Effect of a Motivational Interviewing-Based Intervention on Initiation of Mental Health Treatment and Mental Health After an Emergency Department Visit Among Suicidal Adolescents: A Randomized Clinical Trial

Abstract

Importance: Emergency department (ED) visits present opportunities to identify and refer suicidal youth for outpatient mental health care, although this practice is not routine.

Objective: To examine whether a motivational interviewing-based intervention increases linkage of adolescents to outpatient mental health services and reduces depression symptoms and suicidal ideation in adolescents seeking emergency care for non-mental health-related concerns who screen positive for suicide risk.

Design, setting, and participants: In this randomized clinical trial, adolescents aged 12 to 17 years who screened positive on the Ask Suicide Screening Questions (ASQ) during a nonpsychiatric ED visit at 2 academic pediatric EDs in Ohio were recruited from April 2013 to July 2015. Intention-to-treat analyses were performed from September 2018 to October 2019.

Interventions: The Suicidal Teens Accessing Treatment After an Emergency Department Visit (STAT-ED) intervention included motivational interviewing to target family engagement, problem solving, referral assistance, and limited case management. The enhanced usual care (EUC) intervention consisted of brief mental health care consultation and referral.

Main outcomes and measures: Primary outcomes were mental health treatment initiation and attendance within 2 months of ED discharge and suicidal ideation (assessed by the Suicidal Ideation Questionnaire JR) and depression symptoms (assessed by the Center for Epidemiologic Studies-Depression scale) at 2 and 6 months. Exploratory outcomes included treatment initiation and attendance and suicide attempts at 6 months.

Results: A total of 168 participants were randomized and 159 included in the intention-to-treat analyses (mean [SD] age, 15.0 [1.5] years; 126 [79.2%] female; and 80 [50.3%] white). Seventy-nine participants were randomized to receive the STAT-ED intervention and 80 to receive EUC. At 2 months, youth in the STAT-ED group had similar rates of mental health treatment initiation compared with youth in the EUC group as assessed by parent report (29 [50.9%] vs 22 [34.9%]; adjusted odds ratio [OR], 2.08; 95% CI, 0.97-4.45) and administrative data from mental health care agencies (19 [29.7%] vs 11 [19.3%]; adjusted OR, 1.77; 95% CI, 0.76-4.15). At 2 months, youth in the STAT-ED group and the EUC group had similar rates of treatment attendance (1 appointment: 6 [9.7%] vs 2 [3.6%]; adjusted OR, 2.97; 95% CI, 0.56-15.73; ≥2 appointments: 10 [16.1%] vs 7 [12.7%]; adjusted OR, 1.43; 95% CI, 0.50-4.11). There were no significant group × time differences in suicidal ideation (F = 0.28; P = .72) and depression symptoms (F = 0.49; P = .60) during the 6-month follow-up period. In exploratory analyses, at 6 months, STAT-ED participants had significantly higher rates of agency-reported mental health treatment initiation (adjusted OR, 2.48; 95% CI, 1.16-5.28) and more completed appointments (t99.7 = 2.58; P = .01).

Conclusions and relevance: This study's findings indicate that no differences were found on any primary outcome by study condition. However, STAT-ED was more efficacious than EUC at increasing mental health treatment initiation and attendance at 6 months.

Trial registration: ClinicalTrials.gov identifier: NCT01779414.

Conflict of interest statement

Conflict of Interest Disclosures: Drs Stevens, Boyd, Cohen, Ammerman, and Bridge and Ms Stone reported receiving grants from the Centers for Disease Control and Prevention during the conduct of the study. Dr Marcus reported receiving personal fees from Allergan, Sage Pharmaceuticals, Sunovion, and Janssen Scientific Affairs outside the submitted work. Dr Bridge reported serving as a member of the scientific advisory board of Clarigent Health. No other disclosures were reported.

Figures

Figure 1.. Flow Diagram of Participants in the Trial

ASQ indicates Ask Suicide Screening Questions; EUC, enhanced usual care; STAT-ED, Suicidal Teens Accessing Treatment After an Emergency Department Visit.

Figure 2.. Time to Mental Health Treatment Initiation in Participants Receiving the Suicidal Teens Accessing Treatment After an Emergency Department Visit (STAT-ED) Intervention vs Enhanced Usual Care (EUC)

The log-rank test indicated a significant difference favoring the STAT-ED intervention compared with EUC (χ21 = 4.65; P = .03). As described in the text, 37 participants were lost to follow-up; therefore, it was not possible to assess their engagement with mental health services as assessed by agency report. These participants were included in the analysis but censored immediately after baseline.