Effect of a Motivational Interviewing–Based Intervention on Initiation of Mental Health Treatment and Mental Health After an Emergency Department Visit Among Suicidal Adolescents: A Randomized Clinical Trial
Open accessAbstract
Importance: Emergency department (ED) visits present opportunities to identify and refer suicidal youth for outpatient mental health care, although this practice is not routine. Objective: 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. Design, Setting, and Participants: 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. Interventions: 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. Main Outcomes and Measures: 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. Results: 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). Conclusions and Relevance: 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. Trial Registration: ClinicalTrials.gov identifier: NCT01779414.
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Previous studies have shown that 2-day training courses were sufficient to improve use of MI methods compared with TAU.
“Finally, previous studies have shown that 2-day training courses were sufficient to improve use of MI methods compared with TAU29,47,48,49,70 and we aimed at a realistic approach.”
From Efficacy of Motivational Interviewing to Improve Utilization of Mental Health Services Among Youths With Chronic Medical Conditions: A Cluster Randomized Clinical Trial (2021) · cites this paper as [48]
The Methods (Interventions) report a 2-day MI training course and significantly higher MI proficiency scores for STAT-ED practitioners than for enhanced-usual-care practitioners. But STAT-ED practitioners also received feedback on recorded encounters, so the study does not establish that the 2-day course alone was sufficient to produce the difference; the Limitations note that MI proficiency remained limited. (LLM, conf=0.85)
Experimental — accuracy not yet measuredShort MI seminars have been successful in teaching physicians basic MI skills, but proficiency and long-term experience are associated with its success.
“Short MI seminars have been successful in teaching physicians basic MI skills,36,47,48,49 but proficiency and long-term experience are associated with its success.”
From Efficacy of Motivational Interviewing to Improve Utilization of Mental Health Services Among Youths With Chronic Medical Conditions: A Cluster Randomized Clinical Trial (2021) · cites this paper as [48]
The Methods (Interventions; page unavailable) report that psychiatric social workers received two days of MI training and subsequently scored, on average, at the beginning proficiency level. This lends some support to short training teaching basic MI skills, but the trainees were not physicians and the paper does not describe their training as a seminar. The citation is attached to the first clause; the paper also does not establish the later claim about long-term experience. (LLM, conf=0.82)
Experimental — accuracy not yet measuredThe studies tracked participants for 2 months to 1 year after intervention and ascertained later suicide attempts through medical records or validated self-report.
“Studies followed up study participants for 2 months to 1 year after the intervention to identify subsequent suicide attempts and used either medical record review 28 or validated patient self-report measures [16][17][18]21,23,24 to ascertain suicide attempts.”
Seven studies (50%) assessed subsequent suicide attempts.
“Seven studies (50%) examined subsequent suicide attempts as an outcome, [16][17][18]21,23,24,28”
Three studies (21.4%) used both a brief therapeutic intervention and a brief contact intervention.
“For example, 3 studies (21.4%) included a brief therapeutic intervention plus a brief contact intervention.16,23,26”
Six studies (42.9%) assessed depression.
“and 6 (42.9%) examined depression as an outcome.15,16,[19][20][21][22]”
Nine studies (64.3%) assessed linkage to follow-up care.
“9 (64.3%)examined link to follow-up care as an outcome, 16,[19][20][21][24][25][26][27][28]”
Studies reporting a standard approach to missing data, including multiple imputation or last observation carried forward, were rated medium risk.
“Studies that described a standard method for handling missing data during analysis, such as multiple imputation or last observation carried forward, were assigned a medium risk score. 15,16,18,19,24,25”
Safety Planning Intervention was the most frequent brief therapeutic approach, appearing in 5 studies.
“The most common brief therapeutic intervention was the Safety Planning Intervention, which was delivered in 5 studies.16,18,24,27,28”
Excluding the study by Asarnow et al. resulted in the pooled effect size for depression symptoms among the remaining studies being statistically significant (Hedges g=0.38, 95% CI 0.05-0.71).
“Excluding the study by Asarnowet al 16 resulted in the pooled effect size for the remaining studies being statistically significant (Hedges g = 0.38 [95% CI, 0.05-0.71]).”
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Suicide Prevention in Pediatric Health Care Settings
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Detecting Suicide Risk Among Pediatric Patients: Screening, Clinical Pathways, and Care
Horowitz, L. M., Lowry, N. J., Shi, T., Merai, R., Pao, M., & Bridge, J. A. (2025) · Annual Review of Clinical Psychology · doi:10.1146/annurev-clinpsy-081423-021101 · Cited by 3 · see citing works
Self-citationMotivational Interviewing in an Animal Shelter – A Pilot Study
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Follow-Up Care Offers and Acceptance in Crisis Line Suicide Prevention Services
Fulginiti, A., Doyle, M., Miller, S. M., Lee, S., & Pasquarella, F. J. (2024) · Crisis · doi:10.1027/0227-5910/a000970 · Cited by 1 · see citing works
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Suicide Prevention: Literature Review
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Screening for Suicide Risk in Hospital Admissions: What are the Next Questions?
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Suicide Prevention in Emergency Department Settings
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Suicide Prevention in Emergency Department Settings
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Striking a balance: triage and crisis intervention models within the pediatric emergency room
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COVID-19 stay-at-home orders impacts on suicide attempts among adolescents in the United States
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- Authors
- Grupp-Phelan, J., Stevens, J., Boyd, S., Cohen, D. M., Ammerman, R. T., Liddy-Hicks, S., Heck, K., Marcus, S. C., Stone, L., Campo, J. V., & Bridge, J. A.
- Affiliations
- Division of Pediatric Emergency Medicine, UCSF (University of California, San Francisco) Benioff Children’s Hospitals, San Francisco, California
- Nationwide Children's Hospital (US)
- Cincinnati Children's Hospital Medical Center (US)
- University of Pennsylvania (US)
- West Virginia University (US)
- Corresponding author
- Bridge, Jeffrey A.
- ORCID
- Venue
- JAMA Network Open
- Publisher
- American Medical Association (AMA)
- Published
- 2019-12-20
- Volume
- 2
- Issue
- 12
- Pages
- e1917941
- ISSN
- 2574-3805 (ISSN-L)
- PMC
- PMC6991223
- OpenAlex
- W2995803888
- Cited by
- 57
- References
- 32
- Citations by year
- 2026: 5 · 2025: 6 · 2024: 10 · 2023: 15 · 2022: 6 · 2021: 9 · 2020: 6
- FWCI
- 6.13
- Type
- journal article
- Language
- en
- Open access
- gold
- doi.org
- Licence
- cc-by
- Locations
- JAMA Network Open (publishedVersion, cc-by)
- PubMed Central (publishedVersion, cc-by)
- PubMed (publishedVersion)
- The Research Repository @ WVU (West Virginia University) (submittedVersion, cc-by)
- Funders
- Centers for Disease Control and Prevention (R01CE002129)
- National Institute of General Medical Sciences (U54GM104942)
- National Center for Injury Prevention and Control
- Topics
- Social Sciences › Psychology › Clinical Psychology › Suicide and Self-Harm Studies
- Social Sciences › Psychology › Social Psychology › Mental Health Treatment and Access
- Social Sciences › Psychology › Clinical Psychology › Psychiatric care and mental health services
- Keywords
- motivational interviewing, suicidal adolescents, emergency department visits, outpatient psychiatric care, suicidal ideation, depressive symptoms, suicide risk screening, family involvement, case management, suicide attempts, pediatric emergency care, suicide prevention, school-based intervention, school-based mental health services
- MeSH terms
- Adolescent, Adolescent Behavior, Psychology, Adolescent, Emergency Services, Psychiatric, Female, Follow-Up Studies, Humans, Suicide, Attempted, United States, Treatment Outcome, Suicidal Ideation, Motivational Interviewing
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