I-CARE: Efficacy of a Digital Health Intervention to Reduce Suicidal Ideation during Psychiatric Boarding

Every year 300,000 children and adolescents present to emergency departments (EDs) in the United States with suicidal ideation or suicide attempt. Many of these youth are recommended to receive inpatient psychiatric care given their complex mental health needs. Unfortunately, psychiatric hospitals frequently lack available pediatric beds, which puts the onus of temporary care on acute care hospitals. As a result, a growing number of adolescents with suicidality experience mental health boarding, during which time they spend days to weeks in an ED or inpatient medical unit awaiting transfer for psychiatric hospitalization. Youth experiencing boarding rarely receive evidence-based treatments given a national shortage of mental health professionals and other complex factors related to access to mental healthcare. To address this gap, our multidisciplinary team of pediatricians, psychologists, clinical social workers and patient partners developed a digital health intervention to teach evidence-based psychosocial skills to youth with suicidality during boarding. This program, called I-CARE (Improving Care, Accelerating Recovery & Education), consists of a series of tablet-based videos and exercises, designed to be facilitated by safety attendants who provide one-on-one safety supervision for youth during boarding. In a pilot program evaluation, we’ve shown this digital health intervention to be feasible to implement and acceptable to youth and their caregivers.

We now propose a randomized controlled trial that aims to determine the efficacy of this digital health intervention to reduce suicidal ideation and emotional distress in youth experiencing boarding for suicidality/self-harm. We hypothesize that safety supervision in combination with I-CARE will reduce suicide risk and emotional distress to a significantly greater degree than safety supervision alone. At two sites, adolescents will be randomized to receive standard safety supervision or standard safety supervision plus I-CARE delivered by a trained I-CARE coach who is not a mental health specialist. Two primary outcomes “ suicide risk measured using the Concise Health Risk Tracking and emotional distress measured using the Depression, Anxiety and Stress Scale – will be evaluated. Our sample will include approximately 138 adolescents 12-17 years of age who are boarding with suicidal ideation or following a suicide attempt. We will also conduct a qualitative study at three hospitals, including one where I-CARE has been implemented for approximately two years, to identify barriers and facilitators of program implementation, evaluated using a well-established implementation science framework. The results of this study have the potential to transform healthcare delivery for a population currently underserved by the health system by increasing access to mental health services during a period of tremendous vulnerability. This research directly aligns with the American Foundation for Suicide Prevention priority areas of evaluating technological tools for suicide prevention and applying implementation science methods to improve access to care and address barriers to suicide prevention. If I-CARE is found to be effective, next steps will include its broad dissemination, accompanied by a toolkit of the best practice derived from our qualitative analyses.