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

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，与卫生系统发起的ZS计划相比。一个 对于这个年龄段的人来说，迫切需要有效的ZS战略，因为这是一个发展时期：1) 自杀是第二大死因，比任何内科疾病造成的死亡都多；2)自杀 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(SA) 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 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为：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(ZSBP，www.Sprc.org)；或 2)ZSBP分级关怀自杀预防，将循证自杀预防与 初级保健和急救服务。先前的研究证明了类似的综合医疗- 改善患者结局、护理比率和护理连续性的行为健康干预--一个关键 这是ZS努力的一个问题，因为许多年轻人尽管仍有风险，但仍过早停止护理。ZSBP方法 用途：1)风险评估，将青少年分流到适当的护理水平；2)护理经理提供CBT和DBT 技能培训，支持初级保健和急救临床医生对患者进行评估和治疗；3) 互联网eCBT和治疗性DBT技能视频，以及为低风险青少年提供的全天候教练支持， 加强针对高危青少年的面对面小组和/或个人治疗；以及4)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；6个月 继续治疗。在基线和3个月、6个月和12个月的随访中评估结果。我们 假设与ZSBP中的年轻人相比，被随机分配到ZSBP中的年轻人的发病率将显著降低 致命和非致命的SAS随着时间的推移(主要结果)，并将显示出对次要结果的改善 (随着时间的推移发生的自杀事件、自残事件、抑郁症状)。我们还将实施成本效益 分析。研究结果将为卫生系统和科学提供有关潜在的 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。ZSBP分级护理 对于自杀预防有可能在卫生系统和全国范围内得到更广泛的持续采用 传播，增强我们迎接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.