).

2. Consecutive set of eye movements of approximately 24 seconds by 10 second breaks. Between the sets, subjective units of distress scale (SUDS, scale 0-10) are administered to assess level of distress during imagery.

3. If the image still produces stress, the dual task procedure will be repeated for the target.

4. This procedure is repeated for all target images until all SUDS are at approximately 0.



The patients are receiving care-as-usual treatments during the course of the pilot study. Care-as-Usual for depression within the participating mental health care institution typically consists of (evidence-based) psychotherapy and/or antidepressant treatment.