STEP-ED: Skills To Enhance Positivity in Emergency Departments - PROJECT SUMMARY/ABSTRACT Suicide is a leading cause of death worldwide, accounting for nearly 800,000 deaths each year.4,5 Suicide rates continue to increase in the U.S.6 The period following hospital discharge is one of extremely elevated suicide risk.7,8 Despite this elevated risk, few of these patients receive mental health care post- discharge.9 Thus, there is an urgent need to connect emergency department (ED) patients with accessible, low- burden, evidence-based care that bridges them from the ED through discharge and into their lives. Skills to Enhance Positivity (STEP) is a brief intervention with a promising evidence base that is ideally suited for ED contexts (R34MH101272, R01MH11355612). STEP is a multimodal intervention that integrates several resilience-focused evidence-based interventions for increasing positive affect. STEP involves in-person sessions and follow-up personalized mood monitoring prompts and skills reminders delivered via text messaging over 12 weeks post-discharge to extend the reach of STEP to in-vivo practice at home. STEP leverages research from affective science including the Negativity Bias, the Broaden and Build theory of positive affect, and the Positivity Ratio, to build resilience and cognitive flexibility, ultimately reducing suicidal thoughts and behaviors. Results from open11 and randomized12 trials show that STEP is acceptable11 among suicidal adolescents11 and young adults1,2 and reduces adverse events including suicide behaviors (operationalized as suicide attempts or emergency intervention to intercede an attempt) in suicidal adolescents, even relative to enhanced treatment as usual,12 by approximately 50%. This study addresses the current treatment gap by using implementation science methods to deliver a one- session version of STEP for use among patients at elevated risk for suicide in the ED (“STEP-ED”). Specifically, this project will use a Hybrid Type I Effectiveness-Implementation design to (1) conduct a formative evaluation with patients and staff in two distinct EDs to identify barriers and facilitators to implementing STEP-ED and develop a set of implementation strategies for STEP-ED, (2) test the effectiveness of STEP-ED on the candidate mechanism of positive affect and in reducing suicidal behaviors in adults presenting to two EDs for a suicide- related complaint, and (3) evaluate implementation outcomes via a summative evaluation. The research team (PIs: Dixon-Gordon, Schatten, Yen, Co-Is: Frank, Laws, Schoenfeld) has expertise in clinical trials for suicide prevention, recruiting suicidal patients from medical settings, implementation science, and evaluating behavioral intervention effectiveness. This Hybrid Type 1 Effectiveness-Implementation study has the potential to yield several key outcomes with significant impacts on suicide care. First, we will evaluate the effectiveness of a promising behavioral intervention that may bridge the gap for suicidal patients seen in the ED as they return to their lives. Second, this work will generate critical information to inform the implementation of single-session interventions in emergency settings, including a set of tailored implementation strategies.
