An ED-based RCT of Lethal Means Counseling for Parents of At-Risk Youth



Status:Recruiting
Conditions:Psychiatric
Therapuetic Areas:Psychiatry / Psychology
Healthy:No
Age Range:10 - 17
Updated:8/24/2018
Start Date:August 1, 2017
End Date:October 2019
Contact:Sara Brandspigel, MPH
Email:sara.brandspigel@ucdenver.edu
Phone:303-724-6998

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An ED-based Randomized Clinical Trial of Lethal Means Counseling for Parents of Youth at Risk for Suicide

The National Action Alliance to Prevent Suicide recently released a research agenda aimed at
significantly reducing suicide over the next decade. Aspirational Goal 12, "Reduce access to
lethal means that people use to attempt suicide," calls for identifying effective strategies
to reduce a suicidal person's access to firearms and other lethal means.

A promising strategy is to counsel patients seen in the emergency department (ED) for a
psychiatric emergency to reduce access to firearms (the most lethal suicide method) and
medications (the most common method of suicide attempt). To date, however, few studies have
evaluated changes in firearm storage practices among those who received lethal means
counseling (LMC), and those that have, including a pilot conducted in Colorado by the study
team, have lacked control groups. Results from the pilot, which provided emergency department
based LMC counseling to parents of suicidal adolescents, found that among gun-owning parents,
33% had unlocked guns at home on the day of the ED visit and none did on follow up.

Using the piloted LMC protocol, we will conduct the first randomized, controlled trial (RCT)
of the effectiveness of ED-based LMC on firearm and medication storage. The proposed RCT, to
be conducted in five Colorado hospitals, will test whether parents of at-risk adolescents who
are treated in hospitals that have (vs. have not yet) implemented our LMC protocol are more
likely to store household firearms and medications safely. In addition, we will conduct
in-depth, qualitative interviews with parents who have received LMC counseling to better
understand those factors that affect parents' willingness and ability to make changes to
firearm and medication storage. We will also conduct qualitative interviews with clinicians
to understand factors affecting clinician engagement in LMC.

AIM 1: To assess the effectiveness of an ED-based LMC intervention to improve how parents of
pediatric patients (age 10-17) who visit the ED for a mental health emergency store household
firearms and medication.

AIM 2: To examine how attitudinal and contextual factors shape a) parents' decisions about
firearm and medication storage following LMC, and b) clinicians' delivery of LMC messages.

Suicide is the second leading cause of death for U.S. youth 10-17 years of age. Nationally,
51% of all suicides, and 40% of 10-17 year-olds' suicides, are completed with a firearm. In
Colorado, which has the 6th highest adolescent suicide rate in the nation, more youth more
youth die by suicide than in motor vehicle crashes. Every U.S. study that has addressed the
relationship between access to firearms and suicide has found that such access increases risk
of suicide, not only for the gun owner, but for all household members. Indeed, the relative
risk of suicide associated with household firearms is highest for children and young adults,
and elevated further in those households in which guns are stored loaded and unlocked.

Some of the largest reductions in national suicide rates have occurred when access to a
commonly used and highly lethal suicide method was reduced. Consequently, reducing a suicidal
person's access to lethal means of suicide ("means restriction") is a vital component of any
effective national strategy for reducing suicide rates. Reducing access to firearms is
particularly important given their greater lethality compared with other methods commonly
used in US suicides and the very short deliberation period preceding nearly half of suicide
attempts. Nonetheless, means restriction interventions remain uncommon. The CDC's recently
released Research Priorities for the National Center for Injury Prevention and Control,
acknowledges this gap and calls for evaluation of the feasibility, scalability, and economic
efficiency of means restriction strategies.

A recent study estimated that over 40% of youth suicide victims were seen in the ED in the
year preceding their death. EDs have been identified by the National Action Alliance for
Suicide Prevention as one of two key arenas for improved services to reduce the proportion of
at-risk youth who progress to suicide, yet LMC in emergency departments remains uncommon: ED
clinicians often do not offer any lethal means counseling to at-risk patients and their
families, and many do not counsel on reducing access to firearms in particular. For example,
Grossman and colleagues reported that although 80% of emergency nurses in Illinois had recent
experience with suicidal adolescents, only 28% provided LMC to parents. A record review found
that psychiatric residents at a psychiatric emergency department assessed firearm access in
only 3% of pediatric patients.

ED-based lethal means counseling with parents of youth is a promising approach, but no RCTs
have been conducted: Previous studies on LMC point to the need for fully powered RCTs in this
area. A prospective follow-up study at a hospital ED where staff were instructed to deliver
LMC messages to parents of all at-risk youth found that parents exposed to LMC were more
likely to reduce the youth's access to lethal means than parents who were not exposed (75%
vs. 48% for prescription drugs and 63% vs. 0% for firearms), but the number of gun- owning
households (n=15) was very small. Promising evidence also comes from the pilot investigation
that members of the study team conducted at Children's Hospital Colorado.

Our research team, which includes experts in suicide prevention, LMC, evaluation science,
qualitative research, adolescent mental health, and emergency medicine, is well-suited to
rigorously evaluate the study aims using a mixed-methods approach. Our five hospital sites
will collaborate with study personnel to: a) establish IRB procedures and approvals, b)
develop a system (in nearly all sites via the electronic medical record) to flag eligible
patients, document provision of intervention services, and provide parent contact information
to the study team, c) require the clinicians who will provide LMC to take the online training
during their sites' two-week phase-in period, d) host an in-person training with a study
investigator at a staff meeting during the phase-in period, and e) implement the new lethal
means counseling protocol on their start date. A lead ED clinician at each site will be the
point of contact to help manage logistics and access medical record information for the study
in accordance with HIPAA regulations. The Colorado-based project coordinator (Brandspigel)
will work with hospitals to develop site-specific consent and data transfer processes.

Inclusion Criteria:

- Age limits pertain to the patient seen at the ED for a psychiatric or substance abuse
crisis. It is their parents/guardians who receive the intervention. Parents must speak
either English or Spanish and have a working telephone number or email address.

Exclusion Criteria:

- A patient in institutional care would be excluded. Parents/guardians who were not at
the ED with their child are excluded.
We found this trial at
8
sites
1008 Minnequa Avenue
Pueblo, Colorado 81004
Phone: 719-557-5703
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Colorado Springs, Colorado 80933
Phone: 719-776-6553
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Colorado Springs, Colorado 80909
Phone: 719-365-6139
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Colorado Springs, Colorado 80920
Phone: 719-365-6139
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Colorado Springs, Colorado 80923
Phone: 719-776-6553
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1024 S Lemay Ave
Fort Collins, Colorado 80524
(970) 495-7000
Phone: 970-624-1602
Poudre Valley Hospital A 270-bed regional medical center offering a wide array of treatments, surgeries,...
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Loveland, Colorado 80538
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8300 West 38th Avenue
Wheat Ridge, Colorado 80033
Phone: 303-467-4013
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Wheat Ridge, CO
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