Stratified Stepped-Care for Reducing Suicide Attempts and Self-Harm in Youth: A Randomized Clinical Trial

Identifying effective approaches for reducing suicide attempts and self-harm is critical for preventing suicide deaths and self-harm-related morbidity. This study evaluated whether suicide attempts (SAs), self-harm, and related suicide-risk indicators are reduced when a stratified stepped-care for suicide prevention (SC-SP) intervention is added to health system quality improvement.

Youth selected for past-year suicidal behavior, active suicidal ideation, or previous suicide attempt and/or ≥3 non-suicidal self-injury (NSSI) episodes plus past-year depression (N = 301, ages 12-24 years) were randomized to one of the following: (1) health system Zero Suicide quality improvement (ZSQI) featuring system-level initiatives to improve suicide-risk screening and treatment access; or (2) ZSQI plus SC-SP, which triaged youths to suicide-specific treatments using care-stratification algorithms and a dialectical behavior therapy (DBT)-informed cognitive behavioral therapy (CBT) model, allowing for more intense care with higher and/or increased risk levels. Interviewers blinded to treatment assignment assessed outcomes at 3, 6, and 12-month follow-ups.

Intent-to-treat (ITT) analyses included all randomized participants (95% with ≥1 follow-up assessment). Within SC-SP, 95% received ≥1 intervention contact; 90% were assigned a care level; and 96% received care in their original assigned care level. No significant between-group differences were found in 12-month SA rates (primary outcome) (SC-SP 8.09%; ZSQI 9.59%). Compared to ZSQI, at 12 months SC-SP youths showed significantly less total self-harm (relative risk = 0.46, 95% CI = 0.26, 0.79, p = .006, number needed to treat = 10.2) and depression (secondary outcomes), and greater satisfaction with care. No deaths were detected.

Despite negative results for the primary outcome of SAs, results suggest the promise of SC-SP for reducing youth self-harm and depression and improving patient satisfaction with care.

This randomized trial of 301 youth aged 12 to 24 at risk for suicide compared standard Zero Suicide quality improvement (ZSQI) care with an added program, stratified stepped-care for suicide prevention (SC-SP), to evaluate its effectiveness in reducing suicide attempt and self-harm risk. SC-SP used structured risk assessments to match patients to appropriate treatments, including dialectical behavioral therapy. While groups did not differ significantly in suicide attempts, the SC-CP intervention was associated with significantly less total self-harm (a combination of suicide attempts and non-suicidal self-injury) and depression, and reported greater patient satisfaction with care.

Randomized Trial of Stepped Care for Suicide Prevention in Teens and Young Adults (Step2Health); https://www.

gov/study/NCT03092271.