Augmenting Safety Planning With Text Messaging Support for Adolescents at Elevated Suicide Risk: Development and Acceptability Study

Abstract

Background Suicide is the second leading cause of death among adolescents. A critical need exists for developing promising interventions for adolescents after psychiatric hospitalization who are at a high risk of experiencing repeated suicidal behaviors and related crises. The high-risk period following psychiatric hospitalization calls for cost-effective and scalable continuity of care approaches to support adolescents’ transition from inpatient care. Text messages have been used to improve a wide range of behavioral and health outcomes and may hold promise as an accessible continuity of care strategy for youth at risk of suicide. Objective In this study of 40 adolescents at elevated suicide risk, we report on the iterative development and acceptability of a text-based intervention designed to encourage adaptive coping and safety plan adherence in the high-risk period following psychiatric hospitalization. Methods Adolescents (aged 13-17 years) who were hospitalized because of last-month suicide attempts or last-week suicidal ideation took part in either study phase 1 (n=25; 19/25, 76% female), wherein message content was developed and revised on the basis of feedback obtained during hospitalization, or study phase 2 (n=15; 11/15, 73% female), wherein text messages informed by phase 1 were further tested and refined based on feedback obtained daily over the course of a month after discharge (n=256 observations) and during an end-of-study phone interview. Results Quantitative and qualitative feedback across the 2 study phases pointed to the acceptability of text-based support. Messages were seen as having the potential to be helpful with the transition after hospitalization, with adolescents indicating that texts may serve as reminders to use coping strategies, contribute to improvement in mood, and provide them with a sense of encouragement and hope. At the same time, some adolescents expressed concerns that messages may be insufficient for all teens or circumstances. In phase 2, the passage of time did not influence adolescents’ perception of messages in the month after discharge (P=.74); however, there were notable daily level associations between the perception of messages and adolescents’ affect. Specifically, higher within-person (relative to adolescents’ own average) anger was negatively related to liking text messages (P=.005), whereas within-person positive affect was associated with the perception of messages as more helpful (P=.04). Conclusions Text-based support appears to be an acceptable continuity of care strategy to support adolescents’ transition after hospitalization. The implications of study findings are discussed. Future work is needed to evaluate the impact of text-based interventions on suicide-related outcomes.

Text Message Interventions in Adolescent Mental Health and Addiction Services: Scoping Review

“…Nine studies reported that the intervention had been co-designed with adolescents. Texting frequency ranged from several times per day for one depression-focused study [ 56 ] to once every two weeks or month for another depression-focused study [ 54 ]. Most frequently, interventions were delivered in less than 12 weeks, and adolescents received 1-3 messages per week over that time.…”

“…Text messages across all studies were typically designed to convey empathy and encouragement (eg, “Stop… Breathe… And think about how you got through difficult times before. You got this!” [ 56 ]) and to support coping. The content and authenticity of the messages were cited by adolescent respondents as key elements of their engagement.…”

“…You got this!" [56]) and to support coping. The content and authenticity of the messages were cited by adolescent respondents as key elements of their engagement.…”

Mental Health Outreach via Supportive Text Messages during the COVID-19 Pandemic: Improved Mental Health and Reduced Suicidal Ideation after Six Weeks in Subscribers of Text4Hope Compared to a Control Population

“…TextM are perceived as an acceptable, feasible, and supportive tool during the transition period after discharge for an attempted suicide [ 12 , 38 ]. A mobile (smartphone) app used for data collection in one study showed reliability ( r = 0.84) when compared with paper-based PHQ-9 scores [ 39 ].…”

Adaptive intervention for prevention of adolescent suicidal behavior after hospitalization: a pilot sequential multiple assignment randomized trial

“…Previous studies showed that MI‐SP, booster calls, and Texts can be feasibly delivered and are acceptable among suicidal adolescent inpatients and their parents (Czyz, Arango, Healy, King, & Walton, 2020; Czyz, King, & Biermann, 2019). Here, extending this prior work, the current nonrestricted pilot SMART included all three components and was conducted to begin obtaining the needed empirical basis for constructing an AI for suicidal youth transitioning from inpatient hospitalization.…”