International Review of Psychiatry, February 2015; 27(1): 72–81

Protocol: Reducing suicidal ideation among Turkish migrants in the Netherlands and in the UK: Effectiveness of an online intervention

OZLEM EYLEM1,2,3, ANNEMIEKE VAN STRATEN1,2, KAMALDEEP BHUI3 & AD J.F.M. KERKHOF1,2 of Clinical Psychology, VU University, Amsterdam, the Netherlands, 2EMGO Institute for Health and Care Research, Amsterdam, the Netherlands, 3Wolfson Institute of Preventive Medicine, Queen Mary University of London, UK Int Rev Psychiatry Downloaded from informahealthcare.com by Kainan University on 04/14/15 For personal use only.

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Abstract Background: The Turkish community living in Europe has an increased risk for suicidal ideation and attempted suicide. Online self-help may be an effective way of engagement with this community. This study will evaluate the effectiveness of a culturally adapted, guided, cognitive behavioural therapy-based online self-help intervention targeting suicidal ideation for Turkish adults living in the Netherlands and in the UK. Methods and design: This study will be performed in two phases. First, the Dutch online intervention will be adapted to Turkish culture. The second phase will be a randomized controlled trial with two conditions: experimental and waiting-list control. Ethical approval has been granted for the trials in London and Amsterdam. The experimental group will obtain direct access to the intervention, which will take 6 weeks to complete. Participants in the waiting-list condition will obtain access to the modules after 6 weeks. Participants in both conditions will be assessed at baseline, post-test and 3 months post-test follow-up. The primary outcome measure is reduction in frequency and intensity of suicidal thoughts. Secondary outcome measures are self-harm, attempted suicide, suicide ideation attributes, depression, hopelessness, anxiety, quality of life, worrying and satisfaction with the treatment.

Background Suicide is a major global concern for public health. It has enormous emotional, social and economical implications at the individual as well as collective levels (Bertolote & Fleischmann, 2009; van Spijker et al., 2011). The definition of suicide is still fiercely debated. One approach suggests an overlap between behaviours (e.g. suicidal ideation, attempted suicide, self-harm) that together constitute the suicide spectrum (De Leo et al., 2006; Lawrie et al., 2000, pp. 5–10). Prospective studies suggest that people with suicidal ideation are three times more likely to proceed to self-harm compared to people who do not have such thoughts (Fergusson & Lyskey, 1995; Fergusson et al., 2005). The continuum between suicidal thoughts, worries and behaviours may suggest that people who are worried with suicidal thoughts are more likely to engage in self-harm and suicide attempt (Kerkhof & van Spijker, 2011). There is an increased likelihood of repeating the self-harm as a consequence of habituation and there is a greater risk of death by suicide (Joiner, 2005). Knowledge about suicide in diverse cultural group is limited by theories generated from research among

majority communities living in western countries. Belonging to an ethnic minority however, has been considered as one of the risk factors leading to suicidal behaviours (WHO, 2010). The lower utilization of mental health services among minorities is a concerning public health issue (Bhugra, 2004; Bhui et al., 2003; Juang & Cookston, 2009; Lindert et al., 2008; van der Stuyft et al., 1989; Miranda et al., 2008). The low up-take of mental health services is thought to reflect cultural and linguistic barriers during the help-seeking process (Nadeem et al., 2008; Shim et al., 2009). There is a need for more knowledge about high-risk groups including ethnic minorities, and about culturally specific conceptualizations of suicide, as well as help-seeking and pathways to receive care (Bhui, 2010; Canetto, 2008; Hjelmeland, 2011; Lester, 2012). In the current literature about suicide there is insufficient information on the overall situation of migrants in Europe. More is known about suicidal behaviours among some ethnic groups with a long history of migration into Europe, such as South Asians in the UK (Bhugra, 2002, 2004; Bhugra et al., 1999a, 1999b; Bhui et al., 2007; Hunt et al., 2003;

Correspondence: Ozlem Eylem MSc, MA, Department of Clinical Psychology, VU University Amsterdam, 1 Van Der Boechorststraat 2B-69, Amsterdam, NL 1081 BT, the Netherlands. Tel: ⫹ 31 0646136765. E-mail: [email protected] ISSN 0954–0261 print/ISSN 1369–1627 online © 2015 Institute of Psychiatry DOI: 10.3109/09540261.2014.996121

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Protocol: Reducing suicidal ideation among Turkish migrants in the Netherlands and in the UK Patel & Gaw, 1996), and less is known about other ethnic groups which are becoming prominent ethnic minority populations in Western Europe such as the Turkish speaking community (Burger et al., 2009; Razum & Zeeb, 2004; van Bergen et al., 2008, 2009, 2010; Yılmaz & Riecher-Rössler, 2012). The Turkish speaking community in Europe is one of the fastest growing communities that consists of culturally and linguistically diverse ethnic groups (e.g. Kurdish people from the south-east region, Laz from the Black Sea region). Their history of migration starts with the labour migration agreements in the early 1960s with Western European countries, most notably with Germany. The outflow of Turkish migrants continued mostly to England for various reasons (e.g. labour, political regression) and to Germany for family reunification in the 1970s (Tas et al., 2008; Kilberg, 2014). Today it is estimated that more than 5 million people of Turkish origin live abroad (Kilberg, 2014). In Europe, the largest Turkish migrant populations live in Germany (18.5% of the German population), France (7% of the French population) and in the Netherlands (2.3% of the Dutch population) (Kilberg, 2014). It is difficult to establish accurate statistics in the UK due to the absence of a separate category for Turkish people in national statistics (Tas et al., 2008). The available literature indicates that the Turkish speaking community living in Europe faces special risks for attempted suicide (Burger et al., 2009; Lindert et al., 2008). In the Netherlands, people of Turkish origin die because of suicide at a younger age compared with indigenous Dutch people (Turkish men: 32, Turkish women: 32; Dutch men: 48, Dutch women: 51) (Garssen et al., 2006). There is also an increased risk of suicidal ideation (38.1% for Turkish adolescents versus 28.9% for Moroccan and 17.9% for Dutch) (van Bergen et al., 2008). Furthermore, young Turkish women (15–24) have a 1.6 times higher risk of attempted suicide compared to young women (15–24) from other ethnic backgrounds (Moroccan, Surinamese and Dutch) even though the risk of completed suicide was not increased (Burger et al., 2009). High levels of attempted suicide but a lower suicide mortality rate among young women of Turkish origin has been found in Germany and Switzerland compared with indigenous populations (Razum et al., 1998; Razum & Zeeb, 2004; Yilmaz & RiecherRossler, 2012, 2008). In Turkey, young women are at higher risk for suicide (Ba lı & Sever, 2003; Cakmak & Altuntas, 2009; Clemens, 2011; Devrimci-Ozguven & Sayil, 2003; Polatöz et al., 2010). Overall, in the Turkish community, the most common reasons for suicide are reported as social isolation, intergenerational conflict, or problems in relationships (Razum & Zeeb, 2004; Yilmaz &

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Riecher-Rossler, 2012). In one study it was identified that at least in half of the case studies Turkish women experienced stressful life events related to family honour, questioning of cultural values and selfsacrifice (van Bergen et al., 2010). One of the possible explanations for this higher risk for suicidal behaviours in the Turkish community comes from the level of acculturation. Acculturation is defined as a process that includes exchange of cultures (Berry & Sabatier, 2011; Roccas et al., 2000). Different acculturation strategies (i.e. separation, integration, marginalization and assimilation) differentially relate to mental health outcomes such as depression and suicidal ideation across ethnic groups. Further evidence of this comes from prospective and crosssectional studies. For example, the cultural integration strategy (i.e. positive attitudes towards the heritage culture and the receiving culture) is associated with a lower risk for psychological distress, depression symptoms and suicidal thoughts compared to other acculturation strategies such as separation (i.e. positive attitudes towards the heritage culture and negative attitudes towards the receiving culture ) and marginalization (i.e. negative attitudes towards both cultures); these findings are relevant to a number of ethnic communities (e.g. South Asians, Moroccans, Turks, black Caribbean, black African) (Bhui et al., 2012; Fassaert et al., 2009; Juang & Cookston, 2009; Unlu Ince et al., 2014b; van Leeuwen et al., 2010; van der Stuyft, 1989). Although the choice of a particular acculturation strategy seems to provide a plausible explanation for the risk for suicide, it is not sufficient to explain why this risk is higher in Turkish speaking communities compared to other ethnic minority communities sharing migration experiences. It also does not explain why there is a consistency between high attempted suicide risk among young Turkish women in Turkey as well as in Europe. The findings suggest pathogenic effects of culture. From a sociological perspective one can argue that in the Turkish community suicidal behaviours are related to the culturally specific conceptualization of gender roles transmitted through the generations (Cakmak & Altuntas, 2009; Diehl et al., 2009; White, 1997). Thus, a patriarchal family structure, where men are responsible for the ‘namus’ (honour) of the women in the family, brings restrictions (e.g. not being allowed to go out without a companion or male relative) to the lives of women of Turkish origin (Diehl et al., 2009; van Bergen et al., 2010). Questioning of such restrictions is likely to result in tension between women and the rest of the family. This is perhaps perceived as a ‘threat’ to the unity and the reputation of the family in the community and followed by more tension and further restrictions to control women’s behaviour. In this context, suicide

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might seem the only way to escape from this coercive pattern and the associated feelings (Baumeister, 1990). Online psychological treatments have recently become an addition to the mainstream health system. Given their effectiveness, especially in reducing anxiety and depression symptoms (van’t Hof et al., 2009), they are a promising intervention for improving public mental health. Recent developments suggest that online cognitive behavioural therapy-based (CBT-based) self-help is also effective in reducing suicidal thoughts in the mainstream Dutch population (van Spijker et al., 2014b). Although the effect sizes were small, the intervention group showed reduction in suicidal thoughts (d ⫽ 0.28), hopelessness (d ⫽ 0.28), worry (d ⫽ 0.34) and improved health status (d ⫽ 0.26). These results were consistent at the 3 months follow-up study. Online psychological services have several advantages compared to face-to-face treatment. For example, it is relatively easy to offer treatments in different languages on the Internet. Such a programme offers flexible services which might be beneficial for example for Turkish people who do not seek help because of their fear of being judged or misunderstood by the care-provider (Tas et al., 2008). Additionally, in the Netherlands, it is estimated that almost 80% of the Turkish-speaking population have access to the Internet. The younger generation, which is at greater risk for suicide, has more frequent access than the older generation (CBS, 2012). Further evidence that supports the value of online interventions comes from a trial by Unlu Ince and colleagues who tested the effectiveness of a self-help intervention which was tailored according to the Turkish culture, in reducing the depression symptoms in the Netherlands (Unlu Ince et al., 2013). The intervention group showed significantly more improvement post-test (6 weeks, d ⫽ 1.68) and in follow-up (3 months, d ⫽ 1.13) compared to the waiting-list control group. Although this study was underpowered, culturally adapted online services seem promising for this particular population (Unlu Ince et al., 2013, 2014c). In summary, there is a need to further our understanding of suicidal behaviours, particularly for ethnic groups such as the Turkish speaking community which is currently under-represented in health services and in official statistics of service use. In the current study, acculturation will be considered as a potential co-variate to explain the direction of the relationship between the utilization of online modules and reduction in suicide ideation and in other outcome measures such as depression scores (Bhui et al, 2012; Fassaert et al., 2009; Juang & Cookston, 2009; Unlu Ince et al., 2014b; van Leeuwen et al., 2010; van der Stuyft, 1989). Furthermore, self-harm is included as one of the outcome measures in keep-

ing with the evidence suggesting self-harm as one of the behaviours comprising the suicide spectrum (e.g. Hawton et al.,1999; Fergusson & Lyskey, 1995; Fergusson et al., 2005). Given the complexity of the background leading to suicidal behaviours in the Turkish speaking community (Akpinar, 2003; Cakmak & Altuntas, 2009; Lindert et al., 2008; Polatöz et al., 2010; van Bergen et al., 2010), it is important to make these psychological interventions relevant to their presentations of mental health symptoms (Hjelmeland, 2011). Online forms of service delivery are promising ways of accessing socially excluded populations and other ethnic minorities who need services but cannot access them easily. In light of these, the overarching objective of this study is to adapt and test the effectiveness of CBT-based modules for Turkish speaking populations. Methods and design This study will be performed in two phases. In the first phase the online intervention which is used in the work of van Spijker (2012, pp. 71–72) will be translated and adapted for the Turkish population. The second phase will be a randomized controlled trial (RCT) comparing a web-based self-help intervention with a waiting-list control condition. Adaptation procedure The adaptation of the intervention will be based on focus groups with lay members of the Turkish community and one-to-one interviews with CBT therapists and mental health professionals working with the Turkish communities. Focus groups were chosen as a method to explore how Turkish people construct the meaning of suicidal behaviours, and how they describe suicidal behaviour and remedies for it (e.g. Chu et al., 2012; Feinberg et al., 2012; Rathod et al., 2010). In a group setting, interactions between individuals who share a similar cultural heritage can bring out diverse perspectives that we will need to accommodate in the material of the intervention and in information sheets given to patients when seeking consent. So focus groups will permit access to a range of perspectives all identified within Turkish culture and will make such perspectives amenable to the epidemiological part of this study (Kohrt et al., 2014). One-to-one interviews will be conducted to learn about professional conceptualization of suicidal thoughts and helpful and/or unhelpful interventions while working with the Turkish speaking community. Information from the focus groups and the professionals will be used to modify the language content, for example, specific words used to describe distress, and to tailor the assignments as presented in the

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Protocol: Reducing suicidal ideation among Turkish migrants in the Netherlands and in the UK intervention. The core of the intervention, i.e. CBT, will not be changed. The aim is to interview six professionals and run four focus groups with a maximum of six participants in each group. The focus groups and the interviews with professionals will be in Turkish and/or in English or Dutch. Participants aged 18 or older of Turkish origin who have some experience with using mental health services will be eligible to participate in the groups. For the purpose of this research, the Turkish culture is defined on the basis of the language and place of birth of either the participants or one of their parents. Thus, participants who were born in Turkey or have at least one parent who was born in Turkey are included. Participants will be recruited through the community (banners on websites, social media, flyers, for example). All interested people will receive an information letter about the goal of the focus group, the way it will be performed, and the way data is handled. Statistical analysis of the interviews Thematic analysis will be used as a means of identifying, analysing and reporting explanatory models, and for understanding how elements of the intervention might need modification: patterns (themes) within the recipients’ and professionals’ descriptions of their experience of suicide, seeking help, or disclosing suicidal behaviours. This method minimally organizes and describes the data-set in rich detail. However, it frequently goes further than this, and interprets various aspects of the research topic (Braun & Clarke, 2006). RCT studying the effectiveness of the intervention The second phase of the study will be RCT with two conditions: online intervention and waiting-list control.

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Inclusion and exclusion criteria In order to be eligible to participate in this study, a participant must meet all of the following criteria: 18 years or older, being Turkish, which is defined as being born in Turkey or having at least one parent being born in Turkey and speaking the Turkish, Dutch or English language, and presenting mild to severe suicidal ideation. This is defined as a score 1 and above on the BSS. Total score of the BSS ranges from 0 to 38, with higher scores indicating more severe suicidal thoughts. There is no empirical evidence to support the use of a specific upper cut-off score with the BSS (Beck & Steer, 1993). There is no previous study demonstrating the use of specific BSS cut-off scores in Turkish migrant populations. Thus, no upper cut-off score will be used in order to reach the upper end of the suicidal ideation spectrum. Participants will also need to have access to a PC and the Internet and have sufficient command of English, Dutch or Turkish. Finally they need to be willing to provide their name, telephone number and e-mail address of themselves as well as their GP. Inclusion procedure Recruitment will take place among Turkish speaking population living in the Netherlands and in the UK. Participants will be recruited from the general population through banners on relevant websites (e.g. of community and health organizations), and through social media. A study website will be created including information about the study where potential participants can register themselves. Those who do will receive an e-mail with further information, an informed consent form, and a link to the baseline questionnaire. Those who return the informed consent, provide their contact details and those of their GP, fill out the baseline questionnaire, and do not fulfil our exclusion criteria will be included.

Sample size The sample size of this study will be based on the expected effect of the primary outcome measure: the reduction in frequency and intensity of suicidal thoughts as measured with the Beck Scale for Suicidal Ideation (BSS). We expect an effect size of d ⫽ 0.40. In the previous trial in the Dutch population, an effect size of 0.28 was found (Van Spijker, 2012). There is, however, suggestive evidence from trials indicating larger effect sizes for guided cognitive behavioural-based interventions compared to unguided ones (Cuijpers et al., 2010). Based on power of 0.80 and an alpha of 0.05, 100 participants are needed in each condition. Given the expected drop-out of 30%, the total sample size is determined as being 286.

Randomization The randomization scheme will be derived using random allocation software by an independent researcher. Randomization will take place in blocks of 20, and will be stratified for the UK and the Netherlands. Randomization will take place in a 1:1 ratio. All participants will be informed about the condition they are assigned to. Ethical implications The study has been reviewed by ethics committees in the UK as well as in the Netherlands. One of the major ethical issues was related with the safety of the participants in both conditions in the study. In the

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previous trial run by van Spijker and colleagues, none of the participants in both conditions died because of suicide during the study (van Spijker et al., 2014b). Thus, in the current study we decided to follow the same safety procedure in both conditions. Given the language barrier, we will provide the resources and information about how to seek help in Turkish in the two countries.

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Safety of participants

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3. The safety protocol which was previously developed and followed by Van Spijker will be followed in order to ensure the safety of participants (van Spijker, 2012, pp. 70). This means that suicidal thoughts will be assessed once in every 2 weeks. If a participant scores above the cut-off scores (BSS ⬎ 29) then the researcher will ring the participant to do a risk assessment. If the participant does not answer his/her phone, he or she will be called for three working days at different times of the day. In case of no response after three days of attempting to call, a standardized e-mail will be sent asking the participant to contact us. In addition, if we cannot reach the participant we will contact the GP to inform him/her about the high suicide ideation. This will also be mentioned in the e-mail to the respondent. When we do have contact with the participant we will assess the suicide risk and contact the GP if necessary. This whole procedure will be explained to potential participants in the information letter. In addition it should be noted that participants in both conditions will be encouraged to access treatment while they are enrolled in the programme. They will be provided with links to relevant healthcare providers.

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Intervention The online self-help programme consisting of six modules, which has been developed by van Spijker and colleagues, will be used as the core of the programme. The intervention is described in detail by van Spijker and colleagues (van Spijker, 2012, pp. 72–73). For the current study, we have added two modules about self-harm in keeping with the evidence suggesting an overlap between suicidal worries and thoughts leading to attempted and completed suicide (Fergusson et al., 2005; Hawton & Fagg, 1988; Hawton et al., 2003). We will encourage people to choose six out of the eight modules so the intervention can still be finished within 6 weeks. Every module will consist of information and exercises. Ideally, participants will need to spend 15 minutes twice a day to perform the exercises. The content of the eight modules is as follows. 1. Thinking about suicide: The aim of this week is to teach the participant to gain some control over

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their suicidal thoughts and to identify their automatic thoughts that underlie their suicidal thoughts. In addition, attention will be given to the dichotomous and overgeneralizing character of the suicidal cognitions. Dealing with thoughts and feelings: Participants will learn to realize that seemingly unbearable feelings can be tolerated. Attention will be given to learning to tolerate and regulate intense emotions in a crisis situation. Thinking about the future: Participants will work on their ideas for the future. Are these realistic? Subsequently, participants will compose a realistic idea of the future and formulate new goals. Thinking about the self: Common mistakes in thinking regarding the self will be discussed and worked on. In addition, it is explained that suicidality is a long-term vulnerability. The participants will be taught how to handle this. Attention will be also given to learning to ask for help. Thinking about others: Mistakes in thinking regarding other people will be discussed. In addition, information about the consequences of suicide for relatives and friends will be reviewed. Repetition and relapse: Several important mistakes in thinking will be repeated, as well as several learned skills. Furthermore, attention will be given to relapse and how to prevent this. Acknowledging self-harm: Participants will gain an understanding about the role of self-harm in their lives. They will identify the bad as well as the good things about the behaviour. Exercises will focus on naming the behaviour (e.g. cut) in order to help participants to think of their behaviour without feeling embarrassed or ashamed about it, which are common barriers in disclosing the behaviour. Setting targets: In this part, participants will be encouraged to set realistic targets about their future by using motivational interviewing techniques and a future-oriented reflexive approach (e.g. how does self-harm affect your life? If things were to improve, what might you find yourself doing?).

Guidance Guidance will be provided by moderators (two in the UK and two in the Netherlands), who are supervised by the researcher. The moderators will need to be bi-lingual (English-Turkish or Turkish-Dutch) psychology students at master’s level. A series of meetings will be arranged with them where they will receive training about how the online intervention works, safety protocol, referral system in both countries, and their roles and responsibilities whilst providing

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Protocol: Reducing suicidal ideation among Turkish migrants in the Netherlands and in the UK guidance to participants. Following their agreement with regard to their role as a moderator, regular supervision meetings, which will be held through skype and/or e-mail communications will be arranged with them. After each module the participants will be requested to do ‘homework’. They will receive online feedback from their moderator after the completion of this homework. The aim of this personalized feedback is to help participants understand the methods as explained in the lessons. Moreover, it will be used to motivate the participants to continue with the programme. In cases where the participant does not send in homework, he or she will be contacted by the moderator to see whether the participant is struggling with working on the programme. Waiting-list control condition Participants in the control condition will have access to a website where information about suicide is provided. In addition, specific information about treatment options (e.g. 113 online, Samaritans, mental health organizations) will be provided. After six weeks, after the post-test questionnaire, participants can start with the intervention. Instruments All assessments are self-report instruments and will take place online in the participant’s own preferred language, either Turkish, English or Dutch. Assessments will take place before the randomization (t0), after completing the treatment (t1, 6 weeks) and 3 months after completing the treatment (t2). Primary outcome measure The primary outcome measure in this study is the reduction in the frequency and intensity of suicidal thoughts. This will be measured with the BSS (Beck et al., 1988). The BSS is a 21-item measure assessing the severity of suicidal ideation (Beck et al., 1974,1979). Each item is scored from 0 to 2. The total score is obtained by adding the first 19 items and it ranges from 0 to 38. A high score represents high suicidal ideation. The BSS has good psychometric properties in English (Beck et al., 1988, 1979) and Turkish (Dilbaz et al., 1995; Polatöz et al., 2010). Secondary outcome measures Secondary outcome measures will include depression, suicidal ideation attributes, hopelessness, anxiety, worrying, quality of life, self-harm behaviour, suicide attempt, acculturation, and satisfaction with the treatment.

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Depression will be measured with the Beck Depression Inventory (BDI) comprising 21 items (Beck et al., 1961). Each item is scored from 0 to 3. The severity ranges from minimal depressed (0–13) to severely depressed, indicated by a score of 29 and over (Beck et al., 1961). It is reliable and valid (Beck et al., 1961). The BDI has been validated in Turkish and Dutch populations (Hisli, 1987). Suicidal ideation attributes The Suicidal Ideation Attributes Scale (SIDAS) is a five-item scale assessing frequency (item 1), controllability (item 2), closeness to attempt (item 3), distress (item 4) and interference with daily activities (item 5) on 10-point scales over the past month (van Spijker et al., 2014a). Total SIDAS scores will be calculated as the sum of the five items with total scale scores ranging from 0–50. Higher scores are indicative of greater suicidal ideation severity. An initial validation study of this scale demonstrated that the scale has high internal consistency and good convergent validity (van Spijker et al., 2014a). Hopelessness will be measured with the Beck Hopelessness Scale, which contains 20 true and false statements (Beck & Steer, 1988). Each statement is scored from 0 to 1 and the total score ranges from 0 to 20. A high score indicates a high degree of hopelessness. The instrument has good psychometric properties (Brown, 2011). This is also true for the Turkish version (Seber et al., 1993). Anxiety will be measured with the Anxiety subscale of the Hospital Anxiety and Depression Scale (HADS). (Spinhoven et al., 1997; Zigmond & Snaith, 1983). The anxiety subscale consists of seven items. Each item is scored on a 4-point Likert scale with scores ranging from 0 (no anxiety) to 3 (high anxiety). Total score range is 0–21 (Spinhoven et al., 1997). Scores between 0 to 7 indicate no anxiety, between 8 to 10 indicate possible anxiety, and scores above 11 or 12 are indicative of severe clinical anxiety. The HADS has been demonstrated as a valid and reliable instrument in various Dutch and Turkish populations (Aydemir et al., 1997; Bjelland et al., 2002; Spinhoven et al., 1997). Worrying: The Penn State Worry Questionnaire (PSWQ-PW) is a 15-item inventory assessing both the weekly status of pathological worry and treatment-related changes of worry during the treatment (Stöbber & Bittencourt, 1998). Each item is scored on a 7-point rating scale, ranging from 0 (never) to 6 (almost always). The total score ranges from 0–90 with a high score indicating more worrying. The PSWQ-PW shows good reliability and convergent validity (Stöber & Bittencourt, 1998). The Turkish version also demonstrated reliability (Yilmaz et al., 2008). Quality of life: The Euro Quol (EQ-5D) is an instrument measuring health quality of life and comprises

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five items: mobility, self-care, usual activities, pain/ discomfort, and anxiety/depression (Rabin & Charro, 2001). Each item is required to be rated as 1 (no problem), 2 (some problem) or 3 (extreme problem). Current health state is also rated on a scale ranging from 0 (worst imaginable state) to 100 (best imaginable state). Both Dutch and Turkish versions have been validated (Eser et al., 2007; Lamers et al., 2005). Self-harm and suicide attempt: A question asking about a suicide attempt will be used to assess the presence of a suicide attempt during the course of the study. Additionally, the three screening questions measuring the presence of self-harm will be used from the original instrument (Eylem, 2011). These questions are chosen to be included as they are formulated in line with the evidence supporting the overlap between suicidal thinking, self-harm and suicide attempt (e.g. Fergusson et al., 2005; Hawton et al., 1999). Additionally, initial findings provide supportive evidence for the concurrent validity of the tool (Eylem, 2011). The rest of the questionnaire includes 12 items assessing specific methods, frequency, reasons, severity, feelings before and feelings after self-harm, specific motivations for self-harm, drug or alcohol use, and communication before and after self-harm. Further studies regarding the psychometric properties of this tool are in progress. Satisfaction with the treatment: Participants will be asked to define their satisfaction with each lesson by asking ‘Was this lesson useful to you?’ in Dutch, English and Turkish. The answers will be rated on a 5-point Likert scale. The score per item ranges from 1 (not at all) to 5 (very much). Covariates Acculturation will be measured with the Lowlands Acculturation Scale (LAS) measures the degree of acculturation (Mooren, 2001). It is defined as a dynamic process which includes exchange of cultures (Berry & Sabatier, 2011; Roccas et al., 2000). It consists of 25 items which are rated on a 6-point scale (0: totally disagree, 6: totally agree). LAS is divided into five subscales: skills, tradition, social integration, values and norms, and feelings of loss. Validated Turkish, Dutch and English versions of the instrument are available (Mooren, 2001). Statistical analyses of the RCT The study will be carried out in accordance with the CONSORT guidelines. All analysis will be based on the intention-to-treat sample and missing values will be imputed with multiple imputation procedure as implemented in SPSS. ANOVA will be used to compare the post-test mean scores for the intervention

group with the post-test scores for the control group. Cohen’s delta will be used to determine the effect size of the differences in post-test means. Cohen’s delta will be calculated as the difference between the post-t-test mean scores of the intervention and control group divided by the pooled standard deviation. Effect sizes of 0.8 will be accepted as large, effect sizes of 0.5 are moderate and effect sizes of 0.2 are small (Cohen,1988). Summary and implications The current paper describes a study protocol of a randomized controlled trial comparing a web-based intervention which is adapted to the Turkish culture, to reduce suicidal thinking with a control condition. To our knowledge, this is the first self-help intervention that is adapted to Turkish adults presenting with suicidal thoughts. This will perhaps bring further efforts to identify vulnerable and yet underrepresented ethnic groups. It is also equally important to use this knowledge to develop prevention programmes and to promote policies that are inclusive and encourage access to effective services. Another highlight of this study is the interest in exploring the role of acculturation (i.e. whether greater participation in Dutch and British society is related to increased engagement with the online modules and reduced suicidal thinking) in moderating the relationship between, for example, use of online modules and reduced suicidal thoughts. This will potentially further our understanding of suicidality in a particular vulnerable ethnic group in Europe. In the current study, methods will be used from the formative model of adaptation such as focus groups with the target population and one-to-one interviews with the professionals working with them (Hwang, 2009). Similar methods of adaptations have been tested, and demonstrated high participant satisfaction, adherence and retention (e.g. Chu et al., 2012; D’Angelo et al., 2009; Feinberg et al., 2012; Rathod et al., 2010). Given the diversity within Turkish culture itself, simply translating the Dutch online modules into Turkish language will not be sufficient to make the intervention appealing to participants (Westermeyer, 1990; Kohn et al., 2002). In light of these, the design of this study will contribute to the development of a research process which is robust to international contexts and can be applied to Turkish people in any country. This will make the current research more generalizable and of value. There will be lessons for working with ethnic minorities in general also, where the diaspora may experience different country contexts. There are other strengths about the design of this study. First, running the trial in two countries will make it more likely that a sufficient number of

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Protocol: Reducing suicidal ideation among Turkish migrants in the Netherlands and in the UK people will be recruited in both conditions. The power was an issue in a previous trial, given the exclusion of people presenting with suicidal thinking, high drop-out rate and difficulty with recruitment in this population (Unlu Ince et al., 2013, 2014a). Another important strength is in using moderators representing the Turkish community whilst engaging and collecting data. It is expected that their involvement will reduce the attrition rate and ensure the safety of participants. There are some limitations. In spite of the use of guidance, drop-out attrition happens in Internetbased self-help interventions (Eysenbach, 2005). This can potentially introduce a selection bias which limits the conclusions drawn from the study. Second, given the sensitivity of the study, anonymous participation will not be possible. This might also introduce a selection bias. Third, no diagnostic interview will be conducted due to the broad inclusion criteria, time limitation and the self-help character of the study. Lastly, although the validated instruments, which are available in three languages, have been used before, their psychometric properties in an online environment are not sufficiently known. To conclude, to our knowledge, this study has several unique aspects which will contribute to the literature about cultural adaptation and suicidality. These are targeting a specific ethnic group which is vulnerable and yet under-represented in the literature as well as in the mainstream health care-system, being a cross-cultural study, and using moderators from the community organizations. Acknowledgements The corresponding author wishes to thank Bregje van Spijker and Burcin Unlu Ince for their comments and guidance. Declaration of interest: The corresponding author received a grant from the European Commission (2013/330–460). The authors alone are responsible for the content and writing of the paper. References Akpınar, A. (2003). The honour/shame complex revisited: Violence against women in the migration context. Women’s Studies International Forum, 26, 425–442. Aydemir, O., Guvenir, T., Kuey, L., & Kultur, S. (1997). The validity and reliability of the Turkish version of the Hospital Anxiety and Depression Scale [in Turkish]. Türk Psikiyatri Dergisi, 8, 280–287. Bağlı, M., & Sever, A. (2003). Female and male suicides in Batman, Turkey: Poverty, social change, patriarchal oppression and gender links. Women’s Health and Urban Life, 2, 60–84. Baumeister, R.F. (1990). Suicide as escape from self . Psychological Review, 97, 90–113.

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