Quality Improvement for Acute Trauma-Informed Suicide Prevention Care: Introduction to Special Issue

From 2003 to 2018, the rates of suicide among young people in the United States ages 12 to 17 doubled (Centers for Disease Control and Prevention. Web-based Injury Statistics Query and Reporting System (WISQARS) [online], 2021). Moreover, in the year 2018, the rates of suicide among adolescent girls ages 12 to 17 were the highest in 20 years (Centers for Disease Control and Prevention. Web-based Injury Statistics Query and Reporting System (WISQARS) [online], 2021). Rates of suicide attempts are also high, with 18.8% of high school students in 2019 reporting that they seriously considered suicide, and 8.9% reporting that they attempted suicide in the last year. Nonetheless, a significant proportion of youth experiencing suicidal thoughts or behaviors do not receive medical treatment (Ivey-Stephenson et al., 2020) or have contact with a mental health professional. In particular, in emergency department settings, it is not uncommon for youth with mental health issues to not be seen by a mental health professional (Kalb et al., 2019), or for suicidal youth to not receive therapy following their discharge (Asarnow et al., 2011).

Unfortunately, there is a dearth of evidence-based interventions for suicidal young people (Substance Abuse and Mental Health Services Administration [SAMHSA], 2020). Across the age span, brief interventions have shown promise in addressing acute risk for suicidal behaviors and in facilitating linkage to treatment (Doupnik et al., 2020). Because of the strong relationship between trauma and suicide risk, especially among youth seen in emergency department settings, it is important for brief intervention approaches and other suicide prevention efforts to be trauma-informed (J.R. Asarnow et al., 2020; Tunno et al., 2021, in this special issue. Moreover, because of the diversity of settings in which suicidal youth are seen, it is important to consider if approaches for responding to acute suicide risk should be adapted or tailored for the specific needs of the service settings or targeted populations. This process can include documentation of outcomes, with refinements to interventions and the care process model implemented as part of continuing quality assurance processes (J. R. Asarnow & Miranda, 2014).

This special issue describes innovative approaches to quality improvement in suicide prevention services. The articles in this issue address different points in the care process or clinical pathway. Articles by Mournet et al. (2021) and Giles et al. (2021) highlight how evidence-based screening can be implemented within ED and primary care settings. The Giles et al. manuscript provides an illustration of a care process model for ensuring detection of both traumatic stress reactions and suicide risk, and clinical pathways that consider the needs of individuals suffering from traumatic stress reactions, suicide risk, and those youth who suffer from both.

Several articles go beyond initial screening to focus on secondary approaches to evaluation, screening, and brief interventions for youth suicide and self-harm risk. Papers by Giles et al. (2021), Esposito-Smythers et al. (2021), and Hutcherson et al. (2021) describe implementation of the SAFETY-Acute Intervention, previously known as the Family Intervention for Suicide Prevention. This intervention was recently renamed (a) to emphasize its relationship to the 12-session SAFETY intervention (Asarnow et al., 2015, 2017), for which it is the first session; (b) to underscore the emphasis on safety; and (c) to communicate the usefulness of the intervention even for children living with non-family caregivers (e.g., residential treatment centers) and/or when others outside the family play a major role in keeping the child safe and are included in the intervention. SAFETY-A is a single encounter safety/stabilization focused session plus follow-up caring contacts to support families in linking youth to needed mental health treatment services. Importantly, SAFETY-A is designed both as a therapeutic “behavioral assessment” of suicide/suicide attempt risk that can be used following initial screening to triage youth to an appropriate level of care (Inpatient, discharge home, additional evaluation) and clinical pathway, and as a brief, developmentally nuanced, and trauma-informed cognitive-behavioral crisis stabilization and safety planning intervention that also emphasizes facilitation of linkage to aftercare treatment. In randomized controlled trials, SAFETY-A led to improved treatment initiation and dose, and reduced suicide attempts when combined with the 12-week SAFETY treatment (a DBT-informed cognitive-behavioral and family suicide attempt prevention focused treatment; Asarnow et al., 2015, 2017; Babeva et al., 2020). Quasi-experimental and open trials found early reductions after SAFETY-A delivery in suicidal ideation and intent; improved self-efficacy to stay safe among youth, and improved confidence in ability to keep youth safe among parents (Zullo et al., 2020). The article by Berk et al. (2021) describes a related intervention extended into a crisis clinic model.

Importantly, from a services perspective, papers in this Special Issue address strategies for extending evidence-informed services to settings beyond the mental/behavioral health services and EDs to service settings with strong potential for delivering suicide prevention care to children and adolescents who do not present in mental health or emergency settings. This is a critical issue given low rates of mental health care, particularly evidence-based mental health care, and in ethnic and racial minority communities. The article by O’Neill and colleagues (2021) describes an approach for integrating trauma-informed suicide prevention services in schools featuring a school-based approach to SAFETY-A, and Esposito-Smythers et al. (2021) describe a county-wide initiative to implement SAFETY-A and other therapeutic interventions across a range of services within the county system. The article by Kemp and colleagues (2021) describes implementation of a brief safety planning intervention and follow-up contacts within a juvenile justice population.

Our goal in this Special Issue is to bring together a series of articles demonstrating and discussing strategies for addressing suicide and suicide attempt prevention in our service systems, with the overall goal of motivating efforts to bring evidence-informed suicide and suicide attempt preventive care into the routine community settings that serve children and families. This Special Issue appears while we are still struggling with the COVID-19 pandemic and public health emergency (J.R. Asarnow & Chung, 2021). During this time, we have shifts in service delivery with online versus in-person schooling, mental health services, and health care. While clinicians and services have mobilized and responded creatively to care for our children, we have seen a 31% increase nationally in the proportion of mental health-related ED visits for adolescents ages 12–17 years relative to 2019, with a particularly strong increase among girls, for whom weekly ED visits for suspected suicide attempts were 50.6% higher during February 2021-March 20, 2021 than the same period in 2019 (Yard et al., 2021). These data underscore the current need for attention to suicide prevention care in our young people. Our hope is that this Special Issue will be helpful for guiding efforts to address this need and decrease the risk of premature deaths and suffering, and improve mental health in our children.

Disclosure statement

In accordance with Taylor & Francis policy and my ethical obligation as a researcher, Dr. Asarnow is reporting that she has received grant, research, or other support from the National Institute of Mental Health, the American Foundation for Suicide Prevention, the Substance Abuse and Mental Health Services Administration, the American Psychological Foundation, the Society of Clinical Child and Adolescent Psychology (Division 53 of the APA), and the Association for Child and Adolescent Mental Health. She has served as a consultant on quality improvement for depression and suicide/self-harm prevention, serves on the Scientific Council of the American Foundation for Suicide Prevention, and the Scientific Advisory Board of the Klingenstein Third Generation Foundation.

In accordance with Taylor & Francis policy and my ethical obligation as a researcher, Dr. Goldston is reporting that he has received grant, research, or other support from the National Institute of Mental Health, the National Institute of Alcohol Abuse and Alcoholism, the American Foundation for Suicide Prevention, and the Substance Abuse and Mental Health Services Administration.

Additional information

Funding

The work in this article was supported by the UCLA–Duke Center for Trauma-Informed Adolescent Suicide, Self-Harm, and Substance Abuse Treatment (ASAP Center), which is funded by the Center for Mental Health Services, Substance Abuse and Mental Health Administration (SAMHSA), U.S. Department of Health and Human Services (SM 080041). Points of view in this article are those of the authors and do not necessarily represent the official positions or policies of the U.S. Department of Health and Human Services.