Abstract
Emergency department (ED) visits present opportunities to identify and refer suicidal youth for outpatient mental health care, although this practice is not routine. To examine whether a motivational interviewing-based intervention increases linkage of adolescents to outpatient mental health services and reduces depression symptoms and suicidal ideation in adolescents seeking emergency care for non-mental health-related concerns who screen positive for suicide risk. In this randomized clinical trial, adolescents aged 12 to 17 years who screened positive on the Ask Suicide Screening Questions (ASQ) during a nonpsychiatric ED visit at 2 academic pediatric EDs in Ohio were recruited from April 2013 to July 2015. Intention-to-treat analyses were performed from September 2018 to October 2019. The Suicidal Teens Accessing Treatment After an Emergency Department Visit (STAT-ED) intervention included motivational interviewing to target family engagement, problem solving, referral assistance, and limited case management. The enhanced usual care (EUC) intervention consisted of brief mental health care consultation and referral. Primary outcomes were mental health treatment initiation and attendance within 2 months of ED discharge and suicidal ideation (assessed by the Suicidal Ideation Questionnaire JR) and depression symptoms (assessed by the Center for Epidemiologic Studies-Depression scale) at 2 and 6 months. Exploratory outcomes included treatment initiation and attendance and suicide attempts at 6 months. A total of 168 participants were randomized and 159 included in the intention-to-treat analyses (mean [SD] age, 15.0 [1.5] years; 126 [79.2%] female; and 80 [50.3%] white). Seventy-nine participants were randomized to receive the STAT-ED intervention and 80 to receive EUC. At 2 months, youth in the STAT-ED group had similar rates of mental health treatment initiation compared with youth in the EUC group as assessed by parent report (29 [50.9%] vs 22 [34.9%]; adjusted odds ratio [OR], 2.08; 95% CI, 0.97-4.45) and administrative data from mental health care agencies (19 [29.7%] vs 11 [19.3%]; adjusted OR, 1.77; 95% CI, 0.76-4.15). At 2 months, youth in the STAT-ED group and the EUC group had similar rates of treatment attendance (1 appointment: 6 [9.7%] vs 2 [3.6%]; adjusted OR, 2.97; 95% CI, 0.56-15.73; ≥2 appointments: 10 [16.1%] vs 7 [12.7%]; adjusted OR, 1.43; 95% CI, 0.50-4.11). There were no significant group × time differences in suicidal ideation (F = 0.28; P = .72) and depression symptoms (F = 0.49; P = .60) during the 6-month follow-up period. In exploratory analyses, at 6 months, STAT-ED participants had significantly higher rates of agency-reported mental health treatment initiation (adjusted OR, 2.48; 95% CI, 1.16-5.28) and more completed appointments (t99.7 = 2.58; P = .01). This study's findings indicate that no differences were found on any primary outcome by study condition. However, STAT-ED was more efficacious than EUC at increasing mental health treatment initiation and attendance at 6 months. ClinicalTrials.gov identifier: NCT01779414.
Highlights
Suicide is the second leading cause of death in adolescents aged 12 to 17 years in the United States, and the rate of adolescent suicide increased 87% between 2007 and 2016.1 The annual prevalence of adolescent suicide attempts, the most robust risk factor of youth suicide,[2] is 8.6%, and the rate of attempts that require emergency medical care has increased.[3]With suicide prevention a national priority,[4,5] The Joint Commission recommends that hospitals screen all medical patients for suicide risk.[6]
At 2 months, youth in the STAT-emergency department (ED) group had similar rates of mental health treatment initiation compared with youth in the enhanced usual care (EUC) group as assessed by parent report (29 [50.9%] vs 22 [34.9%]; adjusted odds ratio [OR], 2.08; 95% CI, 0.97-4.45) and administrative data from mental health care agencies (19 [29.7%] vs 11 [19.3%]; adjusted OR, 1.77; 95% CI, 0.76-4.15)
STAT-ED was more efficacious than EUC at increasing mental health treatment initiation and attendance at 6 months
Summary
Suicide is the second leading cause of death in adolescents aged 12 to 17 years in the United States, and the rate of adolescent suicide increased 87% between 2007 and 2016.1 The annual prevalence of adolescent suicide attempts, the most robust risk factor of youth suicide,[2] is 8.6%, and the rate of attempts that require emergency medical care has increased.[3]With suicide prevention a national priority,[4,5] The Joint Commission recommends that hospitals screen all medical patients for suicide risk.[6]. Only 2 pilot studies[10,11] have evaluated the efficacy of interventions for adolescents seeking emergency care for non–mental health–related concerns who screen positive for suicide risk. In 1 study,[10] adolescents who received the Teen Options for Change intervention had a significant reduction in depression symptoms compared with an enhanced usual care (EUC) group during the 2 months after their ED visit, but no significant group differences on suicidal ideation and mental health service use were found. A previous pilot randomized clinical trial[12] assessed the effectiveness of a brief, ED-based mental health service engagement intervention to increase linkage to outpatient mental health services in teens presenting with medical chief concerns and no recent history of mental health issues who screened positive for suicide risk factors using the Columbia Suicide Severity Rating Scale (C-SSRS). Results suggested that adolescents receiving the intervention were more likely than those in the standard referral group to attend a mental health care appointment during the follow-up period
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