Recruitment of adolescents with suicidal ideation in the emergency department: lessons from a randomized controlled pilot trial of a youth suicide prevention intervention

Matthew Tracey, Yaron Finkelstein, Reva Schachter, Kristin Cleverley, Suneeta Monga, Melanie Barwick, Peter Szatmari, Myla E Moretti, Andrew Willan, Joanna Henderson, Daphne J Korczak, Matthew Tracey, Yaron Finkelstein, Reva Schachter, Kristin Cleverley, Suneeta Monga, Melanie Barwick, Peter Szatmari, Myla E Moretti, Andrew Willan, Joanna Henderson, Daphne J Korczak

Abstract

Background: Emergency Departments (EDs) are a first point-of-contact for many youth with mental health and suicidality concerns and can serve as an effective recruitment source for randomized controlled trials (RCTs) of mental health interventions. However, recruitment in acute care settings is impeded by several challenges. This pilot RCT of a youth suicide prevention intervention recruited adolescents aged 12 to 17 years presenting to a pediatric hospital ED with suicide related behaviors.

Methods: Recruitment barriers were identified during the initial study recruitment period and included: the time of day of ED presentations, challenges inherent to study presentation, engagement and participation during an acute presentation, challenges approaching and enrolling acutely suicidal patients and families, ED environmental factors, and youth and parental concerns regarding the study. We calculated the average recruitment productivity for published trials of adolescent suicide prevention strategies which included the ED as a recruitment site in order to compare our recruitment productivity.

Results: In response to identified barriers, an enhanced ED-centered recruitment strategy was developed to address low recruitment rate, specifically (i) engaging a wider network of ED and outpatient psychiatry staff (ii) dissemination of study pamphlets across multiple areas of the ED and relevant outpatient clinics. Following implementation of the enhanced recruitment strategy, the pre-post recruitment productivity, a ratio of patients screened to patients randomized, was computed. A total of 120 patients were approached for participation, 89 (74.2%) were screened and 45 (37.5%) were consented for the study from March 2018 to April 2019. The screening to randomization ratio for the study period prior to the introduction of the enhanced recruitment strategies was 3:1, which decreased to 1.8:1 following the implementation of enhanced recruitment strategies. The ratio for the total recruitment period was 2.1:1. This was lower than the average ratio of 3.2:1 for published trials.

Conclusions: EDs are feasible sites for participant recruitment in RCTs examining new interventions for acute mental health problems, including suicidality. Engaging multi-disciplinary ED staff to support recruitment for such studies, proactively addressing anticipated concerns, and creating a robust recruitment pathway that includes approach at outpatient appointments can optimize recruitment.

Trial registration: ClinicalTrials.gov : NCT03488602 , retrospectively registered April 4, 2018.

Keywords: Adolescents; Clinical trials; Emergency departments; Interventions; Mental health; Pediatrics; Recruitment; Suicide; Youth.

Conflict of interest statement

The authors declare that they have no competing interests.

Figures

Fig. 1
Fig. 1
Original RCT Recruitment Pathway
Fig. 2
Fig. 2
Amended RCT Recruitment Pathway

References

    1. Canadian Institute for Health Information. Child and youth mental health in Canada — Infographic [Internet]. 2019. Available from: [cited 2019 4 Jun].
    1. Canadian Institute for Health Information. Care for Children and Youth With Mental Disorders. 2015. Available from: [cited 2019 3 Sept].
    1. Georgiades K, Boylan K, Duncan L, Wang L, Colman I, Rhodes AE, et al. Prevalence and correlates of youth suicidal ideation and attempts: evidence from the 2014 Ontario child health study. Can J Psychiatr. 2019;64(4):265–274.
    1. Newton AS, Rosychuk RJ, Carlisle CE, Zhang X, Bethell J, Rhodes AE. Time trends in emergency department visits for suicide-related Behaviours by girls and boys in Alberta. Can J Psychiatr. 2016;61(7):422–427.
    1. Rhodes AE, Bethell J, Carlisle C, Rosychuk RJ, Lu H, Newton A. Time trends in suicide-related Behaviours in girls and boys. Can J Psychiatr. 2014;59(3):152–159.
    1. Rhodes AE, Lu H, Skinner R. Time trends in medically serious suicide-related behaviours in boys and girls. Can J Psychiatry. 2015. 2014; 59(10):556–560.
    1. Gandhi S, Chiu M, Lam K, Cairney JC, Guttmann A, Kurdyak P. Mental health service use among children and youth in Ontario: population-based trends over time. Can J Psychiatry. 2016;61(2):119–124.
    1. Liu S, Ali S, Mdcm A, Rosychuk RJ, Newton AS. Characteristics of Children and Youth Who Visit the Emergency Department for a Behavioural Disorder. Can Acad Child Adolesc Psychiatry. 2014;23(2):111–117.
    1. Finkelstein Y, Macdonald EM, Hollands S, Hutson JR, Sivilotti ML, Mamdani MM, et al. Long-term outcomes following self-poisoning in adolescents: a population-based cohort study. Lancet Psychiatry. 2015;2(6):532–539.
    1. Gardner W, Pajer K, Cloutier P, Currie L, Colman I, Zemek R, et al. Health outcomes associated with emergency department visits by adolescents for self-harm: a propensity-matched cohort study. CMAJ. 2019;191(44):E1207–E1216.
    1. Finkelstein Y, Macdonald EM, Hollands S, Sivilotti MLA, Hutson JR, Mamdani MM, et al. Repetition of intentional drug overdose: a population-based study. Clin Toxicol. 2016;54(7):585–589.
    1. Gilley M, Sivilotti MLA, Juurlink DN, Macdonald E, Yao Z, Finkelstein Y. Trends of intentional drug overdose among youth: a population-based cohort study. Clin Toxicol. 2019:1–5.
    1. Robinson J, Hetrick SE, Martin C. Preventing suicide in young people: systematic review. Aust N Z J Psychiatry. 2011;45(1):3–26.
    1. Bennett K, Rhodes AE, Duda S, Cheung AH, Manassis K, Links P, et al. A youth suicide prevention plan for Canada: a systematic review of reviews. Can J Psychiatr. 2015;60(6):245–257.
    1. McDonald AM, Knight RC, Campbell MK, Entwistle VA, Grant AM, Cook JA, et al. What influences recruitment to randomised controlled trials? A review of trials funded by two UK funding agencies. Trials. 2006;7:9.
    1. Sully BGO, Julious SA, Nicholl J. A reinvestigation of recruitment to randomised, controlled, multicenter trials: a review of trials funded by two UK funding agencies. Trials. 2013;14(1):166.
    1. Schandelmaier S, Von Elm E, You JJ, Blümle A, Tomonaga Y, Lamontagne F, et al. Premature discontinuation of randomized trials in critical and emergency care: a retrospective cohort study. Crit Care Med. 2016;44(1):130–137.
    1. Kasenda B, von Elm E, You J, Blümle A, Tomonaga Y, Saccilotto R, et al. Prevalence, characteristics, and publication of discontinued randomized trials. JAMA. 2014;311(10):1045–1052.
    1. Kurt A, Kincaid HM, Curtis C, Semler L, Meyers M, Johnson M, et al. Factors influencing participation in clinical trials: emergency medicine vs. Other Specialties. West J Emerg Med. 2017;18(5):846–855.
    1. Cofield SS, Conwit R, Barsan W, Quinn J. Recruitment and retention of patients into emergency medicine clinical trials. Acad Emerg Med. 2010;17(10):1104–1112.
    1. Cavallo C, Labib MA, Honea N, Nakaji P. Letter: enrollment-to-screening ratio: an undervalued data in randomized clinical trials. Neurosurgery. 2018;82(6):E184–E185.
    1. Korczak DJ, Finkelstein Y, Barwick M, Chaim G, Cleverley K, Henderson J, et al. A suicide prevention strategy for youth presenting to the emergency department with suicide related behaviour: protocol for a randomized controlled trial. BMC Psychiatry. 2020;14;20(1):20.
    1. Reynolds WM. Suicidal ideation questionnaire (SIQ). Odessa, FL Psychol Assess Resour. 1987.
    1. Kaufman J, Birmaher B, Brent DA, Ryan ND, Rao U. K-Sads-Pl. J Am Acad Child Adolesc Psychiatry. 2000;39(10):1208.
    1. Robinson J, Bailey E, Witt K, Stefanac N, Milner A, Currier D, et al. What works in youth suicide prevention? A Systematic Review and Meta-Analysis. EClin Med. 2018;4(5):52–91.
    1. Plemmons G, Hall M, Doupnik S, Gay J, Brown C, Browning W, et al. Hospitalization for suicide ideation or attempt: 2008-2015. Pediatrics. 2018;141(6):e20172426.
    1. R Core Team R. A language and environment for statistical computing. Vienna: R Foundation for statistical. Computing; 2013. .
    1. Rosenbaum Asarnow J, Hughes JL, Babeva KN, Sugar CA. Cognitive-behavioral family treatment for suicide attempt prevention: a randomized controlled trial HHS public access. J Am Acad Child Adolesc Psychiatry. 2017;56(6):506–514.
    1. Bertolote JM, Fleischmann A, De Leo D, Phillips MR, Botega NJ, Vijayakumar L, et al. Repetition of suicide attempts: data from emergency care settings in five culturally different low- and middle-income countries participating in the WHO SUPRE-MISS study. Crisis. 2010;31(4):194–201.
    1. Diamond GS, Wintersteen MB, Brown GK, Diamond GM, Gallop R, Shelef K, et al. Attachment-based family therapy for adolescents with suicidal ideation: a randomized controlled trial. J Am Acad Child Adolesc Psychiatry. 2010;49(2):122–131.
    1. Husain N, Afsar S, Ara J, Fayyaz H, Ur RR, Tomenson B, et al. Brief psychological intervention after self-harm: randomised controlled trial from Pakistan. Br J Psychiatry. 2014;204(6):462–470.
    1. King CA, Kramer A, Preuss L, Kerr DCR, Weisse L, Venkataraman S. Youth-nominated support team for suicidal adolescents (version 1): a randomized controlled trial. J Consult Clin Psychol. 2006;74(1):199–206.
    1. King CA, Klaus N, Kramer A, Venkataraman S, Quinlan P, Gillespie B. The youth-nominated support team–version II for suicidal adolescents: a randomized controlled intervention trial. J Consult Clin Psychol. 2009;77(5):880–893.
    1. King CA, Gipson PY, Horwitz AG, Opperman KJ. Teen Options for Change: An Intervention for Young Emergency Patients Who Screen Positive for Suicide Risk. Psychiatr Serv. 2015;66(1):97–100.
    1. Mehlum L, Ramberg M, Tørmoen AJ, Haga E, Diep LM, Stanley BH, et al. Dialectical behavior therapy compared with enhanced usual Care for Adolescents with Repeated Suicidal and Self-Harming Behavior: outcomes over a one-year follow-up. J Am Acad Child Adolesc Psychiatry. 2016;55(4):295–300.
    1. Ougrin D, Zundel T, Ng A, Banarsee R, Bottle A, Taylor E. Trial of therapeutic assessment in London: randomised controlled trial of therapeutic assessment versus standard psychosocial assessment in adolescents presenting with self-harm. Arch Dis Child. 2011;96(2):148–153.
    1. Pineda J, Dadds MR. Family intervention for adolescents with suicidal behavior: a randomized controlled trial and mediation analysis. J Am Acad Child Adolesc Psychiatry. 2013;52(8):851–862.
    1. Rossouw TI, Fonagy P. Mentalization-based treatment for self-harm in adolescents: a randomized controlled trial. J Am Acad Child Adolesc Psychiatry. 2012;51(12):1304–1313.
    1. David Rudd M, Hasan Rajab M, Orman DT, Stulman DA, Joiner T, Dixon W. Effectiveness of an outpatient intervention targeting suicidal young adults: preliminary results. J Consult Clin Psychol. 1996;64(1):179–190.
    1. Spirito A, Boergers J, Donaldson D, Bishop D, Lewander W. An intervention trial to improve adherence to community treatment by adolescents after a suicide attempt. J Am Acad Child Adolesc Psychiatry. 2002;41(4):435–442.
    1. Wharff EA, Ginnis KB, Ross AM, White EM, White MT, Forbes PW. Family-based crisis intervention with suicidal adolescents: a randomized clinical trial. Pediatr Emerg Care. 2019;35(3):170–175.
    1. Carter GL, Willcox CH, Lewin TJ, Conrad AM, Bendit N. Hunter DBT project: randomized controlled trial of dialectical behaviour therapy in women with borderline personality disorder. Aust New Zeal J Psychiatry. 2010;44(2):162–173.
    1. Cooney E, Davis K, Thompson P, Wharewera-Mika J, Stewart J, Te Pou Te, Whakaaro Nui by. Feasibility of evaluating DBT for self-harming adolescents: A small randomised controlled trial 2010.
    1. Green JM, Wood AJ, Kerfoot MJ, Trainor G, Roberts C, Rothwell J, et al. Group therapy for adolescents with repeated self harm: randomised controlled trial with economic evaluation. BMJ. 2011;342:d682.
    1. Harrington R, Kerfoot M, Dyer E, McNiven F, Gill J, Harrington V, et al. Randomized trial of a home-based family intervention for children who have deliberately poisoned themselves. J Am Acad Child Adolesc Psychiatry. 1998;37(5):512–518.
    1. Hazell PL, Martin G, Mcgill K, Kay T, Wood A, Trainor G, et al. Group therapy for repeated deliberate self-harm in adolescents: failure of replication of a randomized trial. J Am Acad Child Adolesc Psychiatry. 2009;48(6):662–670.
    1. Slee N, Garnefski N, van der Leeden R, Arensman E, Spinhoven P. Cognitive-behavioural intervention for self-harm: randomised controlled trial. Br J Psychiatry. 2008;192(3):202–211.
    1. Wood A, Psych MRC, Trainor G, Rothwell J, Moore A, Harrington R. Randomized trial of group therapy for repeated deliberate self-harm in adolescents. Vol. 40, J. am. Acad. Child Adolesc. Psychiatry. 2001;40(11):1246–1253.
    1. Liabo K, Roberts H. Coproduction and coproducing research with children and their parents. Arch Dis Child. 2019;104(12):1134–1137.
    1. Health Care Consent Act, 1996, S.O. 1996, c. 2, Sched. A. Ontario, Canada; 1996 [cited 2020 Aug 28]. Available from: .
    1. Couglin AW. Medical decision-making in Paediatrics: infancy to adolescence. Paediatr Child Health. 2018;23(2):138–146.

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