A Family-Based Intervention for Suicidal Adolescents and Their Families in the Emergency Department: Results of a Randomized Clinical Trial

Background and Purpose:  Suicide is a significant public health problem, recently ranked as the 2^ndleading cause of death in adolescents in the US.  The Emergency Department (ED) often serves as a portal to the mental health system for suicidal adolescents. The usual practice for suicidal adolescents in emergency psychiatry is evaluation, with little or no in-ED treatment; and disposition, usually to an inpatient psychiatry unit. Unfortunately, often there are not enough inpatient psychiatric beds throughout the system of care for all suicidal adolescents who need them, resulting in patients who “board” in the ED while awaiting appropriate care. Developed exclusively by social workers, the Family-Based Crisis Intervention (FBCI) is a single-session intervention that is designed to sufficiently stabilize patients within a single ED visit by reducing suicidality and increasing individual tools and familial supports, so that they may return home safely with their families. Previous open and pilot trials of FBCI demonstrated feasibility and safety of the intervention, with significant differences in hospitalization rates among a cohort of FBCI patients compared to a retrospectively matched comparison group (36% versus 55%, p<.001).  This paper reports efficacy outcomes, including suicidality, family communication, family empowerment, and client satisfaction, from a randomized clinical trial of FBCI. 

Methods:   A total of N=142 suicidal adolescents (ages 13-18) and their families presenting for a psychiatric evaluation to a large pediatric ED were randomized to be treated with FBCI or treatment as usual (TAU).  Patients and their caregivers completed demographic and validated self-report measures of suicidality, family communication, family empowerment, and client satisfaction which were collected at pretest, posttest, and 3 follow up time points over a one-month period. Data on disposition, psychiatric diagnoses and ED recidivism rates were collected through retrospective chart review. Linear and logistic regressions were used to examine continuous and categorical outcomes of interest, respectively.

Results: Of 142 patients recruited, 76% were female.  The sample was 66% white, 18% mixed, 9% Latino, 6% Black, and 3% Asian, and average age of the adolescent participant was 15.4 years.  At posttest, adolescents randomized to FBCI were significantly more likely to be discharged home with outpatient follow-up care compared to their TAU counterparts (p<0.05); they also reported significant reductions in incendiary communication (p<0.01) and improvements in overall communication (p<0.05) compared to TAU counterparts. Family members of adolescents assigned to FBCI reported significantly higher levels of patient satisfaction (p<0.001) and empowerment (p<0.01) compared to TAU counterparts. Longitudinal outcomes related to psychiatric symptoms (including suicidality), and ED recidivism will also be reported. No completed suicides were reported during the study period by any participant.

Conclusions and Implications:  There is an increasing reliance on the development and translation of evidence-based practices for many conditions in the ED, although the main focus has been on medical interventions.  A focus on evidence-based suicide prevention initiatives is critical to enhancing the long-term health and well-being of adolescents.  FBCI may be a viable alternative to usual care provided by psychiatry, and would reflect the treatment model already used for medical patients in the ED.