Preventing Youth Suicide By Improving Care: Adapting the Family-Based Crisis Intervention for Use in Inpatient Psychiatric Settings

Background and Purpose: Suicide is the second leading cause of death among youth ages 10-24 (CDC WISQARS, 2023). Within this age group, rates of suicide attempts and deaths have increased substantially over the past 10 years, with disproportionate increases among ethnoracially and sexually minoritized groups (CDC WISQARS, 2023). Although nearly all youth who present to Emergency Departments (EDs) following a suicide attempt are psychiatrically hospitalized, currently there are no evidence-based psychiatric inpatient treatments that have been shown to reduce the frequency of suicide-related behaviors or suicide attempts following discharge (Knesper et al., 2010). The Family-Based Crisis Intervention (FBCI) is a brief evidence-based intervention developed to reduce suicide risk among adolescents with recent suicidal ideation and/or suicide attempts (SI/SA). Originally developed for use in the Emergency Department, FBCI is a family-based intervention that seeks to reduce youth SI/SA risk by targeting known mechanisms of suicide risk: family empowerment, family communication, and perceived belongingness. This paper describes preliminary findings from a two-phased study designed to 1) adapt FBCI for use on inpatient psychiatric settings (FBCI-IP) and 2) examine the feasibility, acceptability, appropriateness, and preliminary efficacy of the adapted intervention through a small randomized clinical trial (N=25).

Methods: The ADAPT framework (Moore et al., 2021) guided the approach to adapting FBCI for use within inpatient psychiatric settings. In the first phase of this study, 45 participants (15 service providers, 15 youth recently hospitalized for SI/SA, and 15 caregivers of youth recently hospitalized for SI/SA) were interviewed about their experiences with providing and receiving inpatient psychiatric care, their perspectives on family involvement in treatment, and contextual considerations when delivering FBCI on inpatient psychiatric units. Data were analyzed using thematic analysis (Braun & Clark, 2016; 2019) and informed systematic modifications to FBCI content and training, supervision protocols, and technical assistance practices. Modifications are reported using the FRAME (Wiltsey-Stirman et al., 2019), an expanded framework for reporting adaptations and modifications to evidence-based interventions. In the second phase of the study, FBCI-IP outcomes of interest were examined through a small randomized clinical trial (N=25).

Results. Study participants and stakeholders identified several key methodological innovations that improved the acceptability, feasibility, appropriateness, and potential effectiveness of FBCI-IP. Recommended adaptations pertained to 1) sequencing and dosing of intervention elements to maximize feasibility, acceptability, and impact of core functions, 2) modifications to training, technical assistance, and supervision protocols to support clinicians with varying levels of practice experience, and 3) development of a new post-discharge bridging module that facilitates access to and acquisition of follow up care. Preliminary analyses of outcomes of interest show that FBCI-IP is feasible, acceptable, and appropriate to deliver within inpatient psychiatric settings, yielding gains in hypothesized putative intervention mechanisms (family empowerment, family communication, perceived belongingness) and patient/family satisfaction with care.

Conclusions and Implications. Youth receiving inpatient psychiatric care for SI/SA are at elevated risk for suicide following discharge. FBCI-IP provides an important new clinical tool to help alleviate this risk. The influence of organizational protocols and policies on intervention adaptation and research activities will also be discussed.