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，紧急情况 由于青少年自杀风险，部门就诊和精神科住院的人数也在上升。 虽然精神科住院提供了关键的稳定，但出院的青少年仍处于高位 反复出现自杀危机的风险(例如，自杀未遂、再次住院)。迫切需要新的方法 需要改变危险轨迹并防止青少年从住院过渡到自杀行为 关心。弥合适应性干预(AI)策略-其中治疗的类型、强度和时机可以 个人化以满足自杀青少年不断变化的和不同的治疗需求--与 在高危出院后期间接触青少年的移动技术，我们的目标是确定 减少青少年住院护理后自杀行为的最佳人工智能。我们建立在有希望的证据上 最近完成了一项由NIMH资助的序贯多分配随机试验(SMART) 组成部分干预包括：向以下人员提供激励性访谈(MI)增强的安全计划 青少年和父母住院期间(MI-SP)；向青少年和 父母；以及在出院后一个月内每天向青少年提供基于文本的支持(文本)。此外 为了可行性和可接受性，试点SMART结果表明，某些干预序列得到了改进 改变的关键机制(自我效能、安全计划的使用、应对)，初步与 在出院后3个月降低自杀行为。在本申请中，我们建议进行全面的 智能解决以下具体目标：(1)比较仅以MI-SP或MI-SP+开头的人工智能 关于3个月内自杀行为(实际的、中断的或失败的)主要后果的文本 出院后自杀行为持续时间和自杀意念严重程度的两种继发性结果 超过6个月；以及(2)通过比较四个人工智能来确定干预组件的最佳顺序 嵌入在SMART中的主要和次要结果。青少年(N=300)，年龄13-17岁，住院 由于自杀意念和/或企图，最初将被随机分为单独的MI-SP或有文本的MI-SP。基座 关于青少年对每日调查的反应，在出院后2周内被归类为无应答者 将被重新随机分配到增加的低强度助推器呼叫(一个呼叫青少年，一个呼叫家长)或 高强度助推器(每个电话六次)。次要目标是：(1)确定初始 针对无应答者的干预选择和加强战略；以及(2)审查机制是否 改变(自我效能、安全计划使用、应对)在MI-SP加文本的影响和高-SP+文本的影响之间起中介作用 强度增强剂。这项拟议的研究将通过测试不同的 创新智能设计中的连续性护理策略序列，以确定最佳 技术增强的人工智能旨在减少从住院护理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.