Providing Practice Experiences for School Reintegration (PrESR) to Youth Hospitalized for Suicide-Related Crises 

Summary 

Rates of adolescent suicide-related thoughts and behaviors¹ and psychiatric hospitalization for suicide-related crises have risen over the past decade.^2,3 From 2011 to 2021 the rate of high school students reporting a past-year suicide attempt increased from 8% to 10%,¹ and between 2008 and 2015 rates of hospitalization for suicide-related crises increased from 0.66% to 1.82%.² Although the immediate period following hospital discharge is considered high-risk for subsequent hospitalizations and suicide attempts,⁴ few interventions address the transition from psychiatric hospitalization back into the community.⁵ Although most youth return to schools following hospitalization, schools may be ill-prepared to support these students.⁶ The project’s purpose is to develop, refine, and pilot test a virtual reality intervention, Practice Experiences for School Reintegration (PrESR), provided to youth hospitalized for suicide-related crises. This intervention teaches therapeutic skills, provides practice opportunities to use these skills in stressful situations, and prepares youth for their return to school settings.⁷

Marraccini, both a licensed psychologist and nationally certified school psychologist, led the development of the PrESR to improve interventions delivered during psychiatric hospitalization and to prepare adolescent patients for their return to school. The PrESR was designed based on input and experiences shared by adolescents with lived experience, as well as school and hospital professionals with experience supporting adolescents during and following suicide- related crises. The model was designed to enhance existing treatment by providing lessons on cognitive behavioral therapy (CBT) skills. The intervention also provides scenarios that mimic stressful situations where patients can practice using their new CBT skills. By learning and practicing skills in lifelike scenarios, patients may better understand and apply skills in real life. Although CBT often involves longer treatment protocols than what is feasible for inpatient treatment models, the PrESR was designed with these constraints in mind.⁷ Sessions can be flexibly applied based on patient needs and length of hospitalization (ideally including a minimum of three 40-minute sessions, but up to 10 sessions).

The research team tested a pilot version of the intervention with adolescents and professionals, and further refined it based on their feedback. Presently, the researchers are conducting a pilot optimization trial of the PrESR with adolescents hospitalized for suicide-related thoughts and behaviors. Findings from this trial will help inform how to conduct a larger investigation, possibly to identify the intervention’s best components (like specific CBT skills including affect regulation, cognitive restructuring, and problem solving) or to examine the intervention’s effectiveness for improving outcomes. Findings from this trial, along with an open trial with clinicians and hospitalized adolescents, will also inform barriers and facilitators to implementation.

Significance

The PrESR will likely improve adolescent patient quality of care during psychiatric hospitalization for suicide-related crises in addition to helping facilitate improved school re-integration for adolescent patients following discharge. These outcomes will likely contribute to improved psychological functioning and wellness among adolescents and reduce their risk for suicide-related thoughts and behaviors. Additionally, it is expected that the PrESR will support clinicians working in inpatient settings by providing a structured psychological intervention that can be delivered by a wide range of professionals working in the hospital, including social workers, counselors and therapists, interns, and trainees. This model will also likely improve treatment quality provided to hospitalized youth and contribute to reduced burnout among staff.

Youth hospitalized for suicide-related thoughts and behaviors are a vulnerable population, presenting with complex symptoms and treatment implications. Moreover, rates of suicidal thoughts and behaviors among ethnic and racial minoritized youth have risen in recent years;⁸ also, rates are disproportionally higher among youth identifying as lesbian, gay, bisexual, transgender, queer or questioning (LGBTQ+).⁹ Treatment during hospitalization varies based on the community and hospital providing services, with a focus on stabilization, safety, and medication management.^10,11 By developing an intervention that can be consistently delivered across hospital settings, the PrESR aims to increase supports for youth hospitalized for suicide-related crises, irrespective of the hospital in which they are seen.

Benefits

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

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

The PrESR is a virtual reality application that can be used on a headset to deliver lessons on therapeutic skills. demonstrated.

Clinical

Software technologies

The PrESR is a new tool developed with providers and patients to augment treatment provided to adolescents hospitalized for suicide-related thoughts and behaviors. potential.

Clinical

Therapeutic procedures

A clinical trial will be conducted to determine the efficacy of PrESR for improving well-being and preventing suicide-related thoughts and behaviors. potential.

Community

Disease prevention & reduction

The PrESR aims to enhance quality of care during adolescent hospitalization by providing engaging learning experiences for youth allowing them to learn and practice using therapeutic skills that support their transition following hospital discharge. potential.

Community

Health care quality

The PrESR aims to prevent suicide among adolescents and improve their hospital and discharge experiences. potential.

Community

Life expectancy & quality of life

This research has clinical and community 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.¹² 

Clinical

The PrESR aims to enhance quality of care for adolescents hospitalized for suicide-related crises. Formative data collected from patients to date suggests that most adolescent participants reported “feeling better” based on their ratings on a standardized feedback form after using the PrESR.

Community

Ultimately, the PrESR is meant to be integrated into clinical care such that clinicians will have access to a structured virtual reality tool to enhance their intervention services in an efficient manner. The goal of the PrESR is to reduce the burden on core clinical staff while increasing treatment availability to patients.

Lessons Learned

Partnership with the UNC hospitals and involvement with patients was critical to the development of the PrESR. Further research takes this approach further, by prioritizing patient and public involvement in the expansion of the intervention.