A new study by UCLA and Kaiser Permanente Northwest's Center for Health Research demonstrates a health care approach matching treatment intensity to individual risk levels can significantly reduce self-harm and depression among at-risk adolescents and young adults while improving patient satisfaction with care.
The randomized clinical trial, published in the Journal of the American Academy of Child & Adolescent Psychiatry, is the largest study to date evaluating a stratified stepped-care approach for reducing suicide risk in young Americans.
Suicide is a leading cause of death among young people in the U.S. Self-harm, including suicide attempts and self-injury, is even more common and represents the leading cause of morbidity worldwide for youth ages 10-24. Self-harming behavior is also a strong predictor of future suicide attempts and deaths, making early intervention critical to save lives, said study first author Dr. Joan Asarnow of UCLA Health.
Existing therapies such as dialectical behavior therapy have shown benefits but are time- and resource-intensive for both patients and healthcare systems.
The new study sought to test the efficacy of a stepped-care and care-stratification model to match treatment intensity to the patient's needs.
Researchers enrolled 301 youth ages 12-24 who were at elevated risk for suicide or self-harm and compared two approaches:
- Zero Suicide Quality Improvement (ZSQI): a health system-wide initiative featuring improved suicide-risk screening, treatment access, electronic health record safety planning templates and continuous quality improvement.
- ZSQI Plus Stratified Stepped-Care for Suicide Prevention: An enhanced ZSQI approach that triaged youth to different levels of care based on assessed risk using a dialectical behavior therapy (DBT)-informed cognitive-behavioral therapy model. Lower-risk youth received care management, monitoring and digital mental health tools, while higher-risk youth were offered additional DBT skills groups and individual therapy.
Key Findings
Over the 12-month study period, researchers found:
- 54% reduction in self-harm risk among youth receiving the stepped-care approach compared to standard quality improvement alone
- Significant reduction in depression severity among stepped-care participants
- Higher patient satisfaction with mental health care in the stepped care group
- No deaths in either group during study period
- Lower-than-expected suicide attempt rates in both groups
Asarnow said the stepped-care model offers a potentially scalable solution for health systems to match treatment intensity to patient needs, providing effective yet less resource-intensive treatment for youth with lower risk and reserving more intensive services for higher-risk patients.
"Our results suggest the promise of combining health system quality improvement initiatives with stratified, stepped care that provides more intensive treatment services as assessed risk levels increase," said Asarnow, professor of Psychiatry and Biobehavioral Sciences at UCLA and director of the UCLA Center for Adolescent Suicide and Self Harm Treatment and Prevention & the UCLA Youth Stress and Mood Program. "This approach can lead to significant reductions in self-harm and depression with high levels of patient satisfaction."
The study also maintained high follow-up rates, with 94% of participants completing at least one follow-up assessment over the 12-month period.
While the study did not find significant differences in suicide attempts between groups, lower-than-expected attempt rates were observed in both conditions supporting other research indicating that health system quality improvement using the Zero Suicide Model can lead to reductions in suicide attempts. The researchers note that the significant reduction in self-harm represents an important clinical outcome, as self-harm is associated with elevated risk of later suicide attempts and deaths as well as significant morbidity.
Further research is needed to clarify optimal suicide and self-harm prevention strategies that can be implemented within health care systems, Asarnow said.
New study demonstrates the value of delivering suicide prevention care within health systems.
The study was funded by the National Institute of Mental Health.
