Adaptive Intervention for Prevention of Adolescent Suicidal Behavior After Hospitalization: a Pilot Sequential Multiple Assignment Randomized Trial

Background: The need for effective interventions for psychiatrically hospitalized adolescents who have varying levels of postdischarge suicide risk calls for personalized approaches, such as adaptive interventions (AIs). We conducted a nonrestricted pilot Sequential, Multiple Assignment, Randomized Trial (SMART) to guide the development of an AI targeting suicide risk after hospitalization.

Methods: Adolescent inpatients (N = 80; ages 13-17; 67.5% female) were randomized in Phase 1 to a Motivational Interview-Enhanced Safety Plan (MI-SP), delivered during hospitalization, alone or in combination with postdischarge text-based support (Texts). Two weeks after discharge, participants were re-randomized in Phase 2 to added telephone booster calls or to no calls. Mechanisms of change were assessed with daily diaries for four weeks and over a 1- and 3-month follow-up. This trial is registered with clinicaltrials.gov (identifier: NCT03838198).

Results: Procedures were feasible and acceptable. Mixed effects models indicate that adolescents randomized to MI-SP + Texts (Phase 1) and those randomized to booster calls (Phase 2) experienced significant improvement in daily-level mechanisms, including safety plan use, self-efficacy to refrain from suicidal action, and coping by support seeking. Those randomized to MI-SP + Texts also reported significantly higher coping self-efficacy at 1 and 3 months. Although exploratory, results were in the expected direction for MI-SP + Texts, versus MI-SP alone, in terms of lower risk of suicide attempts (Hazard ratio = 0.30; 95% CI = 0.06, 1.48) and suicidal behavior (Hazard ratio = 0.36; 95% CI = 0.10, 1.37) three months after discharge. Moreover, augmentation with booster calls did not have an overall meaningful impact on suicide attempts (Hazard ratio = 0.65; 95% CI = 0.17, 3.05) or suicidal behavior (Hazard ratio = 0.78; 95% CI = 0.23, 2.67); however, boosters benefited most those initially assigned to MI-SP + Texts.

Conclusions: The current SMART was feasible and acceptable for the purpose of informing an AI for suicidal adolescents, warranting additional study. Findings also indicate that postdischarge text-based support offers a promising augmentation to safety planning delivered during hospitalization.