Integrated Adolescent Substance Use and Suicide Treatment: A Need for Additional Training

Overview: Among adolescents, suicide is the second leading cause of death and substance use increases their risk of attempts. Suicidality and substance use are often treated separately despite clinicians working in addiction being well positioned to treat both. We will discuss the existing state of integrated treatment and training needs.Proposal text: Suicide is the second leading cause of death among adolescents in the US (Kann et al., 2018) and adolescence is the peak period for initiation of substance use (Levy et. al., 2019). For suicidal adolescents substance use can increase risk for attempts (Esang et. al., 2018; Sellers et. al., 2019). Adolescents with higher levels of substance use are at higher risk for suicide attempts (Nock et al., 2013).

Despite the link between these two phenomena, these problems are usually treated separately (Esposito-Smythers et al., 2011) with substance use typically treated on an outpatient basis. Clinicians in outpatient substance use settings are often not adequately trained in how to intervene with suicidal adolescents (Singer & Slovak, 2011). Research has shown that only 15% of social work clinicians use any crisis intervention with suicidal adolescents (Mirick et al., 2016) and many still employ “no suicide contracts” (Roush et al., 2017) despite evidence against their effectiveness (Rudd et al., 2006).

Little research has been conducted to understand what informs clinicians’ work with substance using, suicidal adolescents, what barriers or facilitators exist for implementing integrated treatment in an outpatient substance use setting, and what additional training is needed to implement integrated treatment.

With university IRB approval, five clinicians were recruited from an outpatient substance use treatment center. Clinicians participated in 60-minute in-depth semi-structured interviews to explore their experiences working with suicidal adolescents presenting to substance use treatment. The interviews were conducted via Zoom and a semi-structured interview script guided the interview.

All interviews were audio-recorded and transcribed. A codebook was developed from both deductive codes from the interview guide and inductive codes from topics participants shared. All transcripts were double-coded. Data were analyzed with Nvivo12 using applied thematic analysis (Guest et al., 2012)

Results indicated there are inconsistencies in how and when screening is conducted and how and when assessment and interventions are occurring within a given outpatient program, which clinicians perceived to be a barrier to their work. Other perceived barriers included time, resources, and comfort level in treating suicidal patients. Perceived facilitators included having on-call clinician support for crises, prior training, and the collaborative environment between clinicians. Unexpectedly, clinicians identified facilitators that emerged due to the COVID-19 pandemic, noting the move to telehealth as a facilitator because more patients were accessing treatment and attending appointments consistently than before. The safety protocols developed because of the pandemic was also a facilitator. Lastly, clinicians agreed on the need for additional training specific to screening, assessment, and treatment of suicidal patients, including the need for training in using standardized and validated screening tools, other standardized assessment strategies, and safety planning. They identified role play opportunities as important to their learning.

Access to adequate and comprehensive healthcare, including mental health care, is a human right. Inconsistent procedures in the treatment and assessment of substance-using suicidal adolescents can lead to disjointed care and disrupt clinical rapport. These findings identify specific needs for explicit curricula related to suicide within schools of social work and in professional continuing education.