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.

Background There is considerable scientific interest in finding new and innovative ways to capture rapid fluctuations in functioning within individuals with bipolar disorder (BD), a severe, recurrent mental disorder associated with frequent shifts in symptoms and functioning. The use of smartphones can provide valid and real-world tools for use in measurement-based care and could be used to inform more personalized treatment options for this group, which can improve standard of care. Objective We examined the feasibility and usability of a smartphone to capture daily fluctuations in mood within BD and to relate daily self-rated mood to smartphone use behaviors indicative of psychomotor activity or symptoms of the illness. Methods Participants were 26 individuals with BD and 12 healthy control individuals who were recruited from the Prechter Longitudinal Study of BD. All were given a smartphone with a custom-built app and prompted twice a day to complete questions of mood for 28 days. The app automatically and unobtrusively collected phone usage data. A poststudy satisfaction survey was also completed. Results Our sample showed a very high adherence rate to the daily momentary assessments (91% of the 58 prompts completed). Multivariate mixed effect models showed that an increase in rapid thoughts over time was associated with a decrease in outgoing text messages (β=–.02; P=.04), and an increase in impulsivity self-ratings was related to a decrease in total call duration (β=–.29; P=.02). Participants generally reported positive experiences using the smartphone and completing daily prompts. Conclusions Use of mobile technology shows promise as a way to collect important clinical information that can be used to inform treatment decision making and monitor outcomes in a manner that is not overly burdensome to the patient or providers, highlighting its potential use in measurement-based care.

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.

<b><i>Background:</i></b> Trauma can lead to long-term downregulation of the hypothalamic pituitary adrenal (HPA) axis. However, dehydroepiandrosterone (DHEA) has neuroprotective effects that may reduce the need for downregulation of the axis in response to stress. Furthermore, high DHEA/cortisol ratios are often conceptualized as better markers of DHEA’s availability than DHEA alone, as ratios account for the coupling of DHEA and cortisol in response to stress. <b><i>Objectives:</i></b> In this study, we explored if DHEA and DHEA/cortisol ratios moderated the association between childhood maltreatment and the HPA axis stress response. <b><i>Methods:</i></b> The sample consisted of 101 adolescents (ages 12–16) who completed the Child Trauma Questionnaire (CTQ) and the Trier Social Stress Test (TSST). Cortisol was modeled using saliva samples at 8 time points throughout the TSST. Cortisol and DHEA ratios were examined at baseline and 35 min after stress initiation. <b><i>Results:</i></b> Childhood maltreatment was associated with less steep cortisol activation slope and peak cortisol levels, but DHEA and DHEA/cortisol ratios moderated this effect. At high levels of DHEA, the impact of childhood maltreatment on cortisol peak levels was no longer significant. In contrast, high DHEA/cortisol ratios were associated with an intensification of the impact of childhood maltreatment on peak levels. <b><i>Conclusions:</i></b> Results suggest that DHEA can limit the blunting of the HPA axis in response to childhood maltreatment. However, this protective effect was not reflected in high DHEA/cortisol ratios as predicted. Therefore, high DHEA and high DHEA/cortisol ratios may reflect different, and potentially opposite, processes.