Employing a sequential multiple assignment randomized trial (SMART) to evaluate the impact of brief risk and protective factor prevention interventions for American Indian Youth Suicide

Abstract

BackgroundThis study is built on a long-standing research partnership between the Johns Hopkins Center for American Indian Health and the White Mountain Apache Tribe to identify effective interventions to prevent suicide and promote resilience among American Indian (AI) youth. The work is founded on a tribally-mandated, community-based suicide surveillance system with case management by local community mental health specialists (CMHSs) who strive to connect at-risk youth to treatment and brief, adjunctive interventions piloted in past research.MethodsOur primary aim is to evaluate which brief interventions, alone or in combination, have the greater effect on suicide ideation (primary outcome) and resilience (secondary outcome) among AI youth ages 10–24 ascertained for suicide-related behaviors by the tribal surveillance system. We are using a Sequential Multiple Assignment Randomized Trial with stratified assignment based on age and suicidal-behavior type, and randomizing N = 304 youth. Brief interventions are delivered by AI CMHSs, or by Elders with CMHS support, and include: 1) New Hope, an evidence-based intervention to reduce immediate suicide risk through safety planning, emotion regulation skills, and facilitated care connections; and 2) Elders’ Resilience, a culturally-grounded intervention to promote resilience through connectedness, self-esteem and cultural identity/values. The control condition is Optimized Case Management, which all study participants receive. We hypothesize that youth who receive: a) New Hope vs. Optimized Case Management will have significant reductions in suicide ideation; b) Elders’ Resilience vs. Optimized Case Management will have significant gains in resilience; c) New Hope followed by Elders’ Resilience will have the largest improvements on suicide ideation and resilience; and d) Optimized Case Management will have the weakest effects of all groups. Our secondary aim will examine mediators and moderators of treatment effectiveness and sequencing.DiscussionDue to heterogeneity of suicide risk/protective factors among AI youth, not all youth require the same types of interventions. Generating evidence for what works, when it works, and for whom is paramount to AI youth suicide prevention efforts, where rates are currently high and resources are limited. Employing Native paraprofessionals is a means of task-shifting psychoeducation, culturally competent patient support and continuity of care.Trial registrationClinical Trials NCT03543865, June 1, 2018.

Delta Event-Related Oscillations Are Related to a History of Extreme Binge Drinking in Adolescence and Lifetime Suicide Risk

“…These data also align with recent findings indicating that AI/AN youth and young adults show suicide mortality rates that are more than 2 to 3 times higher than their same-aged European American, African American, and Asian/Pacific Islander peers [ 115 ]. Such findings spotlight the need for prevention and intervention efforts in this high-risk group [ 116 ] and underscore the urgency for increased research within adolescence specifically. These data also align with findings showing increased risk of suicide among AI/ANs in association with alcohol intoxication [ 117 ].…”

Balancing cultural specificity and generalizability: Brief qualitative methods for selecting, adapting, and developing measures for research with American Indian communities.

“…The majority of participants were female (70%) and slightly less than half (42%) of the sample were between the ages of 10–14. All participants experienced a recent suicide attempt, suicide ideation, or binge substance use with suicide ideation to be eligible to participate in the larger study (O’Keefe et al, 2019). Most participants in the present study sample experienced recent suicide ideation (62%), while one-third of participants had a recent suicide attempt (30%), and 8% of participants experienced recent binge substance use with suicide ideation.…”

“…The focus group was held as part of a training on the research procedures for the larger clinical trial which is testing two brief interventions for youth ages 10–24 with recent suicide attempts, suicide ideation, or binge drinking and suicide ideation in partnership with the White Mountain Apache Tribe (O’Keefe et al, 2019). The first psychoeducational-based intervention is provided by Apache case managers, focused on reducing suicide risk, and was previously adapted and tested in the same community (i.e., New Hope; Cwik et al, 2016).…”

“…To examine whether these adaptations and new additions performed adequately, we examined their performance in the first N = 93 participants enrolled in the trial (O’Keefe et al, 2019). Performance was measured by examining Cronbach’s α (reliability; Bland & Altman, 1997), distribution of baseline score (variability), and construct validity using a hetero-trait monomethod correlation matrix (i.e., convergent and discriminant validity; Campbell & Fiske, 1959).…”

“…The purpose of this paper is to describe our process to select, adapt, and develop measures for use in a large study focused on testing the impact of brief interventions aimed at reducing suicide risk and promoting resilience among Native American youth ages 10–24 (O’Keefe et al, 2019). Our approach reflects understanding of a tension that exists in all research across populations—that is, whether the phenomena being measured is universal to all peoples, or the meaning and expression of constructs under consideration are specific to each community and cultural setting.…”