Caring Contacts to Prevent Youth Suicide after an Emergency Department Visit

Summary

Suicide is the third leading cause of death among US adolescents 12-17 years old.¹ Only 35% of youth who die by suicide have received traditional mental health services.² Suicide prevention interventions are needed that can be deployed in non-mental health settings. From 2008-2015, emergency department (ED) visits and hospitalizations by youth for suicidal thoughts and behaviors doubled.³ Of youth seen in the ED for suicidal thoughts and behaviors, as many as 22% attempt suicide within 1 year of the ED visit.⁴ The ED represents a critical contact point to detect suicide risk and initiate suicide prevention interventions.

Caring Contacts are brief messages of care and concern sent to individuals at risk of suicide, usually over a year or more, that do not ask for any response or action from the recipient.⁵  Caring Contacts may work by communicating belonging/connectedness and increasing perceived social support, with recipients making remarks such as, “Thank you for taking the time to recognize that I exist” and “I felt like my life matters”.^6,7 Originally developed in the 1970s and delivered by postal mail, Caring Contacts have recently been translated into text message format. Among adult military personnel, receipt of Caring Contacts by text message decreased the odds of suicidal ideation by 44% and suicide attempts by 48% during follow-up, compared to standard care.⁸ However, few studies have evaluated Caring Contacts among adolescents.⁹ Because text message-based interventions are low burden and scalable, they are well suited to translation to the ED, which has limited resources for suicide prevention.  

In this research study, a multidisciplinary team consisting of pediatric emergency medicine physicians (Drs. Hoffmann and Alpern), experts in design of digital mental health interventions (Dr. Graham), and implementation scientists (Drs. Hoffmann and Beidas) will adapt Caring Contacts via text message to align with adolescent preferences and optimize effectiveness. We will interview adolescents with lived experience, who have visited the emergency department for suicidal thoughts or behaviors, to understand their preferences for text message content, delivery schedule, and how and when to introduce Caring Contacts during an ED visit. Next, we will pilot Caring Contacts delivered via text message after an ED visit to adolescents with suicidal thoughts or behaviors to assess preliminary effectiveness and intervention mechanisms. Finally, we will elucidate barriers and facilitators to implementation of Caring Contacts in the ED to plan for future real-world implementation. 

Significance

These data will support a planned full-scale trial to understand whether Caring Contacts are effective in preventing suicide among youth after ED discharge, and to assess whether Caring Contacts can be implemented successfully in the ED setting. If successful, Caring Contacts have potential to reduce suicides among adolescents during the high-risk, critical time of transition following discharge from the ED. Caring Contacts also have potential to prevent suicide among adolescents who do not access traditional mental health services. This will preserve young lives and future potential while sparing families and peers the profound trauma that follows a suicide. Schools and neighborhoods will remain connected and stable rather than disrupted by crisis and grief. At a societal level, fewer suicidal crises will reduce strain on emergency and behavioral health services and help preserve lifetime productivity.

Benefits

Demonstrated benefits are those that have been observed and are verifiable.

Potential benefits are those logically expected with moderate to high confidence.

Clinical & medical benefits

Aligned Caring Contacts with preferences of adolescents with lived experience. demonstrated.

Patient-guided research

Primary beneficiary:

Patients

Reduce suicide risk through delivery of Caring Contacts to adolescents during the high-risk period after an emergency department visit. potential.

Therapeutic procedures

Primary beneficiary:

Patients

Community & public health benefits

Increase ease of delivery and scalability of Caring Contacts by exploring delivery by text message rather than traditional mail.  potential.

Health care delivery

Primary beneficiary:

Patients

Reach adolescents at risk for suicide who do not access traditional mental health services.  potential.

Health care accessibility

Primary beneficiary:

Patients

Prevent youth suicide, a leading cause of death among US youth.  potential.

Life expectancy & quality of life

Primary beneficiary:

Patients

Economic benefits

Reduce disruptions and trauma among family members, schools, and communities affected by suicide loss.  potential.

Societal & financial cost of illness

Primary beneficiary:

Communities / Public

This research has clinical, community, and economic implications. The framework for these implications was derived from the Translational Science Benefits Model created by the Institute of Clinical & Translational Sciences at Washington University in St. Louis.¹⁰

Clinical

The goal of our work is to design Caring Contacts so that they are aligned with adolescents’ preferences and to determine how well they work to reduce suicide risk among adolescents after an emergency department visit. We will test the feasibility of delivering Caring Contacts by text message, rather than postal mail, to increase scalability and ease of deployment.

Community

Only about one-third of youth who die by suicide have accessed traditional mental health services. Our work tests a promising suicide prevention intervention, Caring Contacts, that can be delivered to adolescents following an emergency department visit, expanding prevention efforts to a high-risk population that may not otherwise be receiving mental health services. Our goal is to determine if Caring Contacts can prevent youth suicide, a leading cause of death among US youth.

Economic

If Caring Contacts can prevent youth suicide, it will reduce loss of life at a young age and prevent years of work productivity lost. Moreover, the impact will also extend to family members, schools, and communities that would otherwise be affected by suicide loss.

Lessons Learned

• Engage patients, their families, healthcare teams, and hospital experts in all stages of the project. Those who will use the intervention should be involved as partners throughout the entire process.
• Identify the people and steps required to implement interventions into routine care. Often, there are more people and steps involved in this process than originally thought.