“This Is Something We Can't Avoid”: A Post-Implementation Study of Challenges with Integrating Suicide Interventions into Outpatient Adolescent Substance Use Treatment

Background and Purpose: Substance use increases suicide risk for adolescents with suicidal thoughts and behaviors (STBs). Typically, adolescents with heavy and/or problematic substance use receive treatment on an outpatient basis, where STBs are rarely addressed in a comprehensive manner. Greater attention to the development and implementation of integrated suicide and substance use interventions in adolescent outpatient substance use treatment settings is essential. As part of a larger pilot intervention project, the goal of this study was to evaluate the implementation processes of the integrated suicide intervention for teens who use substances (iSITS) intervention which was delivered in an outpatient substance use clinic.

Methods: As part of the pilot intervention project we conducted a qualitative post implementation evaluation of the screening, referral, and implementation process of the iSITS intervention. Interview questions were based on the Consolidated Framework for Implementation Research (CFIR 2.0) and explored barriers and facilitators in the innovation, inner setting, and process domains. We conducted semi-structured interviews with 5 providers (3 clinicians, 2 medical providers who conducted suicide screens and aided in referral; 3 males; Mage = 40) from an outpatient substance use clinic. All participants identified as White. Participants averaged 6.1 years of work in the area of adolescent substance use and 3.5 years employed at the recruitment site. Interviews were conducted via Zoom, audio recorded, and then transcribed. Teams of two independent coders analyzed the transcripts using Rapid Qualitative Analysis methods to conduct deductive coding based on the CFIR 2.0, ultimately identifying relevant determinants and to adapt implementation strategies for future trials.

Results: Qualitative analysis indicated barriers to implementation due to low prior access to knowledge and information about suicide risk assessment and intervention, contributing to challenges to implementation readiness among iSITS screeners and clinicians. Screeners and clinicians highlighted the importance of the iSITS study in promoting a culture of learning and competence around suicide risk screening. However, screeners and clinicians expressed lower competency and comfort with suicide risk assessment and intervention and sustaining the relative priority of the intervention. Despite challenges with integrating the research process into existing workflows and clinical care, participants endorsed the overall acceptability of iSITS. Suggestions for improved enrollment and sustained engagement included flexibility around iSITS implementation and additional training to sustain competency and comfort level over time.

Conclusions and Implications: Findings highlight the need to foster a culture of learning and competency around suicide risk screening, assessment, and intervention as a precursor to integrating suicide intervention into an outpatient adolescent substance use treatment setting. In the absence of time and resources to support the development and sustainability of that work culture, interventionists may struggle with relative priority and workflow integration challenges despite the importance of suicide intervention with adolescents. Future studies on integrated suicide interventions should account for establishing and sustaining competency within the intervention setting in order to close the gap on accessible suicide intervention for adolescents in substance use treatment.