Michael Walton

The authors sought to determine whether augmenting usual suicide care with follow-up in the form of instrumental support calls (ISC) or two-way Caring Contacts texts (CC) works best to reduce suicidal ideation and behavior (SI/SB) in adolescents and adults. The Suicide Prevention Among Recipients of Care (SPARC) Trial is a pragmatic comparative effectiveness randomized clinical trial stratified by age, with participants randomized in a 1:1 ratio to ISC or CC. Participants were adolescents (12-17 years, N=723) and adults (18+ years, N=797) who screened at risk for suicide in emergency departments (N=9) and primary care clinics (N=36) between May 2021 and July 2022; primary data collection was completed in August 2023. Outcomes included Columbia-Suicide Severity Rating Scale SI/SB score at 6 months (primary) and 12 months (secondary). Adolescents (N=723; mean age, 14.9 years [SD=1.6]) were mostly female (75%), White (84.1%), and non-Hispanic (84.2%). Adults (N=797; mean age, 38.3 years [SD=15.9]) were mostly female (70%), White (89.1%), and non-Hispanic (90%). At 6 months, outcomes were similar by condition among adolescents, but among adults, SI/SB scores were significantly higher among those receiving CC compared to those receiving ISC (adjusted difference in means [ADM]=0.50, 95% CI=0.12, 0.88). At 12 months, adolescents' SI/SB scores were significantly lower in the CC compared with the ISC condition (ADM=-0.64, 95% CI=-1.11, -0.18), but outcomes were similar by condition among adults. The best suicide prevention follow-up care may vary by age, with adolescents benefiting most from longer-term connection-focused two-way CC and adults benefiting most from more intensive early instrumental support through ISC.

The Joint Commission has recently included seclusion and restraint as quality-of-care indicators for hospital-based inpatient psychiatric services. Their inclusion is the result of abuse of these practices, wide variation across hospitals, and cultural influences, including the consumer and recovery movements. Over the next few years, these indicators will increasingly influence treatment modalities available to hospitalized patients. This Open Forum provides a brief history of changing attitudes toward use of seclusion and restraint. It describes three clinical scenarios that highlight appropriate and humane use of seclusion and restraint and that illustrate the clinical complexities associated with their use. Potential unforeseen consequences of the reduction or elimination of seclusion and restraint are described.