With the staggeringly high rates of youth suicide the U.S. is currently facing—it’s the second leading cause of death for youth aged 10 to 14 and the third leading cause of death for young adults aged 15 to 24 (CDC)—it’s imperative to identify and implement effective strategies to prevent these tragic deaths.
To this end, a research team led by Duke University’s David Goldston, PhD, and UCLA’s Joan Asarnow, PhD, is investigating how to improve care and outcomes among youth during and after emergency department (ED) visits for suicidal risk or behaviors.
Goldston and Asarnow are comparing a crisis therapy session in the ED focused on enhancing safety (Safety-Acute, or SAFETY-A), and SAFETY-A plus a series of brief, phone- or Zoom-based therapeutic follow-up contacts for one year after the youth’s discharge from the hospital (Coping Long-Term with Active Suicide Program, or CLASP). Evidence supports benefits of both interventions individually.
Goldston is an associate professor of psychiatry and behavioral sciences in the Duke University School of Medicine, and Asarnow is a professor of psychiatry and biobehavioral sciences in the David Geffen School of Medicine at UCLA. Their study, funded by the Patient-Centered Outcomes Research Institute (PCORI), spans eight EDs at four academic institutions across the U.S.: Duke University, UCLA, Brown University, and the University of Utah. The study includes more than 1,500 participants ages 15 to 24, with a pending request to expand the study to 13- and 14-year-olds.
Reducing Gaps in Care
Goldston notes that many youths who present to EDs with suicidal episodes do not receive evidence-based care in that setting, and often they don’t receive follow-up care for suicidal risk or behaviors after their ED visit, when they may still be at high risk for suicide.
“Brief interventions have the potential to help reduce later suicide attempts and help young people access treatment after discharge from the emergency department,” Goldston said. “It is not known, however, whether interventions in the ED are sufficient to promote safety, or whether additional brief therapeutic contacts and check-ins with young people help improve outcomes.”
“Our study’s results will clarify whether the additional resources needed to provide therapeutic follow-up calls following an ED intervention lead to improved outcomes, and which patient subgroups are most likely to benefit from a treatment approach that provides therapeutic contact both during the ED visit and after discharge,” said Asarnow. “This information can guide decision-makers regarding how to best develop services and service systems to improve patient outcomes and achieve national suicide prevention goals, including for diverse groups to improve equity.”
Goldston highlights the intentional diversity of the sample, which includes participants of different racial and ethnic backgrounds, LGBTQ youth, youth from rural communities, and young people from socioeconomically disadvantaged families. Importantly, the study sample is large enough that the team will be able to evaluate the effectiveness of the interventions not only across all participants, but also by subgroup.
Broad Input Benefits Study
The project features partnerships among researchers, patients, parents, family members, health and mental health care providers, administrators, payers and policy makers to ensure that results are informed by and important to youth, family members, clinicians and other stakeholders.
“A lot of our partners are people who have had lived experience with suicide risk or attempts ... so they’re bringing that important perspective. It’s been really helpful to us.”
— David Goldston, PhD
“We’ve had community partners involved every step of the way, and that’s been a real benefit to the project,” said Goldston. “A lot of our partners are people who have had lived experience with suicide risk or attempts—for example, they may have had a son or daughter hospitalized after suicide attempts, or lost a son or daughter to suicide—so they’re bringing that important perspective. It’s been really helpful to us.”
About the Interventions
Safety Acute (SAFETY-A), is a brief, trauma-informed, strengths-based intervention to address immediate suicide risk in individuals. This evidence-based intervention was originally developed for young people in the emergency department but has also been implemented in schools, juvenile detention environments, and other settings.
Designed as a collaborative approach between a clinician and patient, SAFETY-A helps a person in crisis consider ways to stay safe. It involves identifying warning signs of distress; coping strategies, supports, and resources to access when in crisis; and steps to decrease access to potentially lethal means of suicide in the patient’s home. The PCORI grant supports SAFETY-A training for clinicians across all study sites.
All participants will receive evidence-based interventions to increase safety, including SAFETY-A, and half will be randomized to participate in the Coping Long-Term with Active Suicide Program (CLASP), which involves a series of “caring contacts” by phone or Zoom with a patient following their emergency department visit. Through these conversations, a clinician can check in with the adolescent or young adult to offer support, assess their continued safety, reinforce key skills and strategies, and help facilitate linkage to follow-up treatment in their community. In a large clinical trial with adults, CLASP was found to reduce suicidal behaviors.
“This study, one of the largest clinical trials to date for youth suicidal behaviors, has the potential to show that a brief therapeutic approach can significantly reduce suicidal behaviors and improve aftercare service use, particularly among population groups that are less likely to receive follow-up care after they leave the emergency room.”
— David Goldston, PhD
“This study, one of the largest clinical trials to date for youth suicidal behaviors, has the potential to show that a brief therapeutic approach can significantly reduce suicidal behaviors and improve aftercare service use, particularly among population groups that are less likely to receive follow-up care after they leave the emergency room,” Goldston noted.
The study has been underway since early 2022 and will continue through 2027. It’s part of a broader body of research being conducted by clinical researchers at the Duke Center for the Study of Suicide Prevention—in collaboration with other institutions, community organizations, and foundations—to advance our understanding of the risk for suicidal behaviors and to reduce suicide attempts and suicide deaths.