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

摘要 我们提出了一个严格的随机试验，以评估一个创新的自杀预防阶梯护理 与卫生系统发起的ZS计划相比，这是一项针对青少年和年轻人的干预措施。一个 这一年龄组迫切需要有效的ZS策略，因为这是一个发展时期，当：1） 自杀是第二大死亡原因，比任何医疗疾病都多; 2）自杀 倾向和行为往往首先发生在这个年龄段; 3）自杀率和自杀企图（SA） 显著增加; 4）有效的干预可以减少风险，痛苦和一生的成本。 该项目将伙伴关系与具有强大基础设施和承诺的卫生系统相结合 与一个成功实施协作步骤的研究团队一起为ZS进行质量改进 卫生系统的护理干预措施，并在临床，卫生服务，经济学和政策方面拥有专业知识 研究和传播。我们将确定并招募300名年龄在12-24岁之间的自杀率和SA升高的年轻人， 使用多阶段筛选过程的风险。符合条件的年轻人将被随机分配到：1）零自杀最佳实践， 强调使用零自杀工具包提高卫生系统质量（BBP，www.sprc.org）;或 2)BBP+自杀预防阶梯式护理，将循证自杀预防与 初级保健和紧急服务。此前的研究表明，类似的综合医疗的价值- 行为健康干预，以改善患者的结果，护理率和护理的连续性-一个关键的 这是ZS努力的一个问题，因为许多年轻人不顾持续的风险过早地停止了护理。BBP+方法 用途：1）风险评估，将青少年分类到适当的护理水平; 2）护理经理提供CBT和DBT 技能培训和支持初级保健和急诊临床医生进行患者评估和治疗; 3） 互联网eCBT和治疗DBT技能视频加上获得教练支持（24/7）为低风险的青少年， 为高危青少年提供更深入的小组及/或个别治疗;及四）定期 监测患者结局，并向临床医生提供实时反馈，以促进决策和使用 阶梯式护理算法干预期为12个月：6个月的急性治疗; 继续治疗。在基线和3、6和12个月随访时评估结局。我们 我假设，与接受BBP的年轻人相比，随机接受BBP+的年轻人的发病率显著降低 致死性和非致死性SA随时间的变化（主要结局），并将显示次要结局的改善 （随着时间的推移，自杀事件，自我伤害事件，抑郁症状）。我们还将进行成本效益 分析。研究结果将为卫生系统和科学提供关键信息， 通过将最先进的科学与实践质量改进相结合来实现ZS目标。BP+阶梯式护理 预防自杀有可能在卫生系统和国家卫生系统内得到更广泛的持续采用。 传播，增强我们应对ZS挑战的能力。

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 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 using a multi-stage screening process. Eligible youths will be randomized to: 1) zero suicide best practices, which emphasizes health system quality improvement using the zero suicide toolkit (ZSBP, www.sprc.org); or 2) ZSBP+ stepped care for suicide prevention, which integrates evidence-based suicide prevention with primary care and emergency services. Prior research demonstrates the value of similar integrated medical- behavioral health 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 and emergency 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.