A Unique Model of Care for Youth in Crisis: A Pilot Open Trial

Abstract

Suicide is the second leading cause of death for those ages 10 to 24 years in the United States, and emergency department (ED) visits due to youth self-injurious thoughts and behaviors (SITB) and increased substantially between 2016 and 2021. Although ED services are essential for an effective system of care, the ED setting is typically not well-suited for the comprehensive, collaborative, and therapeutic evaluation of SITB, treatment planning, and care coordination that youth in a suicidal crisis need. As a result, an urgent care model for mental health designed to provide comprehensive crisis triage and intervention services is needed within outpatient psychiatry. This pilot trial examined the feasibility, acceptability, and preliminary clinical outcomes of a brief, urgent care model, the Behavioral Health Crisis Care Clinic (CCC), designed to provide comprehensive outpatient triage and intervention services aimed at reducing suicide risk for youth in crisis. Participants were 189 youth (ages 10–20; 62.4% female; 58% Caucasian), who had past-week suicidal ideation or behavior, and their caregivers. Results demonstrated the CCC model exceeded feasibility and acceptability benchmarks based on the Service Satisfaction Scale (M scores >3.00). CCC care was associated with significant decreases in self-reported suicide risk based on the CAMS Suicide Status Form with low levels of ED usage during CCC care (7.7%) and 1-month post-treatment (11.8%). Over 88% of patients without established outpatient care at the time of referral were connected to care during CCC treatment, almost all of whom (95%) continued with ongoing mental health care 1-month after ending CCC care.

Youth suicide is a significant and preventable public health problem. While the occurrence, morbidity, and mortality of many pediatric illnesses have waned over the last decade, the incidence of youth suicide is increasing (Curtin et al., 2016; Hedegaard et al., 2018). Despite efforts to address the devastating impact of adolescent death by suicide, rates increased from 2000 to 2020, with young adolescent girls (aged 10–14) demonstrating the largest increase (200%) in the 15-year period observed (Curtin et al., 2016; Garnett, Curtin, & Stone, 2022). Other demographic factors such as race/ethnicity intersect with age-related changes in suicide rates, with recent reports indicating increases in death by suicide for Black youth aged 5–12, whereas White youth demonstrated a decrease in suicide over the same period (Bridge et al., 2018). In addition to death, suicide risk indicators like suicidal ideation, non-suicidal self injury, and suicide attempts (called self-injurious thoughts and behaviors; SITB) are common, and have also disproportionality increased among youth of color (Xiao, Cerel & Mann, 2021). Youth Risk Behavior Survey data suggest 19% of U.S. adolescents in high school report seriously considering suicide, and 9% report making an attempt in a given year (CDC, 2021). These self-injurious thoughts and behaviors (SITB) are recurrent and lead to substantial health care utilization and increased risk for death by suicide (Curtin et al., 2016). Considering the full spectrum of suicide risk outcomes, the scope of the problem during adolescence is significant and there is considerable need to change the course of current trends.

Treatments to Reduce Suicide Risk for Youth

Healthcare systems struggle to meet the needs of youth who experience SITB. Nationally, the most frequent and costly mental health diagnosis is depression, often involving hospital admission due to suicide risk (44% of all mental health admissions, $1.33 billion) (Bardach et al., 2014). This is a growing trend, with ED and inpatient admissions for youth mental health problems increasing 24% from 2007–2015 (Burstein et al., 2019; Plemmons et al., 2018) and 153% from 2016–2021 (CHA PHIS data, 2022). The healthcare system’s current reliance on resource-intensive ED and inpatient settings to care for youth with SITB problematic for three reasons. First, inpatient capacity does not meet the need for youth in crisis, with current inpatient capacity of 5 psychiatric beds per 100,000 residents in our state (Burley & Scott, 2015). Second, inpatient psychiatric care is not yielding neither increased engagement with outpatient behavioral health (Fontanella et al., 2020). Care quality metrics recommend that youth seen for acute care for SITB attend an outpatient mental health appointment within 7 days of ED or hospital discharge, however, approximately half of youth receive no care within this period (Fontanella et al., 2020). Finally, inpatient care has not demonstrated compelling change in decreased SITB (Adrian et al., 2020), and some argue may have iatrogenic effects (Ward & Rizvi, 2021). For these three reasons, outpatient crisis stabilization interventions should be prioritized for development and evaluation.

While there is a paucity of “well-established” interventions for adolescent suicide risk, evidence is emerging from a variety of treatments, and recent meta-analyses suggest the possibility of identifying common elements in effective suicide-specific care (Busby et al., 2020). The only psychotherapy approach with replicated effects for reducing SITB is full-model Dialectical Behavior Therapy (DBT) (McCauley et al., 2018a; Mehlum et al., 2014, 2016). A recent meta-analysis indicates moderate effects of DBT for Adolescents (DBT-A) in reducing self-harm (combined NSSI and suicide attempts) as well as suicidal ideation (Kothgassner et al., 2020). Evidence in support of other promising treatment approaches (e.g. Cognitive Behavioral Therapy for Suicide Prevention [CBT-SP], Safe Alternatives For Teens and Youth [SAFETY], Mentalization-Based-Therapy) is emerging, with a recent meta-analysis suggesting that interventions with a strong family component and with multiple treatment sessions were associated with significant reduction of self-harm compared to studies with weak family involvement and/or single session interventions (Kothgassner et al., 2020; Ougrin et al., 2015). This finding is complicated, however, by the failure of multiple family therapy trials (Cottrell et al., 2018; Diamond et al., 2019a) to demonstrate reductions in SITB compared to treatment as usual or nondirective supportive therapy. There is a pressing need for both the continued evaluation of suicide-specific interventions for adolescents, as well as the identification and scientific evaluation of common elements that characterize quality improvement for suicide-specific intervention.

Goals of the Intervention Model

Our team was tasked with developing a clinical intervention to reduce reliance on inpatient and ED care and improve the experiences of youth and families in suicidal crisis within a large pediatric hospital system. The design of this intervention model required understanding stakeholders’ needs as well as incorporation of available evidence regarding effective treatment for youth with SITB. We conducted qualitative stakeholder analysis including input from youth, families, clinicians, and administrators representing clinical leadership, content experts, resource managers, and direct service providers. The results of this analysis specified five requirements for the intervention: 1) a need to fill a gap in continuum of care between acute and outpatient care, 2) a need to increase support to parents and other caregivers (referred to as “caregivers” in this paper), 3) a need to minimize wait times given the crisis nature of the work, 4) a need for the intervention to be brief to balance efficiency and effectiveness for access issues, and 5) lower costs than those for emergency and inpatient care.

Behavioral Health Crisis Care Clinic Intervention Components

To address stakeholder needs for rapid, low-cost, just-in time care for youth presenting with SITB and their families in an outpatient setting, the Behavioral Health Crisis Care Clinic (CCC) model employs a team-based approach with a case manager and two clinicians (i.e., co-treatment) involved in the care of each family. In this co-treatment model, one clinician is assigned to treat the youth and another to treat the caregiver(s). In each session, clinicians work individually with their assigned family member and then clinicians and family members collaborate to craft and implement a cohesive treatment plan. The CCC model delivers a package of six intervention elements- CAMS-based psychotherapy and driver-based skills training for teens, psychoeducation, lethal means safety and parent skills training for caregivers, and case management supports- based on demonstrated promise in targeting SITB (Doupnik et al., 2020; Werbart Törnblom et al., 2020).

As its cornerstone of SITB treatment, the CCC model utilizes the Collaborative Assessment and Management of Suicidality (CAMS) (Jobes, 2012; Jobes et al., 2016), a treatment framework within which clinicians engage, assess, and treat SITB using a suicide-specific intervention (Jobes, 2016) which includes key suicide treatment elements. CAMS treatment capitalizes on therapeutic alliance, a common treatment element with demonstrated positive outcomes (Ardito & Rabellino, 2011). In CAMS, the clinician partners with the patient to collaboratively treat the suicidal “drivers,” or the problems that the patient articulates compel them to consider suicide. Together, the clinician and patient develop an individualized crisis stabilization plan and ongoing treatment plan based on identified drivers. Thus, as a promising intervention for youth CAMS aims to reduce SITB by enhancing therapeutic alliance and the patient’s motivation to effectively engage in collaboratively targeting and treating SITB (Adrian et al, 2021 Jobes et al., 2016).

Within the CAMS treatment framework, CCC utilizes individualized skills training to simultaneously treat the patient’s drivers of suicide while increasing caregivers’ capacity to effectively manage suicidal crises. A focus on skills training for the management of strong emotion stems from correlation between emotion regulation deficits and SITB (Colmenero-Navarrete, Garcia-Sancho & Salguero, 2021) and suicide intervention research, in which lack of self-efficacy to engage in alternatives to SITB, inability to tolerate strong emotions, and impulsivity are all highly associated with SITB (Linehan, 2015; Rathus & Miller, 2014). Treatment for youth with suicide risk commonly targets these skills, and improvements in youth emotion regulation during treatment mediates the relationship between suicide-focused treatment (i.e., DBT) and self-injury remission at one year follow up (Asarnow et al., 2021). While the CAMS framework does not mandate the use of specific interventions or skills, clinicians in the CCC typically aim to increase the youth’s capacity to manage suicidal thoughts and urges and to cope with distress by improving emotion regulation, increasing exposure to positive reinforcement, and developing more effective communication skills.

Concurrently, CCC clinicians engage caregivers in psychoeducation, lethal means restriction, and skills training aimed at increasing caregivers’ ability to effectively manage suicidal crises. CCC clinicians provide caregivers with psychoeducation about the nature of SITB in order to decrease blame and mitigate difficult caregiver emotions (i.e., guilt, shame) and to increase engagement with safety planning and effective implementation of lethal means restriction (Sale et al., 2018). Lethal means counseling is a well-established practice that aims to decrease access to methods of suicide given high fatality rates (Monuteaux et al., 2019) and is associated with decreased lethality of suicide attempts and reduced suicide rates (Barber & Miller, 2014). Therefore, CCC lethal means counseling involves working with youth and caregivers to evaluate and plan for home safety, weekly check-ins on caregiver progress with means restriction, and tools (e.g., lockboxes) to implement means restriction in the home. Additionally, conflict with caregivers, poor family communication, and caregiver criticism are notable predictors of SITB (Brent et al., 2009), and there is growing evidence in support of including a central family component to strengthen intervention effects for youth with SITB (Blossom et al., in press; Brent et al., 2009; Pineda & Dadds, 2013; Kothgassner et al., 2020; Ougrin et al., 2015). Therefore, similar to parent-focused evidence-based practices for parenting skills (Forehand et al., 2013), caregiver skills training in CCC focuses on increasing the number and quality of positive and effective caregiver-child interactions and improving caregiver-child communication in order to reduce suicide risk.

Finally, CCC treatment includes robust care navigation, an essential component of suicide-specific treatment that aims to reduce SITBs by increasing linkage to care (Doupnik et al., 2020). In CCC, care navigation includes hands-on support with finding psychiatric care resources, navigating the complexities of mental health systems, scheduling and coordinating appointments, and otherwise reducing barriers to care. Care navigation has established impacts on increasing linkage to follow-up care and reducing suicide attempts (Doupnik et al., 2020).

In order to fill a gap in psychological services for youth in suicidal crisis, this study evaluates the CCC model of care designed to provide comprehensive, family-focused crisis management and intervention in an outpatient setting. First, this research aims to assess the feasibility and acceptability of the CCC model based on number of attended visits and perceptions of youth and caregivers. We hypothesized that youth and caregivers would rate CCC as feasible in the outpatient setting and acceptable in format. Second, to evaluate the impact of CCC on suicide risk. We hypothesized self-reported suicide risk and suicide attempts would decrease following CCC. Third, we assessed if CCC connected families to novel support resources (i.e., individual psychotherapy, medication evaluations, group-based treatment for presenting problems) and CCC’s impact on subsequent service use. We hypothesized that outpatient service use would increase following CCC and acute care would decrease following CCC. Finally, given the disparities in access to care and the need for more culturally responsive program development, we evaluated if there were differences in primary questions (acceptability, suicide risk, and linkage) by race/ethnicity. Because prior work has illustrated differences in access to care as opposed to treatment response to care, we hypothesized there would be no significant differences on key outcomes.

Method

Participants

Participants were 189 youth (62.4% girls; 70% White) between the ages of 10 and 20 (M=14.58; SD=2.01) who were referred to CCC due to past week suicidal ideation or behavior. Youth were included in analyses if they received at least 2 sessions in the CCC. Please see Table 1 for demographic description and referral sources of the participants. Exclusion criteria included severe cognitive impairment/developmental delay, no available caregiver or trusted adult to participate in treatment, and primary presenting problem not related to SITB. Patients were recruited from March 18^th, 2019 to January 24^th, 2022.

Table 1.

Demographic characteristics of full baseline sample.

Characteristic	Mean/Percentage
Youth Age	M=14.48 (SD=2.01)
Youth Gender	62.4% Female 22.2% Male 15.4% Nonbinary/Genderqueer
Youth Race	15.3% Multiple races 1% American Indian/Alaska Native 7.4% Asian American 4.2% Black 57.6% White 14.1% Latinx
Caregiver Participating	89.9% Biological parent 5.9% Adoptive parent 0.6% Step parent 1.2% Foster Parent 1.2% Grandparent 1.2% Other
Referral Source
Emergency Department	41.3%
Inpatient Medical	27.5%
Outpatient Triage	18.0%
Other	13.2%

Clinicians provided treatment were social workers, psychologists, and post-doctoral fellows ranging from 0–30 years of professional practice. Clinicians completed the three hour CAMS-Care training and attended a weekly consultation meeting led by the second author.

Procedures

Eligibility was determined based on screening of medical records and consultation with referral source. Because the clinic provides just-in-time care and does not maintain a waitlist, families were not offered enrollment if an appointment was not available within 7 days of referral. Triage priority was given to youth who would be psychiatrically hospitalized in the absence of an appropriate alternative; these included youth boarding in an ED or on a medical floor following medical treatment for a suicide attempt. Additional triage considerations included the prioritization of youth without established outpatient mental health care and those experiencing an acute or first-time suicidal crisis, as these youth were expected to benefit the most from brief outpatient intervention with embedded case management. Youth and their caregivers who met eligibility criteria and attended CCC appointments completed self-report surveys at the first and last appointment. Appointments were provided either in person or via telehealth. Caregivers were contacted one month following CCC discharge to assess for ED visits and linkage to care. All procedures were approved by the Institutional Review Board (Study 2432) and we received a waiver of consent to conduct study procedures.

CCC Intervention

Crisis consultation procedures include up to four sessions of assessment, management, and treatment of SITB (see below). The framework for crisis consultation is based on CAMS, a clinical intervention designed to guide how clinicians engage, assess, and plan treatment with suicidal patients as described in the introduction (Jobes et al., 2006). The treatment includes an assessment framework guided by the Suicide Status Form (SSF) to identify patient-specific drivers and develop the treatment plan consistent with the element of care described in the introduction.

CCC treatment begins prior to the first visit, when caregivers meet by phone with the team’s embedded case manager to receive orientation to treatment logistics and expectations. The case manager has minimum requirements of a Bachelors Degree in Social Science or related field and experience with families in crisis, health care system, basic payer knowledge, and community resources. This same case manager follows the family throughout treatment, providing logistical support and hands-on assistance with connecting to recommended mental health care. Up to four visits can be scheduled within approximately a one-month timeframe to address crisis stabilization goals and transition to ongoing community care. If the youth was at elevated risk and no continuing care was identified in the community, the youth was offered additional visits until ongoing care could be scheduled.

CCC Treatment Component (Duration)	Content	Participants
Pre-visit	Phone screening and orientation to treatment structure, medical record review, insurance identification	Case manager, clinicians, caregiver(s)
First Visit (90 min)
15 min Joint session	Informed consent Orientation to CCC model Discussion of goals and priorities	Youth, caregiver(s), clinicians, case manager (optional)
45 min Split session	Assessment of suicide risk, drivers of risk via the CAMS Suicide Status Form (SSF)	Youth, youth clinician
	Caregiver needs assessment, psychoeducation about suicide, lethal means restriction	Caregiver(s), caregiver clinician
10 min	Clinician huddle to review risk assessment and initial recommendations	Clinicians (Brief break for family)
20 min Joint session	Highlight youth/family strengths Discuss plan for safety, including communication & reducing access to lethal means Review initial treatment plan based on CAMS SSF	Youth, caregiver(s), clinicians
Between visits	Care coordination (connection to novel community mental health resources, coordination of care with established providers, consultation to school)	Case manager, clinicians
Visits 2–4 (50 min), typically scheduled weekly
30 min Split session	Reassessment of risk, drivers, and treatment plan via CAMS SSF Introduce relevant skills	Youth, youth clinician
	Review/troubleshoot lethal means restriction, communication about safety Introduce relevant caregiver skills Discuss disposition plan and care navigation	Caregiver(s), caregiver clinician
5 min	Clinician huddle to review risk assessment and recommendations	Clinicians (Brief break for family)
15 min Joint session	Highlight strengths and progress Update plan for safety Review skills	Youth, caregiver(s), clinicians
Post-discharge	Warm phone handoff to ongoing outpatient provider(s)	Clinicians

Measures

Intervention Feasibility and Acceptability

The feasibility of the intervention was evaluated based on the percentage of youth who scheduled and attended CCC appointment. Youth and their caregivers completed the Peabody Service Satisfaction Scale (SSS; Athay & Bickman, 2012) to assess perceptions of acceptability. Youth responded to six items on a five-point Likert scale. Parents rated four-items on a four-point Likert scale, with an additional item asking for comments on received services. Higher scores reflect higher levels of satisfaction with services, with scores less than 3.00 reflecting low satisfaction for youth and less than 3.25 reflecting low satisfaction for caregivers. Internal consistency of the items was satisfactory for both reporters (α=.90; α = .89; youth and caregiver respectively).

Suicide Risk Outcomes

Demographic characteristics.

Caregivers reported their child’s race, sex assigned at birth, ethnicity, insurance and date of birth on the clinic developed demographic data sheet. Youth reported on their gender identity.

Suicide Attempts.

Caregivers and clinicians reported on a modified version of the Columbia-Suicide Severity Rating Scale (C-SSRS) (Posner et al., 2008) to assess pre-treatment suicidal ideation and lifetime suicidal behaviors including actual, interrupted, and aborted suicide attempts.

Suicidal Ideation.

Youth reported on their pre-treatment SITB via the Ask Suicide Screening Questionnaire (ASQ). The ASQ is a 4-item self-report suicide risk screening measure that assesses SITB. Prior evaluation of the ASQ demonstrates strong sensitivity and specificity as well as predictive validity for 3-month suicidal behavior (Horowitz et al., 2012).

Self-Reported Suicide Risk.

The Suicide Status Form (SSF) includes youth reported overall self-reported risk of suicide on a 5-point Likert scale, which was assessed at each session and used to understand suicide risk reduction from pre to post treatment (Jobes, 2016). The quantitative and qualitative aspects of the SSF have been demonstrated with adequate reliability and validity for youth (Brausch et al., 2020) and adults (Jobes et al., 1997; Jobes & Drozd, 2004).

Service Use

Mental health service use within the 3 months prior to CCC treatment, was assessed through a modified, brief checklist version of the Child and Adolescent Services Assessment (CASA) (Ascher et al., 1996). Specifically, at baseline we obtained caregiver’s report on whether fifteen different services were used by youth (yes/no) for emotional, behavioral or substance use problems. At 1 month follow-up, caregivers completed a three item checklist about services use since the CCC (outpatient mental health services, emergency, and inpatient services).

Data Analysis Plan.

Descriptive statistics are provided to describe participation, service use, and treatment acceptability. To understand service model feasibility, we divided the number of families who scheduled a CCC appointment by the number of families who were offered CCC. Similar to past pilot work, we defined adequate feasibility benchmark to be enrollment of 50% of families who were offered a CCC appointment (Schledier et al., 2020). Based on prior evaluations of the SSS (Athay & Bickman, 2012), we used a score of above 3.25 to benchmark acceptability. McNemar’s test was used to understand the change in proportion of past-month youth suicide attempts based on dichotomized measures for presence of suicidal ideation, past-month suicide attempt, outpatient service connection, and acute care service use. Race/ethnicity was categorized into two categories White and youth of color. T-tests were used to test race/ethnicity differences in continuous outcomes (satisfaction, self-reported suicide risk), while chi-square was used to analyze group differences in categorical outcomes (linkage).

Results

Baseline characteristics

At baseline, the mean suicidal ideation severity score based on the ASQ was M=2.52 (SD=1.06). Seventy-eight percent (N=145) of youth indicated lifetime NSSI. Caregivers reported SITB based on the C-SSRS, with 80% endorsing their child had recent suicidal ideation and 50% reporting a lifetime suicide attempt. Based on clinician-reported chart review, 77% of youth were evaluated in the emergency department, 27.6% received inpatient medical care, and 14.8% received inpatient psychiatric care due to a suicidal crisis in the three months prior to enrolling in CCC. The majority of visits (77%) were in person whereas 23% were via telehealth.

Feasibility and Acceptability of the CCC Model of Care

There were 729 referrals made for CCC services in the time period studied (See Figure 1). From those referrals, 199 youth did not meet eligibility criteria. Two hundred thirty-eight families could not be served due to capacity constraints (N=227) and insurance contract problems (N=11). The capacity constraints were related to clinician deployment. If a clinical team’s identified CCC appointments were filled, referrals were not accepted because they could not begin treatment within the 1 week timeframe from referral. Of the remaining 292 families, 60 declined to participate and 20 did not respond to the invitation, suggesting that the model was unacceptable to 27% of families. Two hundred and twelve families out of 292 (72.5%) accepted the CCC model of care and attended the first appointment, which exceeded our benchmark of 50% enrollment. Of the one hundred and eighty-nine families who did receive the intended intervention package, the mean number of sessions attended was 3.42 (SD=1.41; range=1–8). Youth reported high levels of satisfaction (M=4.12, SD= 1.06) on a 5-point scale. Caregivers reported a high level of satisfaction, with a mean satisfaction score of 3.76 (SD=.41) on a 4-point scale. Both metrics exceeded our acceptability benchmarks (i.e., scores > 3.25 indicating satisfaction with services for youth and caregivers, respectively). The level of satisfaction with services did not vary by youth’s identified race/ethnicity based on youth report (t(95)= .17, p=.87) or caregiver report (t (99)=−1.01, p=.32).

Figure 1. CCC CONSORT Flow Diagram.

Preliminary Clinical Outcomes

McNeman’s test evaluated the proportion of past month suicide attempts prior to treatment and suicide attempts post- CCC treatment, based on clinician report. The test suggested a significant decrease in the proportion of clinician-reported suicide attempts (48% vs. 5.8% respectively, d=.41, SE= .04, z= 8.04, p <.001). Additionally, paired t-tests indicate a decrease in CAMS self-reported suicide risk ratings from pre (M = 2.04, SD = 1.05) to post-treatment (M = 1.53, SD = .81) (t(137) = 6.22, p < .001; Cohen’s d=.53; 95% CI= .30–71). Youth’s self-reported suicide risk was not significantly different for youth identifying as White or youth of color (t (131)=0.75, p =45).

Service Use

For youth who did not have an outpatient individual therapist at entry to CCC services, 88.5% (N= 92) were connected to outpatient care. Among youth who already had established individual outpatient therapy (n=80), 42.5% (n=34) were connected to care augmentation (e.g., medication evaluation, adjunctive group therapy). Youth who had current providers referred for further care due to not being comfortable managing acute risk or provide the elements of care provided in this model.

Across the entire sample, including both youth with and without prior outpatient care, 67% (n= 126) of youth were connected to outpatient resources by our care manager during their CCC treatment. Linkage did not vary by race/ethnicity (χ² (1) =.57, p=.45). In addition, acute care service use decreased from 77% reporting past-month ED visits to 8% following CCC, and 12% one month after discharge. Inpatient psychiatric admissions were 10% pre-CCC, 2% postCCC, and 8% one month after discharge. Table 3 shows the percentage of youth who received outpatient, emergency, and inpatient service at pre, post, and 1 month follow-up.

Table 3.

Frequencies of service use pre, post and at 1 month follow up

Service	Pre-CCC (N=176)	Post-CCC (N=176)	1 month follow up (N=110)
Outpatient Therapist	43%	67%	94%
ED	77%	8%	12%
Inpatient Admission	14%	2%	8%

Discussion

This open pilot trial tested the feasibility, perceived acceptability, and short-term outcomes of the Behavioral Health Crisis Care Clinic (CCC), a just-in-time outpatient service focused on safety and stability for youth presenting in a suicidal crisis. Youth and families reported that the intervention was feasible and acceptable based on our benchmarks. Specifically, youth scheduled and attended sessions at a high rate, and self-reported acceptability among both youth and caregivers was high. Youth and their caregivers who completed treatment in CCC reported significant pre-to-post reductions in self-reported suicide risk and suicide attempts. Further, behavior health service use increased in outpatient service use over time, while decreasing immediate acute care, demonstrating an important trend for managing suicidal crises. Overall, these results suggest that this model of care has promise for supporting youth and their families during suicidal crises.

Rapid mental health treatment after a suicidal crisis is recommended, especially given strong evidence for elevated rates of suicide among those who have received acute psychiatric care (Chung et al., 2017). Despite recent evidence that follow-up within 7 days of acute service utilization is associated with reduced suicide risk, rates of youth engagement with follow-up care are poor (Fontanella et al., 2020). In the present study, youth and families were seen in the CCC outpatient program within 7 days of referral, and then received robust case management support to connect with outpatient care following discharge from the program. This support was effective in establishing novel follow-up care, with an 88.5% rate of connection to care for youth who did not yet have an outpatient provider, and parent report that 94% of those youth connected to novel care attended services during the month following discharge from CCC. Despite this successful connection and sustainment of outpatient care, acute care decreased during CCC but then demonstrated modest increases in the one month follow up period. A longer evaluation period will be needed to see how brief bridging programs can help to support reduced acute care service use, especially given recent evidence that brief care models may reduce strain on the healthcare system, thereby reserving acute services for those most in need (Xie et al., 2022). Assessment of the quality of community follow-up care (e.g., adherence with evidence-based protocols, suicide specific focus) was beyond the scope of the present study, but will be important to address in future work.

Brief interventions that can be deployed following a suicidal crisis are needed. Our preliminary impact on SITB suggests a medium effect size, which is promising given the short duration of treatment. Despite this promise, the effect sizes that are observed may appear smaller than those of longer intervention packages. For example, the SAFETY program demonstrated a medium to large effect size (i.e., d =.73 for suicidal ideation and d= .66 for suicidal behavior) observed following a median of 10 sessions (Asarnow et al., 2017). Similarly, Attachment-Based Family Therapy (ABFT) demonstrated a large effect size of .97 on ideation following a mean of 10 sessions (Diamond et al., 2019b). Regarding suicide attempts, 6% of youth endorsed a suicide attempt during the CCC intervention. This is similar to other programs including SAFETY (5% of youth endorsed SA at 3-month end-of-treatment assessment) (Asarnow et al., 2017)), ABFT (11% of youth endorsed suicide attempts at 3-months) (Diamond et al., 2010, 2019b), and DBT (9.7% of youth endorsed SA at 6-month end-of-treatment assessment) (McCauley et al., 2018b). Future work will need to determine whether the impact is due to the dose of treatment or the framework guiding care.

While not explicitly tested in the current study, the inclusion of adult caregivers in treatment is likely a strength of our therapeutic model and contributed to the observed outcomes. Indeed, the majority of treatments for adolescents that have been shown to decrease SITB in a RCT have a strong family component and utilize two therapists to provide care to both youth and a caregiver. These include DBT for adolescents, SAFETY, Multisystemic Therapy (MST), and CBTs (e.g., I-CBT and CBT-SP). Activating parents to support youth during times of increased suicidal urges and increasing parental sense of self-efficacy in managing SITB has been shown to mitigate risk (Czyz et al., 2018). Caregivers are also crucial in terms of lethal means restriction in the home. In an RCT by King and colleagues (2019), enhancing support from trusted adults through a “Youth-Nominated Support Team” following a psychiatric hospitalization was associated with reduced deaths fourteen years later (King et al., 2019). Thus, regardless of the specific intervention, strengthening adult supports in times of elevated distress and risk through inclusion of caregivers in treatment is beneficial, addressing the specific strategies to involve caregivers remains an important research agenda in youth suicide prevention (Blossom et al., in press).

This study has important limitations to be considered. First, this pilot trial was not randomized nor compared to any other treatment. Thus, it is possible that results are due to common factors that would accompany seeking any psychological intervention during a crisis. The model was designed to address youth in acute suicidal crisis, not those with chronic SITB and so a brief model providing foundational elements of suicide specific care and access were the top priorities. It is possible a longer treatment would have provided additional benefit; however, by necessity would treat fewer youth. Second, the evaluation was conducted over a brief follow-up period and longer periods following treatment will be an important step forward. Further, one-month completion rates were low and may represent bias, and more rigorous follow up is needed to draw any conclusion about the short and long term impacts of the CCC. Additional future directions include understanding the cultural responsiveness of the CCC intervention. While promising that there were not significant difference in core outcomes, recent calls highlight the need for careful attention in intervention development to address low and disparate rates of outpatient follow-up, and the rising rate of suicide indicators among ethnoracially minoritized youth (Alvarez et al., 2022; Sheftall et al., 2022). Finally, to keep the assessment burden very brief, the measures of SITB and other symptoms were limited. In spite of this study’s limitations, it provides an important avenue to increase access to potentially effective services for youth in crisis.

In conclusion, the CCC was developed in response to the need for services that can respond quickly to stabilize and support youth and families as they are getting connected to care following a suicidal crisis. The goals of this brief intervention were to bridge care, to be suicide-specific, responsive, and short term to enhance the odds that youth will continue with outpatient support for SITB following the crisis. The initial evaluation of the CCC model of care suggests that families who participate in the program are satisfied, experience reduced suicidal risk, and rely minimally on emergency services in the month following treatment. These results demonstrate that the approach is worth further exploration in a larger trial to understand the impact of the intervention above and beyond other brief intervention approaches as well as the cost effectiveness of this intervention package.

Table 2.

Self-reported suicide risk ratings pre and post treatment

Variables	Pre	Post	t	p	Cohen’s D	95% Confidence Interval
CAMS SSF Suicide Risk Rating	M=2.12	M=1.58	6.22	< .001	.53	.35–.71

Impact Statement:

Psychological services that promote safety and stability for youth with recent suicidal crises are needed. For interventions to be effective, they need to engage and appeal to youth and families to remain in care. This research evaluates these aspects of care for a novel model of outpatient treatment for the youth and caregiver following a suicidal crisis.