Targeting suicidality in young adults: a randomized, controlled pragmatic, multicentre trial evaluating the (cost)-effectiveness of Attachment Based Family Therapy compared to Treatment as Usual

Young adult suicidality is worldwide and certainly in Belgium and the
Netherlands a prevalent mental health problem, and number one cause of death in
this group with devastating consequences for young adults and their families.
The economic costs of this health issue are substantial. However, the currently
recommended psychological treatments and guidelines targeting treatment of
suicidal youth at ultra-high risk for completed suicide have only limited
effectiveness. Counter-intuitively, the use of antidepressants in youth can in
some cases even increase suicide risk. In keeping with the WHO*s recommendation
to involve the family in treatment of these youth, Attachment Based Family
Therapy (ABFT) proved in several studies in the US promising effectiveness on
suicidality. In the Netherlands and Belgium, this treatment has been
implemented in mental health care settings in the past years and is becoming
increasingly popular among therapists. However, the (cost-) effectiveness of
ABFT in our countries has not been studied in young adults.

In the proposed study, we conduct a randomized controlled trial to evaluate the
(cost-)effectiveness of ABFT compared to Treatment As Usual (TAU) on
suicidality, as delivered in daily practice. We hypothesize that, compared to
TAU, ABFT will lead to stronger reduction of suicide risk, will be more
cost-effective, will improve family functioning and young adult attachment, and
that this effect will hold at follow-up. The primary objective is change in
suicidality, that is, suicidal ideation, attempts and suicide as assessed by
the Suicidal Ideation Questionnaire Junior (SIQ-JR), and as reported by
therapists during treatment. Secondary objectives are cost-effectiveness,
process, working alliance and adherence during treatment, and change in young
adult depressive symptoms, family functioning, and young adult attachment.

A randomized, controlled, pragmatic, multicentre, trial in the Netherlands and
Belgium with 16 participating sites.

Attachment Based Family Therapy (ABFT): ABFT is a manualized treatment, that
emerges from interpersonal theories that suggest suicide can be precipitated,
exacerbated, or buffered against by the quality of family relationships.
Therefore, ABFT focuses on strengthening parent-child attachment bonds to
create a protective and secure base for young adult development. Sessions are
scheduled weekly, and the intervention lasts on average 16 weeks.

Treatment as usual (TAU): Participants in both arms will receive TAU, in the
experimental condition ABFT will be delivered as an add-on. Most treatment
centres* clinical practices rely heavily on the use of antidepressants and/or
CBT or DBT. All regular interventions are allowed in TAU, except for systemic
family therapy of more than 4 sessions in total. Parents are allowed to be
involved in the treatment, which is part of treatment as usual, and can
comprise for instance psycho-education or parental support or skill training.

There is no known risk associated with study participation. Patient burden
comprises four 30-45 minute assessment interviews, which can be held online of
by phone, and one questionnaires-only assessment, over the course of 17.5
months. The participants will be rewarded for their participation with
vouchers. The project will contribute to improving the care for suicidal young
adults with high mortality risk. Treatment of suicidal young adults is
understudied in the Netherlands and Belgium. Results will inform clinical
guidelines and policy makers and improve treatment of suicidal young adults in
The Netherlands and Belgium. Specifically, the involved national suicide
prevention foundations (i.e. 113.NL, the Flemish Expertisecentre
Suicideprevention (VLESP- Flanders), Un pas dans L*Impasse) (Suicide prevention
Wallonia), patient organisations and postdoctoral training centres will
guarantee further dissemination to daily treatment of suicidal young adults.