Developing Adaptive Interventions for Suicidal College Students Seeking Treatment - SMART

The primary aim of this proposal is to conduct feasibility research to inform the
implementation of a future full-scale SMART (sequential, multiple assignment, randomized
trial, Almirall et al., 2012) that will be used to construct adaptive treatment strategies
(ATSs) to address suicidality in college students seeking services at college counseling
centers (CCCs). ATSs individualize treatment via decision rules that can specify how the type
and intensity of an intervention should be sequenced based on variables collected
mid-treatment (or at baseline), such as response to treatment. Suicidality is a frequent
presenting concern among college students seeking treatment; yet, studies with this
population show that some students respond rapidly to treatment whereas others may require
considerably more resources. However, at this time, CCCs, which are overburdened and often
have to resort to waitlists, have no guidance as to how to sequence different approaches with
suicidal students in an empirically-based and cost effective manner. Therefore, empirically
validated ATSs are needed in the provision of services to suicidal college students to
address the heterogeneity of students with this presentation and the variability in response
to interventions. In the present pilot SMART, each participant will progress through two
stages of intervention. In the first stage (S1) 60 participants will be randomized to one of
two brief individual therapy interventions for 4-8 weeks: 1) one that is suicidality-focused
(Collaborative Assessment and Management of Suicidality (CAMS; Jobes, 2006) and 2) one that
relies on Treatment as Usual (TAU) being provided at a CCC. Responders to either program will
discontinue services/ be stepped down and be monitored over time for maintenance.
Non-responders to either intervention who remain in treatment (estimated n = 18) will be
re-randomized to one of two second-stage (S2) higher intensity/dosage intervention options
for an additional 4-16 weeks: 1) CAMS (either continued but for longer period of time or
administered for the first time) or 2) Comprehensive Dialectical Behavior Therapy (DBT,
Linehan, 1993a, 1993b) which includes individual therapy, skills groups, and phone coaching
for the clients and DBT peer consultation for the therapists. This study will enroll
moderately to severely suicidal (endorsing thoughts of wanting to die of 2 or above on 0-4
scale) college students in the "emerging adulthood" phase (18-25 years of age) seeking
services at a CCC. The aims of this feasibility services research project are to 1) develop
and refine a SMART design in a CCC setting; 2) assess the feasibility of conducting a SMART
and its embedded ATSs in a CCC setting; 3) obtain estimates of overall response rate to S1
interventions; and 4) explore the utility of incorporating secondary tailoring variables
(e.g., level of functioning at pre-treatment, ratio of Wish to Live vs. Wish to Die) in the
ATSs in the subsequent larger trial.

Inclusion Criteria:

- enrolled student at University of Nevada, Reno (UNR)

- seeking services at Counseling Services at UNR

- 18 to 25 years of age

- moderate to severe suicidality (indicated by a score of 2 or above (range is 0 "not at
all like me" to 4 "extremely like me") on the Counseling Center Assessment of
Psychological Symptoms (CCAPS-34; Locke et al., 2012) question "I have thoughts of
ending my life."

Exclusion Criteria:

- individual is deemed inappropriate to receive services at UNR Counseling Services by
the intake worker (the primary exclusion criterion).

- participant cannot have been in treatment at UNR Counseling Services within the
previous 3 months.