A Text-Based Expressive Writing Program for Adolescents at Risk of Suicide (WRITE-SAFE)

Effectiveness of a Text-Based Expressive Writing Intervention for Suicidal Adolescents and Young Adults: A Randomized Controlled Trial

The goal of this clinical trial is to learn if a structured expressive writing program can help reduce suicidal thoughts in adolescents and young adults who have experienced suicidal thoughts, suicide attempts, or self-harm. The study will include participants aged 13 to 24 years who are receiving mental health care or have recently been identified as being at risk for suicide.

The main questions the study aims to answer are:

• Does a structured expressive writing program lower suicidal thoughts compared with usual care alone?
• Does the program improve depression, impulsivity, and self-esteem?

Researchers will compare participants who receive the expressive writing program together with treatment as usual to participants who receive treatment as usual alone.

Participants will:

• Be randomly assigned to one of two groups: a writing program group or a usual care group
• Complete questionnaires about mood, suicidal thoughts, and well-being at the start of the study, after 4 weeks, and after 8 weeks
• If assigned to the writing program group, complete guided writing activities several times per week for 4 weeks. Each writing session will take about 15 to 20 minutes and will focus on understanding emotions, personal experiences, relationships, and meaning in difficult experiences.

Researchers will study whether this writing program is a helpful and practical way to support young people who are experiencing suicidal thoughts or emotional distress.

Study Overview

• Status: Not yet recruiting
• Conditions: Suicidal Ideation; Self-Injurious Behavior; Suicide Risk; Adolescent Mental Health
• Intervention / Treatment: Behavioral: Structured Expressive Writing Intervention; Behavioral: Treatment as Usual (TAU)

Detailed Description

Suicide represents a major public health concern among adolescents and young adults. In South Korea, suicide has consistently ranked as the leading cause of death among individuals aged 10-29 years. Preventive interventions targeting suicidal ideation and early stages of suicide risk are therefore urgently needed.

Existing evidence-based interventions for suicidal behaviors, including dialectical behavior therapy (DBT) and cognitive behavioral therapy (CBT), have demonstrated clinical effectiveness but require intensive therapist involvement and specialized training. These characteristics limit their scalability and accessibility in many community and school-based settings.

Expressive writing is a brief psychological intervention originally developed by Pennebaker and colleagues, in which individuals write about emotionally significant experiences. The intervention is believed to promote emotional labeling, cognitive processing, and narrative integration of stressful experiences. Neuropsychological research suggests that labeling emotions may reduce amygdala activation and facilitate regulation through prefrontal cortical mechanisms. Meta-analytic studies have also reported improvements in psychological outcomes among adolescents who engage in expressive writing.

However, randomized controlled trials evaluating expressive writing interventions specifically for adolescents and young adults at risk of suicide remain limited. In addition, most existing interventions are unstructured, which may limit their suitability for high-risk populations.

The present study aims to develop and evaluate a structured text-based expressive writing program designed for adolescents and young adults with suicide risk. The intervention is designed to promote emotional awareness, self-understanding, relational awareness, and meaning reconstruction through guided writing prompts delivered over four weeks.

Participants aged 13-24 years with a history of suicidal ideation, suicide attempts, or non-suicidal self-injury will be recruited from clinical and community settings. After screening and baseline assessment, participants will be randomly assigned to one of two groups:

1. Experimental group: 4-week structured expressive writing intervention plus treatment as usual (TAU)
2. Control group: TAU alone

Participants in the intervention group will complete guided writing exercises multiple times per week. Each writing session will take approximately 15-20 minutes and will be supported by structured prompts designed to facilitate emotional expression and cognitive processing.

Primary and secondary outcomes will be assessed at baseline, 4 weeks (post-intervention), and 8 weeks (follow-up). The primary outcome is change in suicidal ideation measured using the Beck Scale for Suicide Ideation (BSSI). Secondary outcomes include depressive symptoms, impulsivity, self-esteem, and help-seeking behavior.

The study is designed as a randomized controlled trial with parallel assignment. A total of 160 participants will be enrolled. The findings of this study may contribute to the development of accessible and scalable suicide prevention interventions for adolescents and young adults.

• Study Type: Interventional
• Enrollment (Estimated): 160
• Phase: Not Applicable

Contacts and Locations

• Study Contact: Name: Hyun Ju Hong, MD, PhD; Phone Number: 82+031-380-1500; Email: honghj88@gmail.com

Participation Criteria

Eligibility Criteria

• Ages Eligible for Study: Child; Adult
• Accepts Healthy Volunteers: No

Description

Inclusion Criteria:

• Adolescents or young adults aged 13 to 24 years.
• Individuals with a history of suicidal ideation, suicide attempts, or non-suicidal self-injury.
• Individuals currently receiving mental health services or who have been evaluated as having suicide risk within the past 6 months.
• Ability to read and write in Korean.
• For participants under 19 years of age, both participant assent and parental consent are required.

Exclusion Criteria:

• Individuals requiring immediate psychiatric hospitalization.
• Severe intellectual disability or neurodevelopmental disorder that prevents participation in writing activities.
• Acute psychosis or manic episode that would interfere with participation in the study.
• Participation in another suicide prevention clinical trial during the study period.

Study Plan

How is the study designed?

Design Details

• Primary Purpose: Treatment
• Allocation: Randomized
• Interventional Model: Parallel Assignment
• Masking: None (Open Label)

Number of Arms

2

Arms and Interventions

Participant Group / Arm	Intervention / Treatment
Experimental: Expressive Writing Intervention plus Treatment as Usual; Participants in this group receive a structured expressive writing intervention in addition to treatment as usual.	Behavioral: Structured Expressive Writing Intervention; A structured expressive writing program in which participants complete guided writing sessions several times per week for four weeks. Each session lasts approximately 15 to 20 minutes and focuses on emotional awareness and personal reflection.
Active Comparator: Treatment as Usual; Participants receive treatment as usual, which may include standard mental health care or counseling services.	Behavioral: Treatment as Usual (TAU); Participants receive the standard mental health care or support services that are normally available during the study period.

What is the study measuring?

Primary Outcome Measures

Outcome Measure	Measure Description	Time Frame
Change in Suicidal Ideation	Suicidal ideation will be measured using the Beck Scale for Suicide Ideation (BSSI). The outcome measure is the change in BSSI score between baseline and follow-up assessments.	Baseline, 4 weeks, and 8 weeks

Secondary Outcome Measures

Outcome Measure	Measure Description	Time Frame
Change in Depressive Symptoms	Depressive symptoms will be measured using the Beck Depression Inventory (BDI). The outcome measure is the change in BDI score between baseline and follow-up assessments.	Baseline, 4 weeks, and 8 weeks
Change in Impulsivity	Impulsivity will be measured using the Barratt Impulsiveness Scale (BIS-11). The outcome measure is the change in BIS-11 score between baseline and follow-up assessments.	Baseline, 4 weeks, and 8 weeks
Change in Self-Esteem	Self-esteem will be measured using the Rosenberg Self-Esteem Scale. The outcome measure is the change in self-esteem score between baseline and follow-up assessments.	Baseline, 4 weeks, and 8 weeks
Change in Alexithymia	Alexithymia will be assessed using the Toronto Alexithymia Scale (TAS-20). The outcome measure is the change in TAS-20 score between baseline and follow-up assessments.	Baseline, 4 weeks, and 8 weeks
Program Acceptability	Acceptability of the intervention will be assessed using the Acceptability of Intervention Measure (AIM). The measure evaluates participants' perceived acceptability and satisfaction with the intervention.	4 weeks

Collaborators and Investigators

• Sponsor: Hallym University Medical Center

Study record dates

Study Major Dates

• Study Start (Estimated): April 1, 2026
• Primary Completion (Estimated): December 1, 2027
• Study Completion (Estimated): March 1, 2028

Study Registration Dates

• First Submitted: March 13, 2026
• First Submitted That Met QC Criteria: March 13, 2026
• First Posted (Actual): March 18, 2026

Study Record Updates

• Last Update Posted (Actual): March 18, 2026
• Last Update Submitted That Met QC Criteria: March 13, 2026
• Last Verified: March 1, 2026

More Information

Terms related to this study

• Keywords: Expressive Writing; Suicide Prevention; Youth Mental Health; Self-Harm; Adolescent Suicide
• Additional Relevant MeSH Terms: Behavioral Symptoms; Suicide; Behavior; Suicide Prevention; Suicidal Ideation; Self-Injurious Behavior; Therapeutics
• Other Study ID Numbers: HSHH-2026-EW-RCT

Plan for Individual participant data (IPD)

• Plan to Share Individual Participant Data (IPD)?: NO
• IPD Plan Description: Individual participant data will not be shared due to the sensitive nature of the data and the need to protect participant confidentiality, particularly because the study involves adolescents and suicide-related mental health information.

Drug and device information, study documents

• Studies a U.S. FDA-regulated drug product: No
• Studies a U.S. FDA-regulated device product: No