SUMMARY
Suicide among teens is a public health crisis. The Blueprint for Youth Suicide Prevention, developed by NIMH,
the American Academy of Pediatrics, and American Foundation for Suicide Prevention, recommends universal
suicide risk screening, assessment of acute suicide risk, and safety planning (hereafter “suicide prevention”).
However, the effectiveness of primary care suicide prevention in teens is unknown. Moreover, concern about
confidentiality is a primary reason teens do not disclose suicide risk and more than half of teens in primary care
do not receive confidential care (including assure of health information privacy and time alone with a provider).
Implementation of suicide prevention with confidential care may be most effective for improving suicide
outcomes and will need to address barriers to confidential care. We designed universal suicide prevention with
confidential care for teens in partnership with diverse stakeholders in an integrated health system, building on
a pragmatic trial that decreased suicide attempts in adults. Teen suicide prevention was designed with EHR
support to prompt screening and follow-up and practice facilitation to address barriers. After piloting, health
system leaders implemented teen suicide prevention in 30 primary care practices statewide (serving ~8,200
teens with preventive visits annually), with a first implementation phase of systemwide launch of EHR support
followed by a second phase of 10 weeks of practice facilitation staggered by region and completed July 2023.
This study takes advantage of this natural experiment to conduct a quasi-experimental, hybrid type-2
pragmatic implementation study. We test the extent to which implementation of population-based teen suicide
prevention with confidential care improved outcomes during the 3 years after implementation launch (i.e., 3
years of intervention) compared to usual care (4 years prior to launch). SPECIFIC AIMS. Among teens 13-17
years old with preventive visits, we will: 1) test the extent to which implementation of the teen suicide
prevention with confidential care increased the prevalence of safety planning (and secondarily, suicide risk
screening, assessment and confidential care) in teens by comparing 3 years of intervention to 4 years of usual
care; 2) test whether implementation of teen suicide prevention reduced suicide-related events in the 6 months
after a preventive visit by comparing 3 years of intervention to 4 years of usual care; and 3) test whether
receipt of confidential care, compared to no receipt, is associated with greater increases in teen safety
planning in the 3 years of intervention. Secondarily, we will test whether outcomes differed by implementation
phase and assess implementation barriers, facilitators and costs. IMPACT: The real-world reach and
effectiveness of implementation of teen suicide prevention with confidential care is unknown. More than 50% of
teens who die by suicide had a primary care visit within the past year. This study tests whether implementation
of teen suicide prevention with confidential care improves outcomes. If effective, this practical primary care
intervention could be implemented nationwide, preventing a large number of teen suicide deaths each year.
