Background The need for effective interventions for psychiatrically hospitalized adolescents who have varying levels of postdischarge suicide risk calls for personalized approaches, such as adaptive interventions (AIs). We conducted a nonrestricted pilot Sequential, Multiple Assignment, Randomized Trial (SMART) to guide the development of an AI targeting suicide risk after hospitalization. Methods Adolescent inpatients (N = 80; ages 13–17; 67.5% female) were randomized in Phase 1 to a Motivational Interview‐Enhanced Safety Plan (MI‐SP), delivered during hospitalization, alone or in combination with postdischarge text‐based support (Texts). Two weeks after discharge, participants were re‐randomized in Phase 2 to added telephone booster calls or to no calls. Mechanisms of change were assessed with daily diaries for four weeks and over a 1‐ and 3‐month follow‐up. This trial is registered with clinicaltrials.gov (identifier: NCT03838198). Results Procedures were feasible and acceptable. Mixed effects models indicate that adolescents randomized to MI‐SP + Texts (Phase 1) and those randomized to booster calls (Phase 2) experienced significant improvement in daily‐level mechanisms, including safety plan use, self‐efficacy to refrain from suicidal action, and coping by support seeking. Those randomized to MI‐SP + Texts also reported significantly higher coping self‐efficacy at 1 and 3 months. Although exploratory, results were in the expected direction for MI‐SP + Texts, versus MI‐SP alone, in terms of lower risk of suicide attempts (Hazard ratio = 0.30; 95% CI = 0.06, 1.48) and suicidal behavior (Hazard ratio = 0.36; 95% CI = 0.10, 1.37) three months after discharge. Moreover, augmentation with booster calls did not have an overall meaningful impact on suicide attempts (Hazard ratio = 0.65; 95% CI = 0.17, 3.05) or suicidal behavior (Hazard ratio = 0.78; 95% CI = 0.23, 2.67); however, boosters benefited most those initially assigned to MI‐SP + Texts. Conclusions The current SMART was feasible and acceptable for the purpose of informing an AI for suicidal adolescents, warranting additional study. Findings also indicate that postdischarge text‐based support offers a promising augmentation to safety planning delivered during hospitalization.

Suicide is one of the leading causes of death among adolescents in the United States, and risk for recurring suicidal thoughts and behavior remains high after discharge from psychiatric hospitals. Safety planning, a brief intervention wherein the main focus is on identifying personal coping strategies and resources to mitigate suicidal crises, is a recommended best practice approach for intervening with individuals at risk for suicide. However, anecdotal as well as emerging empirical evidence indicate that adolescents at risk for suicide often do not use their safety plan during the high-risk postdischarge period. Thus, to be maximally effective, we argue that safety planning should be augmented with additional strategies for increasing safety plan use to prevent recurrent crises during high-risk transitions. The current article describes an adjunctive intervention for adolescents at elevated suicide risk that enhances safety planning with motivational interviewing (MI) strategies, with the goal of increasing adolescents' motivation and strengthening self-efficacy for safety plan use after discharge. We provide an overview of the intervention and its components, focusing the discussion on the in-person individual and family sessions delivered during hospitalization, and describe the theoretical basis for the MI-enhanced intervention. We then provide examples of applying MI during the process of safety planning, including example strategies that aim to elicit motivation and strengthen self-efficacy for safety plan use. We conclude with clinical case material and highlight how these strategies may be incorporated into the safety planning session. Clinical Impact StatementQuestion: This article describes how motivational interviewing (MI) strategies can be applied in a safety planning session. Findings: This article provides example strategies illustrating how MI might be applied to guide the process of developing a safety plan. Meaning: MI strategies may offer a useful approach for facilitating client engagement during the process of safety planning. Next Valerie J. Micol served as lead for conceptualization and writingoriginal draft, review, and editing. David Prouty served in a supporting role for writingreview and editing. Ewa K. Czyz served as lead for funding acquisition and supervision and served in a supporting role for conceptualization and writingoriginal draft, review, and editing. The authors have no conflict of interest to declare.