Electronic Safety Planning and Text-message Support (eSATS): A Micro-randomized Trial to Develop an Adaptive Text-based Intervention for Patients Discharged with Recent Suicidality

Abstract

Background: Suicide is the 10th leading cause of death in the U.S., representing a significant public health burden. Emergency Departments (EDs) often serve as the first, and only, clinical contact for individuals at risk for suicide, offering opportunity for targeted continuity of care interventions during the high-risk post-discharge period. Best-practice ED guidelines recommend providing high-risk individuals with brief interventions that include safety planning-identifying coping strategies to mitigate suicidal crises-and follow-up contacts. However busy EDs often lack resources to offer these interventions consistently or with fidelity. Innovative approaches that deliver accessible, personalized, and resource-efficient ED-initiated interventions are needed to prevent suicidal behaviors post-discharge. Objectives: Leveraging accessible technologies, we aim to develop an ED-initiated intervention package that incorporates an electronic safety plan (eSP) and adaptive text-based support to facilitate effective post-discharge coping and reduce suicide behavior in high-risk adults. This study consists of three aims: 1) Develop and refine ESP and text-based support with stakeholder input; 2) demonstrate feasibility, acceptability, and initial impact of ESP with text-based support compared to ESP-alone; 3) conduct a pilot MRT to inform JITAI development for high-risk adults. Methods: Interviews and surveys with patients and clinicians will inform development of intervention components in Aim 1. For the clinical trial, 120 adults seeking ED services for suicide-related concerns will receive the eSP alone (n=40) or eSP plus text-based support (n=80) and complete daily EMAs during the 4 weeks following discharge. The eSP with text-based support condition includes an embedded microrandomized trial (MRT), with twice-daily randomizations over the month-long intervention to either receive, or not receive, a text message promoting effective coping. Some messages will incorporate specific items from their eSP (e.g., personal warning signs) and others will be tailored to reflect symptom severity from recent EMAs. The MRT will allow us to optimize the frequency, timing, and content of messages and inform the design of a scalable, adaptive technology-supported intervention for suicide prevention. Follow-up assessments will occur at 1- and 3-months post-discharge. Results (Anticipated): We will demonstrate feasibility, acceptability, and impact of the eSP with text-based support compared to eSP alone and examine intervention impact on hypothesized mechanisms (coping self-efficacy, motivation to use safety plan) and distal outcomes (suicidal ideation and attempts). We will evaluate if provision of any coping message, coping message type, or message timing impacts daily-level proximal mechanisms and distal outcomes. Conclusions: With potential for high public health impact, this proposal addresses a need for effective and scalable continuity of care approaches during the high-risk post-ED period to ultimately improve suicide-related outcomes.