Practitioner Review: Common elements in treatments for youth suicide attempts and self-harm - a practitioner review based on review of treatment elements associated with intervention benefits.

BACKGROUND: Adopting a common elements approach, this practitioner review aims to highlight specific treatment elements that are common to interventions with demonstrated benefits in randomized controlled trials (RCTs) for reducing suicide attempts and self-harm in youth. Identification of common treatment elements among effective interventions offers a key strategy for clarifying the most robust features of effective interventions and improving our ability to implement effective treatment and decrease the lag between scientific advances and clinical care. METHODS: A systematic search of RCTs evaluating interventions targeting suicide/self-harm in youth (ages 12-18) yielded a total of 18 RCTs assessing 16 different manualized interventions. An open coding process was used to identify common elements present within each intervention trial. Twenty-seven common elements were identified and classified into format, process, and content categories. All trials were coded for the inclusion of these common elements by two independent raters. RCTs were also classified into those where trial results supported improvements in suicide/self-harm behavior (n = 11 supported trials) and those without supported evidence (n = 7 unsupported trials). RESULTS: Compared with unsupported trials, the 11 supported trials shared the following elements: (a) inclusion of therapy for both the youth and family/caregivers; (b) an emphasis on relationship-building and the therapeutic alliance; (c) utilization of an individualized case conceptualization to guide treatment; (d) provided skills training (e.g. emotion regulation skills) to both youth and their parents/caregivers; and (e) lethal means restriction counseling as part of self-harm monitoring and safety planning. CONCLUSIONS: This review highlights key treatment elements associated with efficacy that community practitioners can incorporate in their treatments for youth presenting with suicide/self-harm behaviors.

Editorial: COVID-19: lessons learned for suicide prevention.

This editorial discusses lessons learned from the COVID-19 public health emergency as they relate to the prevention of suicide, the second leading cause of death in adolescents and young adults globally. Recognizing that COVID-19 impact and response varied across nations, we offer a US perspective, addressing two questions: (a) what have we learned from this pandemic and mitigation strategies used to reduce cases of COVID-19 illness and deaths; and (b) how can our research advance knowledge and be advanced by work aimed at understanding the impact of this 'unusual' period? Provisional data indicate that during the pandemic and lockdown period, there were some declines in suicide rates for the total US population and no change in youth. However, data also indicate increases in reported suicidal ideation and behavior, mental health-related ED visits, and ED visits for suicidal ideation and behavior in youth. Heterogeneity of pandemic effects is noteworthy, with ethnic and racial minority populations suffering the most from COVID-19, COVID-19-related risk factors, and possibly suicide deaths. As vaccinations can prevent severe COVID-19 cases and deaths, we also have demonstrations of effective 'psychological inoculations' such as community-based interventions for reducing suicide attempts and deaths. During COVID-19, we mobilized to provide clinical care through telehealth and digital interventions. The challenge now is to continue to put our science to work to mitigate the adverse impacts of the pandemic on suicide and suicide risk factors, our children's mental health, and enhance mental health and well-being in our communities.

Future Directions for Optimizing Clinical Science & Safety: Ecological Momentary Assessments in Suicide/Self-Harm Research.

OBJECTIVE: Mobile technology has facilitated rapid growth in the use of intensive longitudinal methods (ILM), such as ecological momentary assessments (EMA), that help identify proximal indicators of risk in real-time and real-world settings. To realize the potential of ILM for advancing knowledge regarding suicidal and self-injurious thoughts and behaviors (SITB), this article aims to provide a systematic review of safety protocols in published ILM studies of youth SITB, highlight considerations for maximizing safety, and offer an agenda for future research. METHOD: We conducted a systematic review of risk management strategies in published studies applying ILM to assess SITB in youth. RESULTS: The review indicated diverse safety strategies, with near-universal use of preventive strategies before beginning ILM surveys. Strategies for participant protection during the survey period included automated protective messages to seek support when elevated risk was detected; and staff-led strategies, some of which included active outreach to parents/caregivers when youth responses suggested elevated risk. Studies assessing suicidality all provided staff-led follow-up. There was minimal information on youth reactivity to intensive longitudinal assessments of SITB. Available evidence did not suggest increased suicidal ideation, suicide attempts, self-injurious behavior, or deaths with ILM. CONCLUSIONS: Based on the review, we propose a research agenda to inform safety procedures in ILM research and a model for managing risk in future ILM studies of youth SITB. This model begins with a needs assessment and proposes a "goodness of fit" approach for matching safety procedures to the specific needs of each ILM study.

Parent and Youth Preferences in the Treatment of Youth Depression.

Patient-centered care requires providing care that is responsive to patient preferences, needs, and values, yet data on parent and youth treatment preferences remains sparse. The present study (1) identifies variations in parent and youth preferences for depression treatment, and (2) explores relationships between parent and youth demographics and psychosocial functioning, and the preferences that parents and youth endorse. Participants were 64 youth and 63 parents awaiting randomization in a clinical trial evaluating psychosocial youth depression treatments. Parents preferred treatments that emphasize learning skills and strategies (82.5%) and include the parent in treatment at least some of the time (96.8%). Youth preferred that the therapist meet mostly with the youth alone (67.2%) but share at least some information with parents (78.1%). Youth (43.8%) tended to respond "don't know" to questions about their preferred therapeutic approach. Understanding parent and youth preferences, especially psychosocial treatment preferences, is needed to provide high-quality, patient-centered care.

Randomized controlled trial of family-focused treatment for child depression compared to individual psychotherapy: one-year outcomes.

OBJECTIVE: Childhood-onset depression is associated with increased risk of recurrent depression and high morbidity extending into adolescence and adulthood. This multisite randomized controlled trial evaluated two active psychosocial treatments for childhood depression: family-focused treatment for childhood depression (FFT-CD) and individual supportive psychotherapy (IP). Aims were to describe effects through 52 weeks postrandomization on measures of depression, functioning, nondepressive symptoms, and harm events. METHODS: Children meeting criteria for depressive disorders (N = 134) were randomly assigned to 15 sessions of FFT-CD or IP and evaluated at mid-treatment for depressive symptoms and fully at roughly 16 weeks (after acute treatment), 32 weeks, and 52 weeks/one year. See clinicaltrials.gov: NCT01159041. RESULTS: Analyses using generalized linear mixed models confirmed the previously reported FFT-CD advantage on rates of acute depression response (≥50% Children's Depression Rating Scale reduction). Improvements in depression and other outcomes were most rapid during the acute treatment period, and leveled off between weeks 16 and 52, with a corresponding attenuation of observed group differences, although both groups showed improved depression and functioning over 52 weeks. Survival analyses indicated that most children recovered from their index depressive episodes by week 52: estimated 76% FFT-CD, 77% IP. However, by the week 52 assessment, one FFT-CD child and six IP children had suffered recurrent depressive episodes. Four children attempted suicide, all in the IP group. Other indicators of possible harm were relatively evenly distributed across groups. CONCLUSIONS: Results indicate a quicker depression response in FFT-CD and hint at greater protection from recurrence and suicide attempts. However, outcomes were similar for both active treatments by week 52/one year. Although community care received after acute treatment may have influenced results, findings suggest the value of a more extended/chronic disease model that includes monitoring and guidance regarding optimal interventions when signs of depression-risk emerge.

Editorial: Suicide and self-harm: advancing from science to preventing deaths.

Globally, suicide is the second leading cause of death among youth ages 15-29-years, and self-harm is one of the strongest known predictors of death by suicide. This editorial introduces the Special Issue on suicide and self-harm, emphasizing the research and policy implications of the included articles. By illustrating advances in our science, the Special Issue both celebrates our achievements and highlights the need to use our science to inform suicide prevention policy and practice to reduce the tragedy of suicide and premature deaths.

Practitioner Review: Treatment for suicidal and self-harming adolescents - advances in suicide prevention care.

BACKGROUND: Suicide is a leading cause of death globally in youths, and suicidal behavior and self-harm are major clinical concerns. This article updates the previous practitioner review (2012) with the aims of integrating new research evidence, including that reported in this Special Issue. METHODS: The article reviews scientific evidence related to steps in the care pathway for identifying and treating youths with elevated suicide/self-harm risk, specifically: (a) screening and risk assessment; (b) treatment; and (c) community-level suicide prevention strategies. RESULTS: Review of current evidence indicates that major advances have been achieved in knowledge regarding clinical and preventive practices for reducing suicide and self-harm risk in adolescents. The evidence supports the value of brief screeners for identifying youths with elevated suicide/self-harm risk and the efficacy of some treatments for suicidal and self-harm behavior. Dialectical behavior therapy currently meets Level 1 criteria (2 independent trials supporting efficacy) as the first well-established treatment for self-harm, and other approaches have shown efficacy in single randomized controlled trials. The effectiveness of some community-based suicide prevention strategies for reducing suicide mortality and suicide attempt rates has been demonstrated. CONCLUSIONS: Current evidence can guide practitioners in delivering effective care for youth suicide/self-harm risk. Treatments and preventive interventions that address the psychosocial environment and enhance the ability of trusted adults to protect and support youths, while also addressing the psychological needs of youths appear to yield the greatest benefits. Although additional research is needed, our current challenge is to do our best to effectively utilize new knowledge to improve care and outcomes in our communities.

Predictors and moderators of recurring self-harm in adolescents participating in a comparative treatment trial of psychological interventions.

BACKGROUND: In primary analyses, dialectical behavior therapy (DBT) was associated with greater reduction in self-harm during treatment than individual/group supportive therapy (IGST). The objective of this paper was to examine predictors and moderators of treatment outcomes for suicidal adolescents who participated in a randomized controlled trial evaluating DBT and IGST. METHODS: Adolescents (N = 173) were included in the intent-to-treat sample and randomized to receive 6 months of DBT or IGST. Potential baseline predictors and moderators were identified within four categories: demographics, severity markers, parental psychopathology, and psychosocial variables. Primary outcomes were suicide attempts (SA) and nonsuicidal self-injury evaluated at baseline, midtreatment (3 months), and end of treatment (6 months) via the Suicide Attempt and Self-Injury Interview (Psychological Assessment, 18, 2006, 303). For each moderator or predictor, a generalized linear mixed model was conducted to examine main and interactive effects of treatment and the candidate variable on outcomes. RESULTS: Adolescents with higher family conflict, more extensive self-harm histories, and more externalizing problems produced on average more reduction on SH frequency from baseline to post-treatment. Adolescents meeting BPD diagnosis were more likely to have high SH frequency at post-treatment. Analyses indicated significant moderation effects for emotion dysregulation on NSSI and SH. DBT was associated with better rates of improvement compared to IGST for adolescents with higher baseline emotion dysregulation and those whose parents reported greater psychopathology and emotion dysregulation. A significant moderation effect for ethnicity on SA over the treatment period was observed, where DBT produced better rate of improvement compared to IGST for Hispanic/Latino individuals. CONCLUSIONS: These findings may help to inform salient treatment targets and guide treatment planning. Adolescents that have high levels of family conflict, externalizing problems, and increased level of severity markers demonstrated the most change in self-harm behaviors over the course of treatment and benefitted from both treatment interventions. Those with higher levels of emotion dysregulation and parent psychopathology may benefit more from the DBT.

Special Editorial: Open science and the Journal of Child Psychology & Psychiatry - next steps?

The JCPP works at the cutting edge of clinical science to publish ground-breaking research across the full range of topics in the field of child psychology and psychiatry. As JCPP editors, who are also active researchers in our own right, we are conscious of the threat posed to our field by what has come to be known as the reproducibility crisis - the fact that many published findings, initially trumpeted as important developments in the field, cannot be replicated and are therefore likely to be spurious (Nature Human Behaviour, 1, 2017, 21). The JCPP is conscious of its responsibility to play its part in addressing this issue as best it can. The roots of the problem are complex and its causes multifaceted. As one part of its response, the JCPP embraces the principles of open science and encourage preregistration of study protocols. Furthermore, we are working towards implementing new systems to promote preregistration with the hope of increasing scientific transparency and accountability and reducing the risks of selective reporting and posthoc rationalisation of findings (Journal of Child Psychology & Psychiatry, 59, 2018, 1).

Reducing Health Risk Behaviors and Improving Depression in Adolescents: A Randomized Controlled Trial in Primary Care Clinics.

Objective: Primary care (PC) is a major service delivery setting that can provide preventive behavioral health care to youths. To explore the hypothesis that reducing health risk behaviors (HRBs) would lower depressive symptoms, and that health risk and depression can be efficiently targeted together in PC, this study (1) evaluates an intervention designed to reduce HRBs among adolescent PC patients with depressive symptoms and (2) examines prospective links between HRBs and depressive symptoms. Method: A Randomized controlled trial was conducted comparing a behavioral health intervention with enhanced Usual PC (UC+). Participants were 187 adolescents (ages 13-18 years) with past-year depression, assessed at baseline, 6 months, and 12 months. Primary outcome was the Health Risk Behavior Index (HRBI), a composite score indexing smoking, substance use, unsafe sex, and obesity risk. Secondary/exploratory outcomes were an index of the first three most correlated behaviors (HRBI-S), each HRB, depressive symptoms, and satisfaction with mental health care. Results: Outcomes were similar at 6 and 12 months, with no significant between-group differences. HRBI, HRBI-S, and depressive symptoms decreased, and satisfaction with mental health care increased across time in both groups. HRBI, HRBI-S, and smoking predicted later severe depression. Conversely, severe depression predicted later HRBI-S and substance use. Conclusions: UC+ and the behavioral health intervention yielded similar benefits in reducing HRBs and depressive symptoms. Findings underscore the bidirectional links between depression and HRBs, supporting the importance of monitoring for HRBs and depression in PC to allow for effective intervention in both areas.

Integrated Primary Medical-Behavioral Health Care for Adolescent and Young Adult Depression: Predictors of Service Use in the Youth Partners in Care Trial.

Objectives: Depression, a chronic and disabling condition, frequently has its first onset during adolescence, underscoring the value of early effective treatment and prevention. Integrated medical-behavioral health care provides one strategy for improving treatment access for adolescents and young adults (AYA). Methods: This study examined predictors of accessing treatment in a multisite randomized controlled trial evaluating an integrated collaborative care intervention aimed at improving access to evidence-based depression treatment through primary health care, compared with usual care. Results: The integrated care intervention was able to overcome barriers to care associated with an initial reluctance to pursue active treatment and older age. Service use was low in both conditions among less acculturated/non-English-speaking families. Conclusions: Results support the value of integrated medical-behavioral health care for improving rates of care. Findings highlight mechanisms by which integrated care may lead to improved rates of care and outcomes for AYA, an underserved and understudied group.

Family-Focused Treatment for Childhood Depression: Model and Case Illustrations.

Although the evidence base for treatment of depressive disorders in adolescents has strengthened in recent years, less is known about the treatment of depression in middle to late childhood. A family-based treatment may be optimal in addressing the interpersonal problems and symptoms frequently evident among depressed children during this developmental phase, particularly given data indicating that attributes of the family environment predict recovery versus continuing depression among depressed children. Family-Focused Treatment for Childhood Depression (FFT-CD) is designed as a 15-session family treatment with both the youth and parents targeting two putative mechanisms involved in recovery: (a) enhancing family support, specifically decreasing criticism and increasing supportive interactions; and (b) strengthening specific cognitive-behavioral skills within a family context that have been central to CBT for depression, specifically behavioral activation, communication, and problem solving. This article describes in detail the FFT-CD protocol and illustrates its implementation with three depressed children and their families. Common themes/challenges in treatment included family stressors, comorbidity, parental mental health challenges, and inclusion/integration of siblings into sessions. These three children experienced positive changes from pre- to posttreatment on assessor-rated depressive symptoms, parent- and child-rated depressive symptoms, and parent-rated internalizing and externalizing symptoms. These changes were maintained at follow-up evaluations 4 and 9 months following treatment completion.

Emergency Department Screening for Suicide and Mental Health Risk.

Suicide is the second leading cause of death among youth ages 10-24. An estimated 1.5 million US adolescents receive their primary health care in the emergency department (ED); this is particularly true for low-income and minority youths who often lack a regular source of care. ED visits can provide a window of opportunity to screen and identify youths with suicide and mental health risk, triage youths based on need, and facilitate effective follow-up care. Recently developed brief therapeutic assessment approaches have demonstrated success in improving rates of follow-up care after discharge from the ED. Furthermore, there is some data supporting clinical benefits when youths receive evidence-based outpatient follow-up care. ED screening combined with effective follow-up, therefore, may provide one strategy for improving mental health and reducing health disparities in our nation. This paper reviews the context in which ED screenings occur, available tools and strategies, and evidence for the effectiveness of tested approaches.

The SAFETY Program: a treatment-development trial of a cognitive-behavioral family treatment for adolescent suicide attempters.

The purpose of this article is to describe feasibility, safety, and outcome results from a treatment development trial of the SAFETY Program, a brief intervention designed for integration with emergency services for suicide-attempting youths. Suicide-attempting youths, ages 11 to 18, were enrolled in a 12-week trial of the SAFETY Program, a cognitive-behavioral family intervention designed to increase safety and reduce suicide attempt (SA) risk (N = 35). Rooted in a social-ecological cognitive-behavioral model, treatment sessions included individual youth and parent session-components, with different therapists assigned to youths and parents, and family session-components to practice skills identified as critical in the pathway for preventing repeat SAs in individual youths. Outcomes were evaluated at baseline, 3-month, and 6-month follow-ups. At the 3-month posttreatment assessment, there were statistically significant improvements on measures of suicidal behavior, hopelessness, youth and parent depression, and youth social adjustment. There was one reported SA by 3 months and another by 6 months, yielding cumulative attempt rates of 3% and 6% at 3 and 6 months, respectively. Treatment satisfaction was high. Suicide-attempting youths are at high risk for repeat attempts and continuing mental health problems. Results support the value of a randomized controlled trial to further evaluate the SAFETY intervention. Extension of treatment effects to parent depression and youth social adjustment are consistent with our strong family focus and social-ecological model of behavior change.

Psychological Science and Innovative Strategies for Informing Health Care Redesign: A Policy Brief.

Recent health care legislation and shifting health care financing strategies are transforming health and behavioral health (a broad term referring to mental health, substance use, and health behavior) care in the United States. Advances in knowledge regarding effective treatment and services coupled with incentives for innovation in health and behavioral health care delivery systems make this a unique time for mobilizing our science to enhance the success of health and behavioral health care redesign. To optimize the potential of our current health care environment, a team was formed composed of leaders from the Societies of Clinical Child & Adolescent Psychology, Pediatric Psychology, and Child and Family Policy and Practice (Divisions 53, 54, and 37 of the American Psychological Association). This team was charged with reviewing the scientific and policy literature with a focus on five major issues: (a) improving access to care and reducing health disparities, (b) integrating behavioral health care within primary care, (c) preventive services, (d) enhancing quality and outcomes of care, and (e) training and workforce development. The products of that work are summarized here, including recommendations for future research, clinical, training, and policy directions. We conclude that the current emphasis on accountable care and evaluation of the outcomes of care offer numerous opportunities for psychologists to integrate science and practice for the benefit of our children, families, and nation. The dramatic changes that are occurring in psychological and behavioral health care services and payment systems also require evolution in our practice and training models.

Improving care for depression and suicide risk in adolescents: innovative strategies for bringing treatments to community settings.

This article reviews the literature on interventions and services for depression and suicide prevention among adolescents, with the goals of placing this science within the context of currently changing health care environments and highlighting innovative models for improving health and mental health. We examine the challenges and opportunities offered by new initiatives and legislation designed to transform the US health and mental health care systems; summarize knowledge regarding the treatment of depression and suicidality/self-harm in adolescents; and describe innovative models for partnering with health systems and communities. This review demonstrates that treatment models and service delivery strategies are currently available for increasing evidence-based care, particularly for depression, and concludes with recommendations for future research and quality improvement initiatives aimed at inspiring additional efforts to put science to work, bridge science and community practice, and develop strategies for partnering with communities to improve care, mental health, and well-being among adolescents.

IL-6 predicts non-suicidal self-injury over 3 months in high-risk adolescents.

BACKGROUND: Suicide is the second leading cause of death in 12- to 17-year-old adolescents in the USA. Research on biological mechanisms contributing to self-harm risk that could be targeted in treatment could help to prevent suicide and self-harm episodes. AIMS: We aimed to evaluate whether markers of inflammation, interleukin-6 (IL-6) and C-reactive protein (CRP), predict self-harm over 3 months within a sample selected for elevated suicide/self-harm risk at project entry. METHOD: Fifty-one adolescents aged 12-19 years selected for elevated suicide/self-harm risk completed three clinical interviews about suicide attempts and non-suicidal self-injury, 3 months apart. At baseline and 3 months, youth also provided blood samples, from which we assayed levels of IL-6 and CRP. RESULTS: Using generalised mixed models, we found that greater levels of IL-6 predicted more self-harm episodes (odds ratio [OR] = 3.3, 95% CI: 1.1, 10.0) and specifically, non-suicidal self-injury (OR = 3.5, 95% CI: 1.1, 11.2), over 3 months. CONCLUSIONS: The study findings increase our understanding of whether and how inflammation may be implicated in risk of self-harm. IL-6 may be a viable biological marker of short-term risk for self-harm.

Remission, Recovery, Relapse, and Recurrence Rates for Suicide Attempts and Nonsuicidal Self-Injury for Suicidal Youth Treated With Dialectical Behavior Therapy or Supportive Therapy.

OBJECTIVE: To evaluate rates of remission, recovery, relapse, and recurrence in suicidal youth who participated in a clinical trial comparing Dialectical Behavior Therapy (DBT) and Individual and Group Supportive Therapy (IGST). METHOD: Participants were 173 youth, aged 12 to 18 years, with repetitive self-harm (including at least 1 prior suicide attempt [SA]) and elevated suicidal ideation (SI). Participants received 6 months of DBT or IGST and were followed for 6 months post-treatment. The sample was 95% female, 56.4% White, and 27.49% Latina. Remission was defined as absence of SA or nonsuicidal self-injury (NSSI) across one 3-month interval; recovery was defined across 2 or more consecutive intervals. Relapse and recurrence were defined as SA or NSSI following remission or recovery. Cross-tabulation with χ2 was used for between-group contrasts. RESULTS: Over 70% of the sample reported remission of SA at each treatment and follow-up interval. There were significantly higher rates of remission and recovery and lower rates of relapse and recurrence for SA in DBT than for IGST. Across treatments and time points, SA had higher remission and recovery rates and lower relapse and recurrence rates than NSSI. There were no significant differences in NSSI remission between conditions; however, participants receiving DBT had significantly higher NSSI recovery rates than those receiving IGST for the 3- to 9-month, 3- to 12-month, and 6- to 12-month intervals. CONCLUSION: Results showed higher percentages of SA remission and recovery for DBT as compared to IGST. NSSI was less likely to remit than SA. DIVERSITY & INCLUSION STATEMENT: We worked to ensure race, ethnic, and/or other types of diversity in the recruitment of human participants. CLINICAL TRIAL REGISTRATION INFORMATION: Collaborative Adolescent Research on Emotions and Suicide (CARES); https://www. CLINICALTRIALS: gov/; NCT01528020.

Psychotropic medication use among adolescents participating in three randomized trials of DBT.

BACKGROUND: Frequently presenting with symptoms of mood or anxiety disorders, substance abuse or borderline personality disorder, suicidal and self-harming adolescents often are prescribed psychotropic medication. Though such treatment may be warranted, recurrent suicidal and self-harming behaviour is often linked to emotion dysregulation where pharmacological treatment has weak empirical support. There is a need for more clinical research into the frequency, type and rationale for pharmacological treatment in this group. In this secondary analysis of three randomized clinical trials of dialectical behaviour therapy for adolescents, we report on psychotropic medication use in the respective samples at the time of recruitment, compare use of psychotropic medication across trials and describe sample characteristics that may be associated with possible differences in psychotropic medication. FINDINGS: Trials were conducted in Norway, the US and Spain (labelled the Oslo, US and Barcelona samples). At baseline, 86% of the Barcelona sample, 67% of the US sample and 12% of the Oslo sample were taking at least one psychotropic medication with antidepressants as the most frequent, followed by antipsychotics (72%, 22% and 1.3% respectively) and mood stabilizers (14.2%, 16.2% and 0%). In the Oslo sample there was a significant association between receiving a diagnosis of major depression and the likelihood of receiving antidepressants, but no such association was found in the Barcelona and US samples. The overall 7-8 times higher proportion of participants in the US and Barcelona samples treated with psychotropic medication could only partially be explained by differences between the samples in diagnostic profiles, symptom severity or level of dysfunction. CONCLUSIONS: Highly prevalent in use among suicidal and self-harming adolescents with borderline features, psychotropic medication was still very unevenly prescribed across trials, differences not explained by differences in sample characteristics suggesting that current treatment practices are not fully empirically supported. We call for continued medical education and increased availability of evidence-based psychosocial interventions.

Zero Suicide Quality Improvement: Developmental and Pandemic-Related Patterns in Youth at Risk for Suicide Attempts.

The Zero Suicide (ZS) approach to health system quality improvement (QI) aspires to reduce/eliminate suicides through enhancing risk detection and suicide-prevention services. This first report from our randomized trial evaluating a stepped care for suicide prevention intervention within a health system conducting ZS-QI describes 1) our screening and case identification process, 2) variation among adolescents versus young adults; and 3) pandemic-related patterns during the first COVID-19 pandemic year. Between April 2017 and January 2021, youths aged 12-24 with elevated suicide risk were identified through an electronic health record (EHR) case-finding algorithm followed by direct assessment screening to confirm risk. Eligible/enrolled youth were evaluated for suicidality, self-harm, and risk/protective factors. Case finding, screening, and enrollment yielded 301 participants showing suicide risk-indicators: 97% past-year suicidal ideation, 83% past suicidal behavior; 90% past non-suicidal self-injury (NSSI). Compared to young adults, adolescents reported: more past-year suicide attempts (47% vs 21%, p<.001) and NSSI (past 6-months, 64% vs 39%, p<.001); less depression, anxiety, posttraumatic stress, and substance use; and greater social connectedness. Pandemic-onset was associated with lower participation of racial-ethnic minority youths (18% vs 33%, p<.015) and lower past-month suicidal ideation and behavior. Results support the value of EHR case-finding algorithms for identifying youths with potentially elevated risk who could benefit from suicide-prevention services, which merit adaptation for adolescents versus young adults. Lower racial-ethnic minority participation after the COVID-19 pandemic-onset underscores challenges for services to enhance health equity during a period with restricted in-person health care, social distancing, school closures, and diverse stresses.