Based on social support and health behavior education models, the YST-II intervention was designed to supplement usual treatments for suicidal adolescents post-hospitalization. The intervention provides psychoeducation and consultative support to youth-nominated adults for three months who, in turn, are asked to have regular supportive contact with adolescents. In this large-scale efficacy trial, the positive effects were small in size, evident for only select outcomes, and moderated by whether or not the adolescent had a history of multiple suicide attempts. For the primary outcome of suicidal ideation, results indicate that YST-II was somewhat helpful in reducing suicidal thoughts more rapidly following hospitalization for those adolescents with histories of multiple suicide attempts. This effect was time-limited, evident only at the 6-week follow-up. Results also indicate that YST-II was somewhat helpful in reducing adaptive impairment among suicidal adolescents without histories of multiple suicide attempts. The hypothesis that positive effects would be moderated by gender was not supported.
The standardized effect sizes associated with YST-II's beneficial and disparate effects for subgroups defined by multiple suicide attempt history were small. The absolute size of these effects, however, is not the primary issue. A supplemental intervention, layered on top of primary treatments for both experimental and control conditions (generally combination treatment), would not be expected to have moderate to large additive effects. One could argue that a relatively small incremental benefit in the lives of youth at elevated risk for suicidal behavior and suicide is clinically meaningful; it may suggest the intervention is indicated if feasibility and costs are manageable. In fact, when considering clinical significance, Kendall et al. note that it is critical to determine whether or not a normative level of symptoms is a realistic goal (Kendall, Marrs-Garcia, Nath, & Sheldrick, 1999
). Because many suicidal adolescents struggle with multiple, longstanding psychiatric disorders and psychosocial impairment, a clinically meaningful reduction in functional impairment or suicidal thinking is a more realistic goal. However, the fact that the positive effects for YST-II were not apparent across related outcomes, including depression severity and hopelessness, suggests a lack of robustness and a need for caution in interpreting positive effects.
That stated, the fact that YST-II was modestly effective initially for the highest risk group of suicidal adolescents, those who have engaged in multiple suicide attempts, is noteworthy. This group is at particularly elevated risk for repetitive suicidal behavior (Goldston et al., 1998
) and is characterized by emotion dysregulation and elevated interpersonal problems (Esposito et al., 2003
). It is possible that YST-II, with the professional support that it offers to the caring adults in suicidal adolescents' lives, had a role in helping these caring adults support and manage the adolescent's transition from the hospital to the community environment. YST-II also had modest positive effects for non-multiple attempters in reducing impairment across a one-year period. This somewhat healthier group, on average, may have been in a better position to benefit from socially supported problem-solving, and to realize gains from such problem-solving over time.
The results of this study differ somewhat from those for YST-I, despite the fact that YST-I also emphasized social support and made use of a TAU comparison group. Although YST-I was a feasibility study and less rigorous scientifically, preliminary findings suggested that it may have been associated with reductions in mood-related functional impairment and suicidal ideation for girls only. However, contrary to study hypotheses, gender did not moderate the modest positive effects in the present study. Interestingly, both studies identified a small main effect of YST in reducing suicidal ideation, which, upon further examination, was a moderated effect. The inconsistency in findings may be due to changes in the intervention, such as the change in duration from six months to three months. It is also possible that an effect for multiple attempter status was not identified in YST-I due to a smaller proportion of multiple attempters in that study. Finally, the preliminary YST-I study was characterized by differential retention across intervention groups, which presented a challenge to the interpretation of findings.
Understanding the Limited Efficacy of YST-II
As with any new treatment or intervention, the first goal is to “do no harm.” Although there were no negative effects associated with YST-II for any primary or secondary outcome variable, there were also no moderate to large or pervasive positive effects. It is possible that the intervention was too “lightweight” in its intensity to overcome or divert the developmental trajectories of these adolescents who were psychiatrically hospitalized for acute suicidality. Interventions consisting only of unconditional postcard or letter contacts have demonstrated positive effects in adult samples (Carter, Clover, Whyte, Dawson, & D'Este, 2007
; Motto & Bostrom, 2001
); however, it is possible that adolescents are at a developmental stage requiring more frequent or intense support to impact mental health than is needed for adults. It is also possible that the supportive involvement of caring persons in YST-II may not have been as unconditional as the support in these studies. The modest findings may also be associated with dysfunctional support systems that could not be sufficiently overcome with this intervention.
Finally, the concept of perceived burdensomeness warrants discussion (Joiner, 2006
). Research suggests that social support, under certain conditions, may increase suicidality through a feeling of burdensomeness on the support person which, in turn, could lead to a diminished sense of self-worth. In support of this conceptualization, Brown, Dahlen, Mills, Rick, and Bilbarz (1999)
found a link between feelings of burdensomeness on one's relatives and increased suicidality. It is possible that an increase in perceived burdensomeness occurred among some YST-II participants; however, data are unavailable to examine this empirically.
The generalizability of findings is limited. The parent/guardian informed consent and adolescent assent rate was only 43%. Given the acuity of adolescents' illnesses on an inpatient unit and the complexity of informed consent documents for a randomized intervention study involving a “vulnerable” population at elevated risk for suicide (King & Kramer, 2008
) (with no knowledge of condition when consenting), this is not unexpected. The consent rate is consistent with other studies evaluating interventions for youth that were not being sought after as primary treatments (e.g., Asarnow et al., 2005
) as well as with the consent rate in the YST-I study (King et al., 2006
). However, it is unfortunate that information is unavailable concerning possible differences in the clinical characteristics and support system characteristics of those who did and did not consent to participate. Despite the absence of demographic differences between those who did and did not consent, the generalizability of findings must be assumed to be limited because of this and the fact that the sample was predominantly Caucasian.
Methodological limitations include the lack of assessment of suicidal intent. Given the few cases in which parent and adolescent reports of suicidal ideation differed, there may have been errors in reporting. Another limitation is the absence of fidelity assessments for telephone check-ins with youth-nominated supportive adults. These check-ins were not audiotaped or rated. In addition, the extent to which the nominated support persons' contacts with the adolescents were actually perceived by the adolescents as being supportive was not assessed.
Implications for YST-II and Directions for Further Research
YST-II was not associated with a sufficiently clear or pervasive pattern of positive effects to warrant a recommendation for clinical application. However, findings certainly suggest or hint at some positive benefits for this relatively “light” intervention. It is possible that components could be further developed and integrated into more targeted and/or multi-faceted intervention strategies. For example, research could examine a YST intervention redesigned specifically to facilitate and support treatment adherence and family reintegration post-hospitalization. It could be targeted specifically to the needs of multiple suicide attempters with modifications to the psychoeducational content and guidelines for staff consultations with support persons. Alternatively, it could be redesigned as one component of a multi-faceted intervention that includes psychoeducation, safety planning with parent and adolescent (with follow-up check-ins to support and provide guidance to responsible adults), and case management to facilitate treatment adherence. Another research direction would be to study the impact of YST-II on the support persons themselves. It may reduce parental anxiety and improve quality of life for those who have daily responsibility for suicidal adolescents following hospitalization.
Given the limited positive effects for YST-II, other types of social support or social integration interventions may warrant research with adolescents, such as the “unconditional” postcard intervention (Carter et al., 2007
; Motto & Bostrom, 2001
). In addition, it is recommended that future research begin to study combinations of primary treatments and supplemental interventions as such a “strong arm approach” may be indicated. Multiple evidence-based interventions – in combination or in sequence – will likely be necessary to achieve substantial positive outcomes for adolescents who present with severe suicidal thoughts or suicide attempts.
This large-scale randomized controlled intervention trial demonstrated that YST-II, which provides psychoeducation to youth-nominated adults and aims to facilitate their supportive role with adolescents, had positive effects that were small in size, evident for only select outcomes, and moderated by whether or not the adolescent had a history of multiple suicide attempts. That is, there was no evidence of robust or pervasive positive effects. Specifically, YST-II plus treatment-as-usual, relative to treatment-as-usual only, was associated with more rapid reductions in suicidal thoughts for those had had made multiple suicide attempts. In addition, for those who had not made multiple suicide attempts, YST-II was associated with modestly greater reductions in psychosocial impairment over time. Despite the fact that YST-II is a non-intensive and relatively low cost supplemental intervention, the effect sizes for these benefits were small and inconsistent with a recommendation for widespread clinical application. It is recommended that further research with YST-II or related approaches target the intervention more specifically to a subset of the highly heterogeneous population of suicidal adolescents and consider carefully the importance of a multi-faceted approach.