Leveraging behavioral economics and implementation science to engage suicidal patients in mental health treatment

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PROJECT SUMMARY Patients at high risk for suicide are less likely to die by suicide if they engage in mental health treatment. Suicidal individuals have difficulty initiating and sustaining involvement in mental health services, yet no studies have systematically developed and tested strategies to increase treatment initiation for suicidal patients. Consistent with NIMH’s Strategic Objective 4 to strengthen the public health impact of NIMH-supported research, the primary objective of this study is to develop acceptable, feasible, low-cost, and effective strategies that increase patients’ attendance at a first mental health visit following identification of suicide risk in primary care. We will partner with a large, diverse health system that has implemented collaborative care in eight urban primary care practices to rapidly prototype and test promising strategies to achieve this objective. Rapid prototyping involves a series of rigorous experiments to optimize operations in the early-study stages. Industries outside of healthcare commonly use this approach to learn quickly and “de-risk” decision-making on a short timeline prior to a large rollout. The strategies we develop and test will be informed by behavioral economics and implementation science methods, leveraging the University of Pennsylvania’s P50 ALACRITY center, and will include strategies that target key mechanisms that impede treatment attendance. First, we will identify characteristics of patients who do or do not attend a first mental health visit following referral using medical records and claims data. Then, we will apply established approaches to contextual inquiry to identify barriers and facilitators to mental health treatment attendance for individuals at risk of suicide. We will use direct observation and brief interviews with key stakeholders (from within and outside of the Penn health system) to understand key barriers and facilitators to engaging patients at risk for suicide in mental health services. Finally, we will rapidly prototype and test strategies to optimize engagement. Using established procedures from implementation science and behavioral economics, relevant theories and frameworks and the extant literature, we will identify preliminary strategies to support attendance at first mental health visit. Strategies will also be developed in collaboration with a team of experts in suicide, implementation science, behavioral economics, and primary and mental health care. Based on the literature and our previous work, we anticipate that strategies that increase motivation (e.g., financial incentives) and foster connectedness (e.g., Caring Contacts) will be needed. We will then iteratively test and refine these preliminary strategies. Throughout this process, we expect to uncover additional barriers and facilitators that will allow us to further refine and optimize implementation strategies. The primary output will be a menu of the most promising and feasible implementation strategies to support the initiation of mental health services for patients at risk of suicide that will be tested in a subsequent trial. The long-term goal of this work is to increase engagement in mental health services for suicidal individuals.