Stratified Stepped-Care for Reducing Suicide Attempts and Self-Harm in Youth: A Randomized Clinical Trial
Article
Asarnow, JR, Clarke, GN, Firemark, AJ et al. (2026). Stratified Stepped-Care for Reducing Suicide Attempts and Self-Harm in Youth: A Randomized Clinical Trial
. JOURNAL OF THE AMERICAN ACADEMY OF CHILD AND ADOLESCENT PSYCHIATRY, 10.1016/j.jaac.2025.12.008
Asarnow, JR, Clarke, GN, Firemark, AJ et al. (2026). Stratified Stepped-Care for Reducing Suicide Attempts and Self-Harm in Youth: A Randomized Clinical Trial
. JOURNAL OF THE AMERICAN ACADEMY OF CHILD AND ADOLESCENT PSYCHIATRY, 10.1016/j.jaac.2025.12.008
Objective: Identifying effective approaches for reducing suicide attempts and self-harm is critical for preventing suicide deaths and self-harm–related morbidity. This study evaluated whether suicide attempts (SAs), self-harm, and related suicide-risk indicators are reduced when a stratified stepped-care for suicide prevention (SC-SP) intervention is added to health system quality improvement. Method: Youth selected for past-year suicidal behavior, active suicidal ideation, or previous suicide attempt and/or ≥3 non-suicidal self-injury (NSSI) episodes plus past-year depression (N = 301, ages 12-24 years) were randomized to one of the following: (1) health system Zero Suicide quality improvement (ZSQI) featuring system-level initiatives to improve suicide-risk screening and treatment access; or (2) ZSQI plus SC-SP, which triaged youths to suicide-specific treatments using care-stratification algorithms and a dialectical behavior therapy (DBT)–informed cognitive–behavior therapy (CBT) model, allowing for more intense care with higher and/or increased risk levels. Interviewers blinded to treatment assignment assessed outcomes at 3, 6, and 12-month follow-ups. Results: Intent-to-treat (ITT) analyses included all randomized participants (95% with ≥1 follow-up assessment). Within SC-SP, 95% received ≥1 intervention contact; 90% were assigned a care level; and 96% received care in their original assigned care level. No significant between-group differences were found in 12-month SA rates (primary outcome) (SC-SP 8.09%; ZSQI 9.59%). Compared to ZSQI, at 12 months SC-SP youths showed significantly less total self-harm (relative risk = 0.46, 95% CI = 0.26, 0.79, p = .006, number needed to treat = 10.2) and depression (secondary outcomes), and greater satisfaction with care. No deaths were detected. Conclusion: Despite negative results for the primary outcome of SAs, results suggest the promise of SC-SP for reducing youth self-harm and depression and improving patient satisfaction with care. Clinical trial registration information: Randomized Trial of Stepped Care for Suicide Prevention in Teens and Young Adults (Step2Health); https://www.clinicaltrials.gov/study/NCT03092271
