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

We propose a rigorous randomized trial to evaluate an innovative stepped care for suicide
prevention intervention for adolescents and young adults, compared to a zero suicide program
initiated by a health system. An effective zero suicide 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 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 zero suicide 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 suicide attempt risk using a
multi-stage screening process. Eligible youths will be randomized to: 1) zero suicide best
practices, which emphasizes health system quality improvement (ZSQI); or 2) ZSQI plus 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 zero suicide efforts, as many youths discontinue
care prematurely despite continuing risk. The ZSQI plus stepped care for suicide prevention
approach uses: 1) risk assessments to triage youths to appropriate care levels; 2) care
managers to deliver cognitive behavior therapy and dialectical behavior therapy skills
training and support primary care and emergency clinicians with patient evaluation and
treatment; 3) internet-delivered cognitive-behavior therapy and dialectical behavior therapy
treatment components plus access to coaching support 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 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. Results will provide critical information
for health systems and science regarding the potential to achieve zero suicide goals by
integrating state of the art science with practice quality improvement.

Inclusion Criteria:

1. Presence during past year of a suicide attempt, interrupted suicide attempt, aborted
suicide attempt, or active suicidal ideation with a plan; or 2) past year depression,
plus a history of a suicide attempt and/or recurrent self-harm;

2. Age 12-24 years

Exclusion Criteria:

1. Mental health/behavioral symptoms that would preclude productive engagement in study
assessments or intervention (e.g., active psychosis; drug dependence)

2. Life threatening medical illness or other characteristics that would impede study
participation (e.g. plans to move from Oregon during study period; plans for placement
out of the home, insufficient locator information for follow-up)

3. Youth receives majority of mental health care outside of the Kaiser-Permanente health
system.