Strategic Treatment and Assessment for Youth (STAY)

This multi-method, multi-phase pilot trial is designed to explore initial implementation and effectiveness of a theoretically-driven, culturally-tailored, measurement-based care (MBC) approach, Strategic Treatment Assessment for Youth (STAY), for racial and ethnic minoritized (REM) youth with depressive symptoms or suicidal thoughts and behaviors (STB). STAY offers an innovative, culturally-tailored approach to retain REM youth with depressive symptoms with or without STB in mental health treatment. In this R34 study, the investigators will first refine the STAY clinical protocol and implementation plan, develop STAY instrumentation (STAY, Aim 1), and then pilot test the effectiveness of STAY in three community-based mental health clinics (Aim 2). Aim 2 focuses on testing the protocol through a pilot Hybrid Type 2 trial by comparing clinicians randomly assigned to STAY (intervention condition) as compared to those assigned to the MBC As Usual (active comparison condition). Results from this pilot trial will inform optimal study procedures, measures, and site selection for a subsequent, fully-powered Hybrid Type 2 trial to examine STAY implementation, effectiveness, and scalability.

This multi-method, multi-phase pilot trial is designed to explore initial implementation and effectiveness of a theoretically-driven, culturally-tailored, measurement-based care (MBC) approach, Strategic Treatment Assessment for Youth (STAY), for racial and ethnic minoritized (REM) youth with depressive symptoms or suicidal thoughts and behaviors (STB). STAY offers an innovative, culturally-tailored approach to retain REM youth with depressive symptoms with or without STB in mental health treatment. In this R34 study, the investigators will first refine the STAY clinical protocol and implementation plan, develop STAY instrumentation (STAY, Aim 1), and then pilot test the effectiveness of STAY in three community-based mental health clinics (Aim 2). Aim 2 focuses on testing the protocol through a pilot Hybrid Type 2 trial by comparing clinicians randomly assigned to STAY (intervention condition) as compared to those assigned to the MBC As Usual (active comparison condition). Results from this pilot trial will inform optimal study procedures, measures, and site selection for a subsequent, fully-powered Hybrid Type 2 trial to examine STAY implementation, effectiveness, and scalability.

In Aim 1 of the research plan, the investigators will refine the STAY protocol and intervention plan based on the study team's preliminary development of the STAY model, protocol, and implementation plan. The STAY protocol includes a clinician manual (including clinician guide for each STAY component, step-by-step instructions, sample scripts, clinical vignettes) and assessment measures. The STAY implementation plan includes the STAY training, goals and objectives, responsibilities, and timelines. The investigators will employ user-centered design (UCD) methods guided by a Discover, Design, Build, and Test (DDBT) Development process to revise the STAY protocol and implementation plan to ensure STAY is aligned with the needs of deployment contexts and end users. A sample size of N=12 users (i.e., clinicians and clinical administrators) divided into three cohorts of four participants each will be used as per recommendations for user-centered design (UCD) testing for complex interventions. Aligned with best practices, sampling will balance both novice and more experienced users. Participants will interact with the STAY protocol and implementation plan prototypes and engage in usability tests, including cognitive walk-throughs and lab-based user testing. Participants will also compete the 10-item Intervention Usability Scale. Iterative data analysis and prototyping between each cohort will be used to rapidly refine the STAY protocol and implementation plan to optimize usability. Then, the STAY Observational Coding System (SOCS) will be developed to assess its feasibility and scalability for future trials, as well as a 10-item STAY Knowledge, Skills and Attitudes (KSAT) Measure to tap core knowledge domains and implementation mechanisms to be assessed in the Aim 2 trial. At the end of Aim 1, the study team will have refined a STAY protocol and implementation plan. The investigators will also have an observational coding system to assess STAY fidelity and a brief, pragmatic measure to assess knowledge, attitudes and practices of clinicians trained in STAY.

In Aim 2 of the research plan, the investigators will conduct a pilot effectiveness-implementation Hybrid Type 2 trial of STAY vs MBC As Usual. Using a randomized design, 20 clinicians at three public mental health sites will be stratified by site and randomly assigned to STAY (intervention condition) or to MBC As Usual (active control condition). Clinicians randomized to STAY will receive the STAY protocol, and MBC As Usual clinicians will receive standard MBC educational materials used in the study team's other MBC studies. Clinicians in both conditions will attend a one-day training and monthly, 1-hour, post-training consultation calls for 6 months. Clinicians in both conditions will be asked to implement MBC with REM youth and their families who meet eligibility criteria and facilitate study referrals. All clinicians will complete measures at baseline (pre-training) and post-training and post-implementation (6-month post-training follow-up). Half of the clinicians in each condition will be randomly selected to participate in the SOCS. Youth/caregiver dyads will be recruited on a rolling basis due to enrollment patterns at the clinical sites, which is why the investigators are planning 20 months of data collection to achieve 4-month follow-up measures from all youth. Youth and caregivers will complete measures at baseline (within 30 days of their first contact with the site), 2-months (8 weeks) and 4-months (16 weeks) following the baseline measure. Youth measures capture implementation outcomes (e.g., clinicians' cultural humility and cultural comfort), engagement mechanisms (e.g., treatment relevance and acceptability, therapeutic alliance), service outcomes (e.g., attitudinal engagement), and youth symptom outcomes (e.g., depression symptoms, suicidal ideation and behavior). Caregiver measures capture implementation outcomes (e.g., clinicians' cultural comfort), engagement mechanisms (e.g., treatment relevance and acceptability, therapeutic alliance), and service outcomes (e.g., attitudinal engagement). Youth and caregivers will also be asked to consent to secondary data collection by the study team to obtain medical records information for their attendance, discharge reason and fidelity of MBC. Clinician measures capture implementation outcomes (e.g., feasibility, acceptability, appropriateness).

The investigators will assess STAY implementation outcomes of fidelity, feasibility, acceptability, and appropriateness (primary outcomes). Further, the investigators will explore whether STAY, as compared to MBC As Usual, will result in (secondary outcomes): (1) Greater therapeutic alliance and treatment relevance and acceptability (engagement mechanisms); (2) Greater session attendance, attitudinal engagement and treatment completion (service outcomes); and (3) Greater reduction in youth depressive symptoms, suicidal ideation and behavior (treatment outcomes).

Appropriateness of Methods Follow up intervals are informed by typical treatment length and retention measures in prior research. Sample size was determined based on the resources and time frame constraints of 3 years; participating clinicians and families will be recruited in year 1, quarter 4 to finish all data collection in year 2. Also, individual clinician patterns in MBC administration and feedback can feasibly be examined with this small sample size, as has been useful in other implementation pilot studies.

Knowledge gained from this pilot will be used to refine the research strategy for a fully powered, subsequent R01 with optimal procedures. Piloting STAY with procedures that would be exactly mirrored in a future, multi-site R01 provides numerous learning opportunities about the feasibility and parameters of measures, study recruitment and data collection procedures (e.g., collecting youth- and caregiver-reported data over the phone), clinician engagement in consultation calls, record review procedures to track fidelity, missing data patterns, and range and pattern of session attendance for both the STAY and MBC As Usual groups. Also, site variation in this trial is expected to provide information about how different sites handle STAY implementation, which the investigators can further investigate as site-level variation in a fully-powered R01 trial. Outcomes of this trial could inform potential additions to the R01 design, such as 1) enhancements to STAY to more comprehensively address logistical barriers, 2) testing STAY among REM adolescents with conditions other than depression, and/or 3) a fully-powered Type 2 Hybrid trial to detect clinician effects, moderators, and effectiveness outcomes.

Eligibility Criteria:
\*Note: This study includes data collection from mental health clinicians, youth, and parents/caregivers. The age limits for each participant group vary and are specified below.

Inclusion Criteria for Aim 2 Adolescent client participants:

* Age 12 to 18
* Identify as a racial or ethnic minoritized (i.e., Black or African American; American Indian or Alaska Native; Asian American, Native Hawaiian or Other Pacific Islander; Hispanic or Latinx) youth
* Have at least moderate depression symptoms based on moderate range of a validated depression assessment collected at intake by the participating agency such as the Center for Epidemiological Studies Depression Scale for Children (CES-DC) or Hamilton Depression Index with or without Parent- or adolescent- reported or healthcare provider- documented thoughts and/or behaviors related to self-harm or suicide in the three (3) months prior to first contact with participating agency
* Assigned or triaged to work with one of the clinician participants included in the study (below)
* Made first contact (e.g., initial phone call, attended intake appointment) with a participating agency less than or equal to one (1) month prior to the recruitment date (but ideally within (1) week of intake appointment)
* English- or Spanish-speaking
* Legal parent or guardian available to provide informed consent
* Able to provide informed assent

Inclusion Criteria for Aim 2 Parent/Guardian participants:

* Legal guardian of one of the adolescent client participants included in the study (above)
* English-speaking
* Able to provide informed consent

Inclusion Criteria for Aim 2 Clinician participants:

* Provides community-based mental health treatment to youth
* Holds a professional license or certification in their state to provide mental health treatment OR are supervised by a clinician with professional license or certification in their state to provide mental health treatment
* Are a clinician identified for recruitment because they are part of a participating mental health clinic/site
* Age 18 or older
* English- or Spanish-speaking
* Able to provide informed consent

Individuals who do not meet all inclusion criteria are, by definition, excluded. There are no other exclusion criteria.