Comprehensive meta-analytic [22, 23] and systematic review [24, 25, 26] studies published in the past decade highlight existing interventions for youth with suicidal ideation or behavior that vary in treatment modality, targets, as well as evidence base supporting their effectiveness. A persistent challenge concerning intervening with adolescents at risk for suicide is that few psychosocial interventions have demonstrated to be effective [22, 27, 28]. To date, the treatment with most empirical support is Dialectical Behavioral Therapy (DBT-A) [29, 30], although even this well-established intervention showed benefits that were not sustained over time [29]. Yet, the prevalence of adolescent suicidal ideation and behavior clearly make them a treatment priority. In this section, we summarize recent randomized controlled trials (RCTs) in which the primary focus was prevention of suicidal ideation or suicidal behavior.

First, an RCT involving adolescents, ages 12–18, hospitalized for suicidal ideation and/or suicide attempts assessed the efficacy of a brief therapist-delivered intervention (As Safe As Possible or ASAP), a safety plan mobile application (BRITE app), and their combination (ASAP + BRITE app) [31]. The therapist delivered ASAP was grounded in an MI framework, focused on safety planning and skill acquisition, while the BRITE app included a personalized safety plan along with emotion regulation and distress tolerance skills. Moreover, as part of the ASAP and/or BRITE app, adolescents and their caregivers received two brief follow-up calls. Adolescents (n = 240) were randomized to one of four groups: ASAP with BRITE app, BRITE app, ASAP, or treatment as usual (TAU). There were no differences between the two interventions, either alone or together, and TAU on suicide attempts, suicidal ideation, non-suicidal self-injury, or suicidal events. In further moderation analyses, adolescents who were hospitalized for suicide attempts and assigned to BRITE app had a lower rate of follow-up suicide attempts. Taken together, the results were nuanced, suggesting that BRITE may lower suicide attempt risk for a subset of youth with recent attempts.

A second RCT was carried out nationwide via online recruitment with 565 adolescents, ages 13–16, with non-suicidal self-injury (NSSI) within the prior month and recent negative views of the self. In this study, youth were randomized to the web-based Project SAVE (Stopping Adolescent Violence Everywhere), a 30-minute self-administered single-session intervention drawing on elements of CBT, or to a 30-minute active control program with supportive therapy [32]. Project SAVE was perceived as acceptable; however, there were no group differences for the pre-registered outcomes of 3-month NSSI frequency or suicidal ideation or for post-intervention self-reported likelihood of future NSSI. Although adolescents randomized to Project SAVE reported post-intervention improvements in self-hatred and desire to stop future NSSI, overall results suggested that improvements in longer-term suicidal and non-suicidal self-injury outcomes may require additional or more intensive approaches.

A comparative effectiveness trial of a brief suicide crisis intervention based on Interpersonal Psychotherapy for Adolescents (IPT-A-SCI) for children and adolescents (N = 309) with depression, anxiety, or suicidal ideation/behavior showed no difference between the brief IPT-A-SCI, treatment as usual or waitlist on outcomes of interest including suicidal ideation, depression symptoms, or anxiety [33]. Youth were recruited in an outpatient depression and suicide clinic, and this intervention included 5 weekly 50-minute sessions and 4 follow up personal emails. Sessions focus on the development of a safety plan, evaluating interpersonal relationships, development and practice of coping strategies, and relapse prevention [33].

Finally, we describe two pilot studies exploring adjunctive interventions integrating follow-up contacts during high-risk care transitions. In the first pilot using a sequential multiple assignment randomized trial (SMART), 80 adolescent inpatients [34] were first randomized to a Motivational Interview-Enhanced Safety Plan (MI-SP), either alone or with daily post-discharge supportive text messages. Adolescents were re-randomized two weeks after discharge to an added booster call or to no call. Adolescents who received supportive text messages showed improved safety plan use, self-efficacy to refrain from suicidal action, and coping by support-seeking, as did youth randomized to booster calls. Supportive texts were also associated with lower intensity of daily suicidal urges and greater coping self-efficacy. Though needing additional empirical support, text messaging could offer a promising follow-up strategy and extend interventions, such as safety planning.

The second pilot RCT examined a text-based intervention for parents of adolescents seeking ED services for suicidal ideation or attempts ([35], under review). The automated text messages included two types: messages encouraging parents to follow through with recommendations for their adolescent (e.g., restricting lethal means) and messages supporting parents’ own well-being (e.g., coping tips). Parents (n = 120) were randomized to a control group or an intervention group consisting of one or both types of messages. These preliminary findings supported the feasibility and acceptability of this intervention and pointed to its positive impact on parental engagement in suicide prevention activities and lowering post-ED suicide attempts among adolescents. The unique focus on caregivers highlights the potential of low-burden parent-facing interventions as an additional strategy for lowering youth suicidal behavior during high-risk periods.

Altogether, there have been notable recent efforts toward building a stronger evidence-base for suicide-specific interventions for youth. Nevertheless, while demonstrating feasibility and acceptability, none of the recent large-scale RCTs reviewed showed an impact on suicidal ideation or attempts, and the two pilot trials require replication.

As the field looks toward addressing gaps in treatment approaches for adolescents at risk for suicide, we pose four recommendations. First, while recognizing the limitations of existing interventions, it may be that some treatment approaches, while not effective across the board, may in fact be beneficial for some youth. Though relatively infrequently tested in the suicide prevention literature [36], examining treatment moderators as part of RCTs could avoid prematurely discounting interventions that do not show overall effects and may inform how to personalize treatments [36]. For example, while the mobile BRITE app did not lower the suicide attempt risk overall, it was beneficial for those with recent attempts [31]. Second, as suicidal youth are not homogeneous with respect to risk profiles [37] or time-varying changes in risk states [38], a related consideration is to test adaptive interventions that specify how, when, and for whom interventions should be delivered. While this section described pilot work seeking to inform an adaptive intervention for youth at risk for suicide [34], large-scale studies will be necessary to guide progress in this area. Third, studies summarized in this section suggest a shift toward more scalable interventions that rely on technology to extend their reach [31, 34] or increase access to stand-alone support [32]. Nevertheless, caution is needed to scrutinize potential limitations of technology-based interventions, as such approaches may not necessarily lead to lasting improvement [32] or benefit all teens [31]. Finally, as we work to improve the effectiveness of preventive interventions, it is critically important to simultaneously address implementation issues, such that interventions are designed with features that improve intervention access and eventual uptake in real-world settings.

Crisis Lifeline. The 988 Crisis Lifeline is a nationally accessible service that offers live support via call, chat or text options. This service is considered to be a critical component of current suicide prevention efforts [39]. A recent study of Lifeline chatters’ views of the Lifeline’s perceived effectiveness revealed that 39% of chatters were minors [40] and 71.4% were 24 years old or younger. Two-thirds of chatters found the service helpful and nearly half reported a decrease in suicide-related concerns related to their chatting experience. Compared to adults, minors had a significantly higher odds of finding the chat helpful [40]. This converges with evidence from a 2022 study that analyzed data from crisis texters and found that the majority (i.e. 76%) were under 25 years old [41]. Highlighting the potential value of crisis support, 31% of texters 13 years or younger reported that they had no additional sources of help for their current crisis. Additionally, Hispanic, Black, and Native Hawaiian or Other Pacific Islander texters had lower rates of getting help from a therapist or doctor. Those who self-identified as belonging to a sexual or gender minority group and those reporting more than one race represented a greater proportion of texters compared to the general population. These findings highlight the potential benefit of the crisis texting resource for youth in general as well as for systematically marginalized groups, indicating its important role in advancing health equity. Additional research is needed that examines the effectiveness in relation to youth mental health and behavioral outcomes.