Bridging Gaps in Care Following Hospitalization for Suicidal Adolescents: As Safe As Possible (ASAP) and BRITE App.

OBJECTIVE: We present results from a 2-site, randomized clinical trial to assess the efficacy of a brief intervention (As Safe As Possible [ASAP]), a safety plan phone application (BRITE), and their combination on suicide attempts, suicidal ideation, non-suicidal self-injury, re-hospitalizations. and suicidal events among adolescents. METHOD: Adolescents (n= 240; 12-17 years of age) who were hospitalized for suicidal ideation with plan and/or intent, and/or suicide attempt, were assigned to 1 of 4 treatment conditions in a 2 by 2 design: ASAP+BRITE app+treatment as usual (TAU); (2) BRITE+TAU; (3) ASAP+TAU; and (4) TAU alone. Independent evaluators assessed suicidal ideation and behavior at 4, 12, and 24 weeks using the Columbia-Suicide Severity Rating Scale (C-SSRS) and re-hospitalization using the Child and Adolescent Services Assessment (CASA). RESULTS: No group differences were found on primary outcomes, except that ASAP participants were less likely to be re-hospitalized over 6 months (15.6%, vs 26.5%, p = .046). Participants hospitalized for an attempt and assigned to BRITE had a lower rate of subsequent attempts (odds ratio [OR] = 0.16, p = .01) and a greater time to attempt (hazard ratio [HR] = 0.20, p = .02). ASAP+BRITE, albeit not statistically significant, was most consistently associated with a reduction (60% reduction) in suicide attempts. CONCLUSION: ASAP, BRITE, and their combination are equally effective at decreasing risk for suicidal events 6 months post hospital discharge among suicidal adolescents; the ASAP intervention (with or without BRITE) was associated with lower rates of re-hospitalization. The BRITE app in youth hospitalized for suicide attempt had promising outcomes in regard to future attempts. DIVERSITY & INCLUSION STATEMENT: We worked to ensure sex and gender balance in the recruitment of human participants. We worked to ensure race, ethnic, and/or other types of diversity in the recruitment of human participants. We worked to ensure that the study questionnaires were prepared in an inclusive way. The research was performed with permission from the University of Pittsburgh Institutional Review Board and the University of Texas Institutional Review Board. One or more of the authors of this paper self-identifies as a member of one or more historically underrepresented racial and/or ethnic groups in science. One or more of the authors of this paper self-identifies as a member of one or more historically underrepresented sexual and/or gender groups in science. One or more of the authors of this paper received support from a program designed to increase minority representation in science. We actively worked to promote sex and gender balance in our author group. We actively worked to promote inclusion of historically underrepresented racial and/or ethnic groups in science in our author group. The author list of this paper includes contributors from the location and/or community where the research was conducted who participated in the data collection, design, analysis, and/or interpretation of the work. CLINICAL TRIALS REGISTRATION INFORMATION: Establishing Efficacy of an Inpatient Intervention and Phone App to Reduce Suicidal Risk (ASAP+BRITE); https://clinicaltrials.gov/study/; NCT03825588.

Positive and negative social media experiences and proximal risk for suicidal ideation in adolescents.

BACKGROUND: Social media (SM) has received considerable attention as a potential risk factor for adolescent suicide. Few empirical studies, however, have examined adolescents' daily negative and positive experiences on SM and its proximal impacts on suicidal ideation (SI), particularly using intensive monitoring designs. METHOD: Adolescents (N = 60; 14-17 years; 49% girls; 62% LGBTQ+) recruited using SM across the United States and participated in an 8-week intensive monitoring protocol. Ecological momentary assessment (three brief surveys per day) asked about negative and positive SM experiences and SI (passive and active). Multilevel modelling was used to evaluate the within-person relationships between daily SM experiences (e.g. individual fluctuations compared to a person's average) and SI, controlling for average levels of SM experiences, SM use screen time, and lifetime SI. RESULTS: Significant within-person effects of negative and positive SM experiences were associated with days when adolescents had SI. Specifically, on days when teens endorsed more frequent negative SM experiences than usual, they were more likely to report SI. However, more positive SM experiences than usual were associated with a lower likelihood of having SI. There were no significant effects of SM use ('screen time') on SI or on the reverse associations of SI on next-day SM experiences. CONCLUSIONS: Results indicate that SM experiences may be dynamic and modifiable risk and protective factors for SI in adolescents, whereas there is no effect of SM screen time on SI. Our results highlight that targeting negative SM experiences and augmenting the positive experiences on SM may be critical targets to improve teens' mental health and prevent suicide, rather than focusing on limiting SM screen time.

Predictive Validity of the K-CAT-SS in High-Risk Adolescents and Young Adults.

OBJECTIVE: Suicide is a leading cause of death in adolescents and young adults and has increased substantially in the past 15 years. Accurate suicide risk stratification based on rapid screening can help reverse these trends. This study aimed to assess the ability of the Kiddie Computerized Adaptive Test Suicide Scale (K-CAT-SS), a brief computerized adaptive test of suicidality, to predict suicide attempts (SAs) in high-risk youth. METHOD: A total of 652 participants (age range, 12-24 years), 78% of whom presented with suicidal ideation or behavior, were recruited within 1 month of mental health care contact. The K-CAT-SS, scaled from 0 to 100, was administered at baseline, and participants were assessed at about 1, 3, and 6 months after intake. Weekly incidence of SAs was assessed using the Adolescent Longitudinal Interval Follow-up Evaluation and Columbia-Suicide Severity Rating Scale. A secondary outcome was suicidal behavior, including aborted, interrupted, and actual SAs. RESULTS: The K-CAT-SS showed a 4.91-fold increase in SAs for every 25-point increase in the baseline score (95% CI 2.83-8.52) and a 3.51-fold increase in suicidal behaviors (95% CI 2.32-5.30). These relations persisted following adjustment for prior attempts; demographic variables including age, sex, gender identity, sexual orientation, and race/ethnicity; and other measures of psychopathology. No moderating effects were identified. At 3 months, area under the receiver operating characteristic curve was 0.83 (95% CI 0.72-0.93) for 1 or more SAs. CONCLUSION: The K-CAT-SS is an excellent tool for suicide risk stratification, particularly in higher-risk populations where other measures have shown lower predictive validity.

Impact of trauma exposure and depression comorbidity on response to transdiagnostic behavioral therapy for pediatric anxiety and depression.

By adolescence, two-thirds of youth report exposure to at least one traumatic event, yet the impact of trauma history is not routinely considered when evaluating the effect of psychotherapeutic interventions. Trauma may be a particularly important moderator of the effects of transdiagnostic therapies for emotional disorders, as trauma exposure is associated with risk for the development of comorbid depression and anxiety. The current study examined the history of trauma exposure and the presence of clinically significant depression as moderators of treatment outcomes in the Brief Behavioral Therapy (BBT) trial, the largest study of transdiagnostic psychotherapy for youth. Youths (age 8-16 years) were randomized to BBT (n = 89) based in pediatric primary care or assisted referral to outpatient community care (ARC; n = 86). Clinical response, functioning, anxiety symptoms, and depression symptoms were assessed at post-treatment (Week 16) and at follow-up (Week 32). A significant three-way interaction emerged between the treatment group, comorbid depression, and trauma exposure. BBT was broadly effective for 3/4 of the sample, but, for anxious-depressed youth with trauma exposure, BBT never significantly separated from ARC. Differences in outcome were not accounted for by other participant characteristics or by therapist-rated measures of alliance, youth engagement, or homework completion. Implications for models of learning and for intervention theory and development are discussed.

Adolescent, Parent, and Provider Perceptions of a Predictive Algorithm to Identify Adolescent Suicide Risk in Primary Care.

OBJECTIVE: To understand adolescent, parent, and provider perceptions of a machine learning algorithm for detecting adolescent suicide risk prior to its implementation primary care. METHODS: We conducted semi-structured, qualitative interviews with adolescents (n = 9), parents (n = 12), and providers (n = 10; mixture of behavioral health and primary care providers) across two major health systems. Interviews were audio recorded and transcribed with analyses supported by use of NVivo. A codebook was developed combining codes derived inductively from interview transcripts and deductively from implementation science frameworks for content analysis. RESULTS: Reactions to the algorithm were mixed. While many participants expressed privacy concerns, they believed the algorithm could be clinically useful for identifying adolescents at risk for suicide and facilitating follow-up. Parents' past experiences with their adolescents' suicidal thoughts and behaviors contributed to their openness to the algorithm. Results also aligned with several key Consolidated Framework for Implementation Research domains. For example, providers mentioned barriers inherent to the primary care setting such as time and resource constraints likely to impact algorithm implementation. Participants also cited a climate of mistrust of science and health care as potential barriers. CONCLUSIONS: Findings shed light on factors that warrant consideration to promote successful implementation of suicide predictive algorithms in pediatric primary care. By attending to perspectives of potential end users prior to the development and testing of the algorithm, we can ensure that the risk prediction methods will be well-suited to the providers who would be interacting with them and the families who could benefit.