I-CARE: The Effectiveness of a Modular Digital Intervention to Reduce Suicidal Ideation and Emotional Distress during Pediatric Psychiatric Boarding - PROJECT SUMMARY The COVID-19 pandemic has contributed to a substantial increase in suicidal ideation, suicide attempts, and suicide deaths among US adolescents. Emergency departments (EDs) at acute care hospitals increasingly serve as gateways to care for youth with suicidality; this trend has been further exacerbated during COVID-19. When youth with suicidal ideation or attempt are deemed to require inpatient psychiatric care, the demand for beds often exceeds supply, leading to psychiatric boarding. During this time, youth may wait days to weeks in an ED or inpatient medical unit until psychiatric admission; boarding frequencies and durations have both increased during COVID-19. Youth experiencing boarding rarely receive evidence-based psychotherapies given a national shortage and uneven distribution of mental health professionals. To address this gap, a multidisciplinary team of pediatricians, psychologists, clinical social workers and patient partners developed a modular digital intervention to deliver 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 web-based animated videos and activities grounded in cognitive behavioral therapy, prioritized through a rigorous Delphi process. I-CARE is designed to be facilitated by safety attendants who currently provide 1-on-1 safety supervision for youth during boarding. Accordingly, I-CARE requires minimal additional resources beyond those already available at acute care hospitals. In a pilot program evaluation, I-CARE has been shown to be feasible to implement and acceptable to youth, clinicians, and their caregivers, with levels of emotional distress significantly decreased following participation. Building on this preliminary data, this Hybrid Type 1 effectiveness trial will use a cluster randomized stepped wedge design at 6 hospitals (960 youth 12-17 years with suicidal ideation or attempt) to: (i) apply the Dynamic Adaptation Process to optimize I-CARE training and implementation while maintaining intervention fidelity and taking into account COVID-19 and variation across hospitals; (ii) determine the effectiveness of I-CARE to reduce emotional distress, suicidal ideation and suicide attempts using validated measures compared to usual care, assess the effects of I-CARE on motivation for change (target mechanism), and determine whether greater motivation for change mediates I-CARE effects on emotional distress, suicidal ideation and attempts, and (iii) apply the RE-AIM framework to identify barriers to and facilitators of I-CARE reach, effectiveness, adoption, implementation and maintenance from the perspectives of youth, caregivers, and clinicians. The results of this study have the potential to transform healthcare delivery for a population currently underserved by the health system, increasing access to mental health services during a period of tremendous vulnerability while applying a novel digital intervention with substantial potential for scalability.
