Randomized Trial of Stepped Care for Suicide Prevention in Teens and Young Adults

家长奖摘要 我们提出了一项严格的随机试验来评估一种创新的阶梯式护理预防自杀 对青少年和年轻人的干预，与健康机构发起的零自杀(ZS)计划相比 系统。对于这个年龄段的人来说，迫切需要一种有效的ZS策略，因为这是一个发展时期 当：1)自杀是第二大死因，死亡人数超过任何疾病；2) 自杀倾向和行为通常首先发生在这个年龄段；3)自杀和自杀未遂的比率 (4)有效的干预可以减少一生中的风险、痛苦和成本。 该项目将伙伴关系与拥有强大基础设施和承诺的卫生系统结合在一起 与成功实施协作STEP的研究团队一起提高ZS的质量 卫生系统中的护理干预，并具有临床、卫生服务、经济和政策方面的专业知识 研究和传播。我们将确定并招募300名12-24岁的自杀率升高和SA的年轻人 风险。符合条件的青年将被随机分为：1)零自杀最佳做法，强调卫生系统 使用ZS工具包提高质量(ZSBP，www.Sprc.org)；或2)ZSBP针对自杀的阶梯式护理 预防。先前的研究证明了类似干预措施在改善患者预后方面的价值， 护理比率和护理的连续性--这是ZS努力的一个关键问题，因为许多年轻人过早地停止了护理 尽管存在持续的风险。ZSBP方法使用：1)对青少年进行风险评估，将其分流到适当的护理 级别；2)护理经理提供CBT和DBT技能培训，并支持初级保健临床医生 患者评估和治疗；3)互联网eCBT和治疗DBT技能视频以及培训 为低风险青少年提供全天候支持，并加强面对面小组和/或个人治疗 高危青少年；以及4)定期监测患者结局，并实时反馈给临床医生 促进分级护理算法的决策和使用。干预期为12个月：6 急性治疗6个月，继续治疗6个月。结果在基线和在 分别随访3、6和12个月。我们假设，与ZSBP的年轻人相比，年轻人被随机分配到 随着时间的推移，ZSBP的致命性和非致命性SAS的发生率将显著降低(主要结果)，并将显示 二次结局的改善(随着时间的推移自杀事件、自残事件、抑郁症状)。 我们亦会进行成本效益分析。结果将为卫生系统提供关键信息 以及关于通过将最先进的科学与实践相结合来实现ZS目标的潜力的科学 质量提升。ZSBP阶梯式自杀预防护理有可能得到更广泛的持续采用 在卫生系统内和全国传播，加强我们应对ZS挑战的能力。

Parent Award Abstract We propose a rigorous randomized trial to evaluate an innovative stepped care for suicide prevention intervention for adolescents and young adults, compared to a zero suicide (ZS) program initiated by a health system. An effective ZS strategy for this age group is critically needed because this is a developmental period when: 1) suicide is the second leading cause of death, accounting for more deaths than any medical illness; 2) suicidal tendencies and behaviors often first occur in this age span; 3) rates of suicide and suicide attempts (SAs) increase dramatically; and 4) effective intervention can reduce risk, suffering, and costs over lifetimes. The project combines a partnership with a health system that has strong infrastructure and commitment to quality improvement for ZS with a research team that has successfully implemented collaborative stepped care interventions in health systems and has expertise in clinical, health services, economics, and policy research and dissemination. We will identify and enroll 300 youths ages 12-24 with elevated suicide and SA risk. Eligible youths will be randomized to: 1) zero suicide best practices, which emphasizes health system quality improvement using the ZS toolkit (ZSBP, www.sprc.org); or 2) ZSBP+ stepped care for suicide prevention. Prior research demonstrates the value of similar interventions for improving patient outcomes, rates of care, and continuity of care- a critical issue for ZS efforts, as many youths discontinue care prematurely despite continuing risk. The ZSBP+ approach uses: 1) risk assessments to triage youths to appropriate care levels; 2) Care Managers to deliver CBT and DBT skills training and support primary care clinicians with patient evaluation and treatment; 3) internet eCBT and therapeutic DBT skills video plus access to coaching support (24/7) for lower risk youths, with stepped up in-person group and/or individual treatment added for higher risk youths; and 4) regular monitoring of patient outcomes, with real-time feedback to clinicians to facilitate decision-making and use of the stepped care algorithms. The intervention period is 12 months: 6 months of acute treatment; and 6 months of continuation treatment. Outcomes are assessed at baseline and at 3, 6 and 12-month follow-ups. We hypothesize that, compared to youths in ZSBP, youths randomized to ZSBP+ will have significantly lower rates of fatal and nonfatal SAs over time (primary outcome) and will show improvements on secondary outcomes (suicide events over time, self-harm episodes, depressive symptoms). We will also conduct cost effectiveness analyses. Results will provide critical information for health systems and science regarding the potential to achieve ZS goals by integrating state of the art science with practice quality improvement. ZSBP+ stepped care for suicide prevention has potential for broader sustained adoption within the health system and national dissemination, enhancing our capacity to meet the ZS challenge.