The development team had long-lasting experience both in face-to-face treatments for individuals with suicidal ideation (TT) and digital treatment formats for mental disorders (LBS). In the first step, we made an overview of intervention components used in face-to-face therapy based on CBT manuals for the treatment of suicidal ideation [34-37,39-43]. In the next step, we created a list of potential web-based modules that we considered feasible for a remote blended care intervention, and we developed first drafts for 11 web-based modules (see Qualitative Study, Intervention).

We revised the drafts of the web-based modules and developed additional modules based on the feedback from therapists and lay counselors. In addition, we developed a treatment manual to guide the therapeutic process. The development team reviewed and discussed the recommendations and incorporated them into the design of web-based modules and the treatment manual when deemed reasonable and applicable.

A brief overview of the qualitative results is provided here; see Multimedia Appendix 1 for the detailed findings along with quotes from psychotherapists and lay counselors.

We revised the modules and designed the treatment manual in line with the feedback from therapists and lay counselors. Furthermore, we developed a 2-day training to instruct therapists for treatment. The training included 1 day of training on face-to-face interventions for patients with suicidal ideation as displayed in the manual, and 1 day of training on the use of the web-based modules and particularities of video therapy.

Meeting the recommendations for blended care design, we specified how to blend the modules with the therapy sessions, including hints for potentially burdening modules to specifically prepare the patients for the therapy sessions. We developed an informed consent sheet detailing the safety procedures and we added information on data privacy for the patients to an introductory web-based module. Following the recommendation to adapt the treatment to the needs of the respective patient, we developed an individualized treatment format. We incorporated the treatment components suggested by participants.

Concerning the contents of web-based modules, we addressed the recommendations by simplifying the language and explanations of concepts and adding graphics where applicable. Furthermore, in an attempt to provide patient examples with sufficient similarity to each patient, we chose 3 example patients who covered different psychopathogeneses, genders, and age groups. Furthermore, we incorporated the feedback on how to transmit empathy and validation in web-based modules. We addressed the safety recommendations by adding reminders about the safety plan and the emergency number to each module. In addition, we discussed and addressed any module-specific feedback.

Regarding the navigation and layout of modules, we standardized the module procedures based on the feedback. This included an overview of the module at the beginning and an outlook on the next steps at the end of each module. We developed an introductory module that provided general information about the web-based modules and the therapy process. For patients with lower digital literacy, we provided a sheet explaining the login and registration process. We developed a simple and consistent module layout in line with participants’ feedback. Moreover, we inserted pictures with a clear connection to the contents and to the everyday lives of patients.

The final GO-ONline program was designed as a remote blended intervention, consisting of 12 sessions of outpatient psychotherapy via a videoconferencing system and web-based self-help modules. The manualized program is based on CBT and strictly focuses on the treatment of suicidal ideation and behaviors, as proposed in previous manuals on the treatment of patients with suicidal ideation [34-37,39-43].

We developed 31 web-based modules covering a wide range of intervention components; a full list is displayed in Table 1. We incorporated most components we identified in CBT treatment manuals into the intervention, with few exceptions (eg, when there was mixed evidence such as for antisuicide contracts [46], or when the intervention seemed too complex for a short-term therapy). In the blended intervention, there are no obligatory web-based modules: any relevant modules can be selected and assigned based on the individual case conceptualization and treatment plan. Patients are supposed to work on the modules between the video therapy sessions as a preparation or follow-up. The therapist can view the patient's entries in the web-based modules. Example screenshots are displayed in Figure 1.

The treatment process is divided into 3 phases (compare [37]; Figure 2): during the initial phase, the objectives include understanding the suicidal crisis, conducting a risk assessment, identifying reasons for living, and implementing crisis therapy strategies. These strategies encompass the development of a safety plan, means restriction, and the establishment of strategies to address symptom load (eg, panic, nightmares, insomnia, dissociation, and rumination). At the end of the initial phase, an individual case concept is developed and discussed with the patient. The case concept guides the intervention selection in the second treatment phase. Accordingly, the focus of the second treatment phase centers on addressing 1 or 2 core “suicidal drivers” [35], that is perceived burdensomeness, thwarted belongingness, hopelessness, entrapment, worthlessness, or unbearability (Figure 2). Standard cognitive behavioral therapy methods (eg, cognitive restructuring, problem-solving, and behavioral activation) are used to address the different “suicidal drivers.” In the final phase, relapse prevention strategies (relapse prevention task and letter to the suicidal self) are implemented to prepare patients for potential future suicidal crises. All treatment components of the initial therapy phase are obligatory, whereas all further treatment modules are freely selectable based on the individual case conceptualization.

The treatment manual includes the following safety protocol. First, at the beginning of each video therapy session, therapists perform a risk assessment. Second, patients are informed that module contents and daily diary are not reviewed outside of the therapy sessions. Third, patients are required to consent to perform therapy sessions from the same address. In cases where a patient fails to attend a scheduled therapy session and cannot be reached within 15 minutes, a designated contact person is immediately called. If deemed necessary, therapists call the police.

In this study, we have developed a remote blended treatment for individuals with suicidal ideation, integrating video therapy and digital self-help modules. Qualitative interviews with therapists and lay counselors offered valuable insights on how to design blended care specifically for this target group, with web-based modules being recognized as a valuable complement to therapy sessions. Intervention components were selected based on previous treatment manuals for this target group [34-37,39-43]. The remote blended format is designed to leverage the high accessibility of digital formats while incorporating full sessions with a therapist.

In the treatment design, we carefully addressed several important issues that emerged from this qualitative study and the review of previous treatment manuals. In terms of treatment safety, therapists and lay counselors highlighted that certain web-based modules, such as motivational interviewing or narrative interviews, could be particularly challenging for patients as they confront them with a suicidal crisis. They recommended to carefully integrate the self-help modules into therapy sessions, enabling therapist to address potential issues and unwanted effects. Therefore, we flagged potentially burdensome web-based modules in the manual and provided guidance on how to prepare for and follow up on critical modules during the therapy sessions. Importantly, all therapy programs that have demonstrated efficacy in reducing suicidal behaviors [34,37,47] include specific strategies to respond to suicidal urges [48]. Based on these treatment manuals, we prioritized treatment safety as the first and only obligatory treatment target. Safety planning [49] and means restriction [50] have been shown to be effective in preventing suicidal behavior and were therefore implemented in the program. In line with the feedback from participants, the web-based modules include regular reminders about the safety plan, taking a break, or calling an emergency number if necessary.

Another issue to consider in blended care for individuals with suicidal ideation is the high heterogeneity in mental disorders or life circumstances associated with a suicidal crisis, as well as varying levels of severity of suicidal ideation and behaviors. The therapists and lay counselors emphasized the importance of tailoring the intervention to meet each patient's specific needs, highlighting the need for a personalized treatment approach. In addition to increasing the acceptability [51], personalized interventions aim to increase the effectiveness of interventions [52]. In our program, therapists create an individual case conceptualization and adapt the therapy to suit the needs of each patient. The treatment manual offers a range of optional intervention components to target individual suicidal drivers [35]. However, developing web-based modules for this broad target group is challenging. To address this, we provide a large pool of 31 modules, from which only the relevant ones are selected in a shared decision-making process. Additionally, we have included patient examples representing various clinical and sociodemographic characteristics.

Based on the participants’ feedback, we designed the web-based modules as simple and user-friendly as possible, considering that many patients struggle with concentration issues.

Several limitations need to be considered. First, we did not include participants with lived experience of suicidal ideation. A participatory approach involving people with lived experience is strongly recommended [53]. However, this paper represents the initial step in treatment development; input from people with lived experience of suicidal ideation will inform the further revision of the intervention as part of a feasibility trial. Second, the sample size in the qualitative study was small, and we did not assess whether data saturation was reached. Obtaining more feedback is necessary to ensure a comprehensive understanding. To address this limitation, we are planning a larger study with a more diverse participant pool to capture a broader range of perspectives and experiences. Third, the therapists’ views might partly reflect their knowledge of and attitude toward digital interventions. Therapists had moderate experience with treating patients with suicidal ideation and were recruited from a department where digital interventions were a primary research focus, potentially limiting the range of responses. Moreover, participants’ perspectives might be partly biased by common assumptions or personal experiences, such as their expectations regarding the age group that would benefit from blended care. Thus, we will capture the actual experiences of therapists treating patients using a blended care program in an upcoming feasibility study. Fourth, the therapists and lay counselors did not review the treatment manual during its development, as it was created after conducting the qualitative interviews. Nevertheless, the insights gained from these interviews played a crucial role in shaping the entire treatment program. The manual itself is based on previous face-to-face treatment manuals, and as part of the feasibility study, we will seek feedback to further refine it.

In conclusion, our remote blended care treatment, which integrates video therapy and digital self-help modules, holds promise in meeting the needs of individuals with suicidal ideation. The program prioritizes safety planning and means restriction as essential treatment components while tailoring the treatment to the specific needs of each patient. Further research, including the perspectives of people with lived experience, is essential to determine the intervention’s effectiveness, acceptability, and practicality in comparison to established care models.