Clinician Perspectives on an Integrated Adolescent Substance Use and Suicide Treatment

Background and Purpose: Suicide is the second leading cause of death among youth aged 10-14 and the third leading cause of death for youth aged 15-24. Up to 46% of adolescents who attempt suicide report being under the influence of alcohol or other drugs. Despite the functional interrelationship between suicide and substance use in adolescents, there are no evidence-based interventions addressing suicide risk for adolescents in substance use treatment. The purpose of this study is to develop and test an intervention targeting suicidal thoughts and behaviors (STB) among adolescents in outpatient substance use treatment. In the first phase of this study, we conducted qualitative in-depth interviews with clinicians at an adolescent outpatient substance use program to understand how they currently address STB. The findings of this phase will inform the development of the integrated Suicide Intervention for Teens who use Substances (iSITS), which will be evaluated through a pilot trial in subsequent phases.

Methods: Participants in this study phase were 5 clinicians (3 social workers and 2 psychiatrists) working at an outpatient substance use clinic in a major Northeastern city (Average years practiced=9.4; 80% female; MAge=42). Clinicians participated in 60-minute in-depth semi-structured interviews over Zoom to explore their experiences working with adolescents with STB. Clinicians were also presented with components of the integrated Alcohol and Suicide Intervention for Suicidal Teens (iASIST) and asked for feedback on adapting a similar model for their setting. All interviews were audio-recorded and transcribed. A codebook was developed with both deductive codes from the interview guide and inductive codes from topics participants shared. All transcripts were double-coded. Data were entered into Nvivo12 for analysis.

Results: Interviews revealed that these clinicians are addressing STB, but they do not use a consistent evidence-based or integrated framework, and three out of five clinicians identified their own anxiety in addressing STB as a barrier to treatment provision. While all clinicians reported engaging in suicide screening, risk assessment, and safety planning, no single validated tool is used across the clinic for these purposes. These clinicians are already using many of the components of iASIST including assessing and enhancing motivation for change and goal-setting, but not connecting these elements to suicide. Clinicians felt that additional training around formalized safety planning and other aspects of an integrated treatment protocol would be helpful. The most consistent concern expressed by clinicians was having the time and resources to effectively implement an integrated intervention.

Conclusions and Implications: Our findings suggest that clinicians providing outpatient substance use treatment to adolescents already have many of the clinical skills to effectively address STB in this population. However, integrated treatments are needed to systematically address STB in adolescents in substance use treatment. Integrated treatment for substance use and STB can build on clinicians’ existing skills, boost clinician confidence, and help adolescents better understand the connection between their substance use and STB. The clinicians interviewed provided valuable feedback on iASIST that will be used to develop iSITS for use in outpatient substance use treatment settings.