Department of Psychiatry, University of Michigan, Ann Arbor, MI, USA.
Department of Psychology, University of Michigan, Ann Arbor, MI, USA.
J Child Psychol Psychiatry. 2021 Aug;62(8):1019-1031. doi: 10.1111/jcpp.13383. Epub 2021 Feb 15.
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.
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).
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.
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.
需要为有不同程度出院后自杀风险的精神病住院青少年提供有效的干预措施,这需要个性化的方法,例如适应性干预(AI)。我们进行了一项非限制的试点序贯、多次分配、随机试验(SMART),以指导针对住院后自杀风险的 AI 的开发。
将 80 名青少年住院患者(年龄 13-17 岁;女性占 67.5%)随机分为第一阶段接受强化安全计划的动机访谈(MI-SP),该计划在住院期间单独或与出院后的基于文本的支持(Texts)联合提供。出院后两周,参与者在第二阶段重新随机分配接受附加电话增强电话或不接受电话。在四周、一个月和三个月的随访期间,通过每日日记评估变化机制。这项试验在 clinicaltrials.gov 上注册(标识符:NCT03838198)。
程序是可行且可接受的。混合效应模型表明,随机分配到 MI-SP+Texts(第一阶段)和随机分配到增强电话(第二阶段)的青少年在每日水平的机制上都有显著改善,包括安全计划的使用、避免自杀行为的自我效能感以及通过寻求支持来应对。与单独接受 MI-SP 相比,随机分配到 MI-SP+Texts 的青少年在一个月和三个月时的应对自我效能感也显著更高。虽然这是探索性的,但 MI-SP+Texts 与 MI-SP 相比,在出院后三个月自杀企图(风险比=0.30;95%CI=0.06,1.48)和自杀行为(风险比=0.36;95%CI=0.10,1.37)的风险较低方面的结果朝着预期的方向发展。此外,增强增强电话对自杀企图(风险比=0.65;95%CI=0.17,3.05)或自杀行为(风险比=0.78;95%CI=0.23,2.67)没有整体有意义的影响;然而,增强电话对最初分配到 MI-SP+Texts 的人最有益。
当前的 SMART 对于为自杀青少年提供 AI 是可行和可接受的,值得进一步研究。研究结果还表明,出院后的基于文本的支持为住院期间提供的安全计划提供了有前途的增强。