Skills to Enhance Positive Affect in Suicidal Adolescents

The prevalence of suicidal behaviors in adolescents remains unacceptably high. Reviews of
published randomized controlled trials (RCTs) for adolescent suicidality conclude that
treatments to date have been minimally efficacious. The preponderance of interventions focus
on crisis intervention, underlying psychiatric disorders, regulating negative affect and
reducing cognitive distortions. However, our pilot work and other recent data suggest the
importance of considering how low positive affectivity contributes to suicide risk
independent of other risk factors and may be another mechanism that leads to suicidal
behaviors. Our model is based on Fredrickson's empirically-supported Broaden and Build model
which asserts that the function of positive affect (PA) includes helping individuals thrive
by improving social supports, problem-solving, and personal resilience. Each of these areas
is instrumental in decreasing suicidal behavior. We propose that PA increases survival
directly by decreasing suicidal ideation and indirectly by increasing social support and
problem-solving. In this R34 treatment development grant we seek to develop a novel,
individual skills-based, PA intervention, delivered adjunctively to treatment as usual (TAU),
targeting the highest risk adolescents - those hospitalized due to suicide risk. We focus on
three strategies that have been demonstrated to increase sustainable (vs. transient) PA in
community and depressed adults: meditation, gratitude, and savoring. There are several ways
to practice each strategy; we take into account patient preferences in a personalized
approach in which patients select the practice(s) that fits best with their needs and
circumstances. We propose using multiple means of intervention delivery that includes text
messaging, to reinforce in-vivo practice. Our intervention, Skills To Enhance Positivity
Program (STEP) includes two phases: a) in-person phase consisting of 3 individual in-person
sessions and 1 joint parent session during the inpatient hospital stay to teach positive
affect skills and develop a personalized intervention; b) remote delivery phase which
consists of weekly telephone booster calls and daily text messages over 4 weeks
post-discharge. The phone calls will be used to review or adjust personalized intervention
components and reinforce use of skills. The text messages will include self-scripted
reminders to practice skills and links to online resources. STEP will be tested in an open
trial with 20 participants, and after further revision, in a pilot RCT, compared to TAU in a
sample of 50 adolescents. The primary goal of this intervention is for patients to increase
positive affect by incorporating skills and practices into their normal home-based routines,
which we believe will lead to increases in problem-solving and social support and decreases
in suicidal ideation. This is a novel intervention for a high-risk acute population via a
different mechanism (i.e. PA), and conceptually distinct from other empirically examined
theoretical approaches.

Inclusion Criteria:

- current hospital admission due to concern of suicide risk

- ability of patient to speak, read, and understand English sufficiently well to
complete the procedures of the study

- living at home

Exclusion Criteria:

- active psychotic disorder

- cognitive deficits that preclude full understanding of study materials

- adolescents who have become wards of the state and do not intend to return to the home
of their biological or adoptive parents