Safer Still

The period immediately following inpatient psychiatric hospital discharge poses an extremely high risk of
suicide. Among youth, roughly 20% of all suicide deaths occur in those who had an inpatient hospital stay in
the year before death. This concentration of suicide risk should stimulate research on developing and
evaluating strategies that protect young patients from suicide during this critical transition period. Unfortunately,
well-established interventions for safe transitional care to prevent suicide do not exist. We propose to develop
an interactive intervention “Safer Still” to help promote safe storage of firearms during the critical period
immediately following psychiatric hospitalization. Suicide is the second leading cause of death among
adolescents in the United States, and firearms are used in more than 40% of these deaths. Our innovative
intervention entails no clinician involvement outside of routine care and is based on behavioral economics
(BE), a model that features insights from psychology, economics, and marketing to enhance individual decision
making. Through technology, we will implement a series of BE “nudges” to promote safe firearm storage in a
sample of parents of adolescents at high risk for suicide who own firearms and have disclosed unsafe
household storage practices. The aims of this hybrid type 1 effectiveness-implementation study will be
achieved in two phases. First, guided by the PRISM (Practical, Robust, Implementation, and Sustainability
Model) framework, the Safer Still intervention will be refined based on clinician and family feedback from key
informant interviews and participant usability testing phases. We will use PRISM domains to increase our
understanding of Safer Still implementation and sustainability. Second, a randomized controlled trial (RCT) will
be conducted to test the effectiveness of Safer Still, while systematically collecting data related to the potential
implementation in real-world settings. During the RCT, we will recruit 80 firearm-owning parents or guardians
of adolescents aged 12-17 years living in households with unsafe firearm storage and randomly assign them to
either the Safer Still intervention (n=40) or Enhanced Usual Care (EUC; n=40). Our central hypothesis is that
Safer Still will be superior to EUC in reducing unsafe household firearm storage after hospital discharge. Our
secondary aim is to examine clinician and family perspectives on the acceptability, feasibility, and
appropriateness of Safer Still. We will also examine a potential mediator (stages of change) and two
moderators (adolescent history of a suicide attempt and parental primary reason for firearm ownership) of
intervention effects. Our investigative team offers an extensive track record in youth suicide prevention
research, BE, mental health intervention research, lethal means restriction, culturally informed health services,
and technology intervention development and deployment. Our project will be conducted through inpatient and
crisis stabilization units of one of the largest pediatric behavioral health providers in the United States. Our
long-term goal is to decrease suicide in at-risk youth through preventative interventions.

Grant Number: 5P50MH127476-04
NIH Institute/Center: NIH
Principal Investigator: JEFFREY BRIDGE