Developing Adaptive Interventions for Suicidal College Students Seeking Treatment - SMART
Condition: Suicide
MeSH terms: Suicide
Study type: Interventional

Summary: 
      This pilot study tested the feasibility of utilizing an adaptive intervention strategy for
      college students who are suicidal when first seeking treatment at a campus clinic. Right now,
      the typical strategy may rely on a "one size fits all" approach, but in fact suicidal
      students vary greatly on what and how much they need. This study will pave the way for
      subsequent larger trials for clinical decision making (trying one approach, and if that
      doesn't work, another) to be empirically developed and tested in a subsequent large-scale
      multisite trial with the goal of maximizing resources in overburdened college counseling
      centers. This pilot study followed by a subsequent large-scale trial could eventually
      significantly impact service delivery to suicidal college students at college counseling
      centers.
    

Detailed description: 
      The primary aim of this proposal was to conduct feasibility research to inform the
      implementation of a future full-scale SMART (sequential, multiple assignment, randomized
      trial, Almirall et al., 2012) that will be used to construct adaptive treatment strategies
      (ATSs) to address suicidality in college students seeking services at college counseling
      centers (CCCs). ATSs individualize treatment via decision rules that can specify how the type
      and intensity of an intervention should be sequenced based on variables collected
      mid-treatment (or at baseline), such as response to treatment. Suicidality is a frequent
      presenting concern among college students seeking treatment; yet, studies with this
      population show that some students respond rapidly to treatment whereas others may require
      considerably more resources. However, at this time, CCCs, which are overburdened and often
      have to resort to waitlists, have no guidance as to how to sequence different approaches with
      suicidal students in an empirically-based and cost effective manner. Therefore, empirically
      validated ATSs are needed in the provision of services to suicidal college students to
      address the heterogeneity of students with this presentation and the variability in response
      to interventions. In the present pilot SMART, each participant progressed through two stages
      of intervention. In the first stage (S1) 62 participants were randomized to one of two brief
      individual therapy interventions for 4-8 weeks: 1) one that is suicidality-focused
      (Collaborative Assessment and Management of Suicidality (CAMS; Jobes, 2016) and 2) one that
      relies on Treatment as Usual (TAU) being provided at a CCC. Responders to either program will
      discontinue services/ be stepped down and be monitored over time for maintenance.
      Non-responders to either intervention who remain in treatment (estimated n = 18) were
      re-randomized to one of two second-stage (S2) higher intensity/dosage intervention options
      for an additional 4-16 weeks: 1) CAMS (either continued but for a longer period of time or
      administered for the first time) or 2) Comprehensive Dialectical Behavior Therapy (DBT,
      Linehan, 1993a, 1993b) which includes individual therapy, skills groups, and phone coaching
      for the clients and DBT peer consultation for the therapists. This study enrolled moderately
      to severely suicidal (endorsing thoughts of wanting to die of 2 or above on 0-4 scale)
      college students in the "emerging adulthood" phase (18-25 years of age) seeking services at a
      CCC. The aims of this feasibility services research project were to 1) develop and refine a
      SMART design in a CCC setting; 2) assess the feasibility of conducting a SMART and its
      embedded ATSs in a CCC setting; 3) obtain estimates of overall response rates to S1
      interventions; and 4) explore the utility of incorporating secondary tailoring variables
      (e.g., level of functioning at pre-treatment, ratio of Wish to Live vs. Wish to Die) in the
      ATSs in the subsequent larger trial.
    

Intervention name(s): Stage 1 Treatment as usual (TAU); Stage 1 CAMS; Stage 2 CAMS; Stage 2 Dialectical Behavioral Therapy (DBT)
Intervention type(s): Behavioral; Behavioral; Behavioral; Behavioral
Intervention description(s): 4-8 weeks of the treatment typically provided by that counselor with the caveat that neither DBT nor CAMS can be provided.; 4-8 weeks of Collaborative Assessment and Management of Suicidality (CAMS); 4-16 weeks of Collaborative Assessment and Management of Suicidality (CAMS); 4-16 weeks of Dialectical Behavioral Therapy (DBT)
Allocation: Randomized
Intervention model: Parallel Assignment
Intervention model description: This study used a Sequential Multiple Assignment Randomized Trial (SMART) design to pilot 4 adaptive treatment strategies (ATSs): ATS1 - Start with Stage 1 CAMS; if responding, end treatment; if not, continue on to Stage 2 CAMS. ATS2 - Start with Stage 1 CAMS; if responding, end treatment; if not, continue on to Stage 2 DBT. ATS3 - Start with Stage 1 TAU; if responding, end treatment; if not, continue on to Stage 2 CAMS. ATS4 - Start with Stage 1 TAU; if responding, end treatment; if not, continue on to Stage 2 DBT.
For Stage 1, we hypothesized that CAMS would show more improvement on suicide-related variables than TAU and would be more effective with suicidal college students presenting with less complexity at baseline. We did not identify hypotheses for clinical outcome variables in Stage 2 because it was exploratory in nature and focused on the feasibility and acceptability of implementing a SMART design to address suicidal risk in college students.
Masking: Single (Outcomes Assessor)
Primary purpose: Treatment
Keywords: Suicide; College student mental health; CAMS- Collaborative Assessment and Management of Suicidality; SMART -- Sequential Multiple Assignment Randomized Trial; DBT -- Dialectical Behavior Therapy; ATS -- Adaptive Treatment Strategy