Effectiveness of Two-Way Caring Texts vs One-Way Caring Texts vs Usual Care: A Pragmatic Randomized Controlled Trial

Background:

Caring Contacts (CC) are simple, non-demanding messages sent by mail or by text to remind people that they are cared for, and that help is available. CC have been shown to significantly reduce suicide ideation, attempts, and deaths, and there is growing interest in scaling up this intervention.  In research studies, CC has involved two-way messages to which recipients can reply, but in practice, one-way texts are typically used due to operational simplicity and cost.  However, it is unknown whether one-way CC texts are as effective as two-way CC texts.

Research Aims:

1. Measure the effectiveness of augmenting best available usual care with two-way Caring Contacts text messages (CC2) and one-way Caring Contacts texts (CC1) compared to best available usual care alone (UC) for preventing suicidal ideation and behavior. 
   Hypothesis: CC2 and CC1 are more effective than usual care.
   
   
2. Determine whether CC1 are noninferior to CC2 for preventing suicidal ideation and behavior.
   Hypothesis: CC1 are inferior to CC2.
   
   
3. Describe the feasibility of implementing CC2 and CC1 in partnership with a state crisis and suicide prevention hotline.
   Hypothesis: CC2 will require more resources than CC1 but both will be acceptable and feasible to deliver through a state crisis and suicide hotline.

Methods & Sample:

This randomized controlled trial will enroll 894 adult and adolescent (12-17 years) participants who screen at risk for suicide at primary care or behavioral health clinics in Idaho.  Participants will be randomized to one of three intervention arms.

Interventions:

All participants will receive best available usual care from the health system, which may include appropriate suicide risk assessments and interventions such as a safety plan, appropriate referrals, and medication management.  Additionally, people will be randomized to receive one of the following treatments:

UC: A list of resources and encouragement to call 988 as needed. 

CC1: 25 caring text messages over 12 months, i.e.: Sara, I hope your week is going well.

Participants cannot reply to CC1 texts. 

CC2: 25 caring text messages to which participants can respond, i.e: Hi Tara, I hope your week is going well, feel free to let me know how you’re doing if you’d like.  If participants choose to reply, a follow-up specialist texts back and forth with them.

Outcomes:

We will measure suicide ideation, attempts, and deaths at baseline, 3, 6, and 12 months after study enrollment.  The primary outcome will be cumulative suicidal ideation and behavior over a 12-month period, measured using a self-complete version of the Columbia Suicide Severity Rating Scale.  

Impact:

CC could be feasibly delivered by 988 crisis lines and by health systems with potential to reach millions of people with suicidal ideation. Our projections show that delivering CC at scale could reduce annual US suicide deaths by 10%-20%, but it is critical that the version of CC being delivered be effective.

Next Steps:

Dissemination of results and scale-up of the best version of CC should be prioritized after this research is complete.