Adaptive intervention to prevent adolescent suicidal behavior following psychiatric hospitalization: A Sequential Multiple Assignment Randomized Trial

摘要 青少年自杀率的上升是一个紧迫的公共卫生问题。同时，紧急 由于青少年自杀风险而到艾德部门就诊和精神病住院的人数也在增加。 虽然精神病住院治疗提供了关键的稳定，出院的青少年仍然在升高， 复发性自杀危机的风险（例如，自杀企图、再住院）。新方法迫切需要 需要改变风险轨迹并预防从住院过渡到住院的青少年的自杀行为 在乎桥接适应性干预（AI）策略-其中治疗的类型，强度和时间可以 针对自杀青少年不断变化和多样化的治疗需求， 移动的技术，以达到青少年在高风险的出院后期间，我们的目标是确定一个 减少住院治疗后青少年自杀行为的最佳AI。我们建立在有希望的证据， 最近完成的NIMH资助的试点序贯多分配随机试验（SMART）的多， 组件干预包括：动机访谈（MI）-增强的安全计划交付给 住院期间的青少年和父母（MI-SP）;向青少年和 父母;和基于文本的支持（文本）提供给青少年每天出院后一个月。此外 可行性和可接受性，试点SMART结果表明，某些干预序列得到了改善 改变的关键机制（自我效能，安全计划的使用，应对），并初步与 出院后3个月自杀行为减少。在这项申请中，我们建议进行全面的 SMART旨在解决以下具体目标：（1）比较开始仅使用MI-SP或MI-SP+的AI 3个月内自杀行为（实际、中断或流产企图）的主要结局文本 出院后和两个次要结局，即至自杀行为的时间和自杀意念的严重程度 （2）通过比较四种人工智能，确定干预成分的最佳顺序 嵌入SMART中的主要和次要结局。青少年（N=300），年龄13-17岁，住院 由于自杀意念和/或企图，最初将被随机分配至MI-SP单药治疗组或MI-SP联合文本治疗组。基于 关于青少年对每日调查的反应，那些在出院后2周内被归类为无反应者 将被重新随机分配至添加的低强度加强呼叫（一次呼叫青少年，一次呼叫父母）或 高强度助推器（每种六次呼叫）。第二个目标是：（1）确定初始的主持人 干预方案和无应答者的增强战略;（2）检查机制是否 的变化（自我效能，安全计划的使用，应对）介导的影响，MI-SP加文本和高- 强度增强剂。拟议的研究将通过测试不同的公共卫生影响， 创新SMART设计中的连续性护理策略序列， 技术增强的AI旨在减少从住院治疗过渡的年轻人的自杀行为。

ABSTRACT The increasing rates of suicide among adolescents is an urgent public health concern. In parallel, emergency department (ED) visits and psychiatric hospitalizations due to youth suicide risk have also been on the rise. Although psychiatric hospitalization provides critical stabilization, discharged adolescents remain at elevated risk for recurrent suicidal crises (e.g., suicide attempts, rehospitalizations). New approaches are urgently needed to alter risk trajectories and prevent suicidal behavior among adolescents transitioning from inpatient care. Bridging an adaptive intervention (AI) strategy—wherein type, intensity, and timing of treatment can be individualized to address suicidal adolescents’ changing and heterogenous treatment needs—together with mobile technology to reach adolescents during the high-risk post-discharge period, our goal is to identify an optimal AI for reducing youth suicidal behavior after inpatient care. We build on promising evidence from our recently completed NIMH-funded pilot sequential multiple assignment randomized trial (SMART) of a multi- component intervention comprised of: a Motivational Interview (MI)-enhanced safety plan delivered to adolescents and parents during hospitalization (MI-SP); post-discharge booster calls provided to youth and parents; and text-based support (Texts) delivered to adolescents daily for a month after discharge. In addition to feasibility and acceptability, the pilot SMART results suggested that certain intervention sequences improved key mechanisms of change (self-efficacy, safety plan use, coping) and were, preliminarily, associated with lower suicidal behavior 3 months after discharge. In this application, we propose to conduct a full-scale SMART to address the following specific aims: (1) Compare the AIs that begin with MI-SP alone or MI-SP plus Texts on the primary outcome of suicidal behavior (actual, interrupted, or aborted attempts) within 3 months post discharge and the two secondary outcomes of time-to-suicidal behavior and severity of suicidal ideation over 6 months; and (2) Determine the optimal sequence of intervention components by comparing four AIs embedded in the SMART on primary and secondary outcomes. Adolescents (N=300), ages 13-17, hospitalized due to suicidal ideation and/or attempt will be initially randomized to MI-SP alone or MI-SP with Texts. Based on adolescents’ responses to daily surveys, those classified as non-responders within 2 weeks post discharge will be re-randomized to added low-intensity booster calls (one call with adolescent and one call with parent) or high-intensity boosters (six calls with each). Secondary aims are to: (1) Identify moderators of initial intervention options and of augmentation strategies for non-responders; and (2) Examine whether mechanisms of change (self-efficacy, safety plan use, coping) mediate the impact of MI-SP plus Texts and that of high- intensity boosters. The proposed research will have significant public health impact by testing different sequences of continuity of care strategies within an innovative SMART design to identify an optimal technology-augmented AI targeting suicidal behavior reduction among youth transitioning from inpatient care.