Engaging Suicidal Patients in Mental Health Treatment
Condition: Suicide; Depression; Mental Health Impairment; Suicidal Ideation; Suicidal
MeSH terms: Suicide; Suicidal Ideation
Study type: Interventional

Summary: 
      The investigators will identify characteristics of suicidal patients who do or do not attend
      a first mental health visit following referral using administrative data. Then, the
      investigators will apply established approaches to contextual inquiry to identify barriers
      and facilitators to mental health treatment attendance for individuals at risk of suicide.
      Using established procedures from implementation science and behavioral economics, the
      investigators will then leverage the insights gleaned from Aims 1 and 2, relevant theories
      and frameworks, and the extant literature to develop preliminary strategies to support
      attendance at first mental health visit. Strategies will be developed in collaboration with a
      team of experts in suicide, implementation science, and behavioral economics. These
      preliminary strategies will then be iteratively tested and refined. The investigators also
      will assess putative mechanism using behavioral tasks and self-report tools.
    

Detailed description: 
      In 2017, there were more than 800,000 deaths by suicide worldwide. Patients at high risk for
      suicide are less likely to die by suicide if they engage in psychotherapy. However, despite
      the development of evidence-based practices (EBPs) for suicide prevention, rates of suicide
      in the U.S. have increased by approximately 30% over the past two decades. One way to lower
      these rates would be to increase treatment initiation among those at risk. Suicidal
      individuals have difficulty engaging in mental health services, yet no studies have
      systematically developed and tested strategies to increase treatment initiation for suicidal
      patients.

      Nearly two-thirds of people who die by suicide interact with a primary care clinician in the
      year prior to death, making primary care an optimal setting in which to identify individuals
      at risk for suicide and connect them to mental health care. Yet only half of those referred
      by primary care providers attend an initial mental health visit, even when referred to care
      within the same practice. Various strategies to increase attendance at first appointment,
      including reminder calls and texts, motivational and informational interventions, and case
      management, have demonstrated small to moderate effects. Even when these strategies are
      implemented, approximately 40% of patients do not initiate treatment, suggesting that
      additional work is needed.

      The primary objective of this study is to develop acceptable, feasible, low-cost, and
      effective strategies that increase patients' treatment initiation (i.e., attendance at a
      first mental health visit) following identification of suicide risk in primary care. The
      investigators will partner with a large, diverse health system to rapidly prototype and test
      promising strategies to achieve this objective. Rapid prototyping involves a series of
      rigorous tests to optimize operations in the early-study stages. Industries outside of health
      care commonly use this approach to learn quickly and "de-risk" decision-making on a short
      timeline prior to a large roll-out. To maximize generalizability, the investigators will use
      rapid prototyping to develop strategies for increasing attendance in both collaborative care
      and outpatient specialty mental health. The strategies the investigators develop and test
      will be informed by behavioral economics and implementation science methods, leveraging the
      University of Pennsylvania's P50 ALACRITY center. In accordance with an experimental medicine
      approach to behavior change, the investigators will also identify and target mechanisms of
      action that impede treatment attendance. The specific aims are to:

      Aim 1. Identify characteristics of suicidal patients who do or do not attend a first mental
      health visit following referral. The sample will include adults 18 years and older, including
      Medicare, Medicaid, and commercial insurance enrollees, who are referred for mental health
      services after an initial screening in primary care identified suicidal ideation. Using
      medical records, the investigators will compare characteristics of patients who initiate
      treatment to those patients who do not. When possible, the investigators will utilize
      insurance claims data to identify any mental health services utilization that occurred
      outside the health system. The investigators also will explore data from patients who report
      suicidal ideation in primary care and are not referred to mental health services.

      Aim 2. Apply established approaches to contextual inquiry to identify barriers and
      facilitators to mental health treatment attendance for individuals at risk of suicide. The
      investigators will use direct observation and brief interviews with key stakeholders,
      including leaders (n = 12), primary care providers (n = 12), behavioral health providers (n =
      12), mental health intake coordinators (n = 5), and patients who do (n = 12) and do not (n =
      12) attend a first mental health visit following referral from primary care to understand key
      structural and behavioral barriers, facilitators, and mechanisms to engaging patients at risk
      for suicide in mental health services. The investigators also will use behavioral tasks and
      self-report measures to assess putative mechanisms of action in patient stakeholders.

      Aim 3. Rapidly prototype and test strategies to optimize engagement. Using established
      procedures from implementation science and behavioral economics, the investigators will
      leverage the insights gleaned from Aims 1 and 2, relevant theories and frameworks (e.g.,
      EAST, Science of Behavior Change), and the extant literature to develop preliminary
      strategies to support attendance at first mental health visit. Based on the literature and
      their previous work, the investigators anticipate that strategies that target temporal
      discounting (e.g., incentives) and foster perceived social support (e.g., Caring Contacts)
      will be needed. Strategies will be developed in collaboration with a team of experts in
      suicide, implementation science, and behavioral economics. The investigators will then
      iteratively test and refine these preliminary strategies. Throughout this process, the
      investigators expect to uncover additional barriers and facilitators that will allow us to
      further refine and optimize implementation strategies. The investigators will assess putative
      mechanism using behavioral tasks and self-report tools.

      The primary output will be a menu of promising and feasible implementation strategies that
      directly address barriers to the initiation of mental health services for patients at risk of
      suicide. These strategies will be tested in a subsequent multisite R01. The long-term goal is
      to reduce deaths by suicide by increasing engagement in evidence-based mental health services
      for individuals at risk of suicide.
    

Intervention name(s): Rapidly prototype and test strategies
Intervention type(s): Behavioral
Intervention description(s): We will generate strategies for facilitating treatment initiation that address barriers and leverage facilitators, in partnership with a team of experts in behavioral science and implementation science. We will favor simple, established strategies with freely available resources (e.g., Caring Contacts templates) to promote scalability, but will also consider other potential strategies as indicated. We will explore both low- (e.g., manualized text messaging) and high-tech (e.g., electronic health record integrated patient messaging) strategies to maximize relevance across contexts. Next, prototype-strategy designs will be validated through rapid-cycle tests in this real world context and in a manner that is inexpensive and allows us to fail fast and learn quickly. After testing a given implementation strategy, the team will debrief and decide whether to refine or adjust it.
Intervention model: Single Group Assignment
Masking: None (Open Label)
Primary purpose: Prevention