Adaptive intervention for prevention of adolescent suicidal behavior after hospitalization: a pilot sequential multiple assignment randomized trial
Open accessAbstract
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.
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Results for all outcomes were consistent with those of the full sample after removal of non-RCT-designed studies and on inclusion of studies that involved any SPI component in the control condition.
“Results for all outcomes were consistent with those of the full sample after removal of non–RCT-designed studies and on inclusion of studies that involved any SPI component in the control condition39,42 (eFigure in Supplement 1).”
From Safety Planning Interventions for Suicide Prevention in Children and Adolescents (2025) · cites this paper as [39]
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Self-citation
- Authors
- Czyz, E. K., King, C. A., Prouty, D., Micol, V. J., Walton, M., & Nahum‐Shani, I.
- Affiliations
- University of Michigan (US)
- Institute for Social Research University of Michigan Ann Arbor MI USA
- Corresponding author
- Czyz, Ewa K.
- Venue
- Journal of Child Psychology and Psychiatry
- Publisher
- Wiley
- Published
- 2021-02-15
- Volume
- 62
- Issue
- 8
- Pages
- 1019-1031
- ISSN
- 0021-9630 (ISSN-L)
- 1469-7610
- PMC
- PMC10044463
- OpenAlex
- W3129292092
- Cited by
- 54
- References
- 50
- Citations by year
- 2026: 9 · 2025: 16 · 2024: 11 · 2023: 5 · 2022: 7 · 2021: 6
- FWCI
- 4.95
- Type
- journal article
- Language
- en
- Open access
- bronze
- doi.org
- Locations
- Journal of Child Psychology and Psychiatry (publishedVersion)
- PubMed (publishedVersion)
- PubMed Central (acceptedVersion)
- Deep Blue (University of Michigan) (submittedVersion)
- Funders
- National Institute of Mental Health (K23‐MH‐113776‐01)
- Topics
- Social Sciences › Psychology › Clinical Psychology › Suicide and Self-Harm Studies
- Social Sciences › Psychology › Applied Psychology › Digital Mental Health Interventions
- Social Sciences › Psychology › Clinical Psychology › Personality Disorders and Psychopathology
- Keywords
- adaptive interventions, adolescent suicide prevention, suicidal behavior, psychiatric hospitalization, motivational interviewing, safety planning, coping self-efficacy, suicide attempts, personalized interventions, mechanisms of change, support seeking, sequential multiple assignment randomized trial, daily diary
- MeSH terms
- Adolescent, Adolescent Behavior, Aftercare, Female, Hospitalization, Humans, Male, Patient Discharge, Suicide, Attempted, Suicidal Ideation
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