Good afternoon, or good morning, everyone. Thank you for joining for today's webinar. My name is Adam Chu. I'll be serving as moderator. Today's webinar is titled Digital Mental Health Interventions for Suicide Prevention Among Young Adults, and it features Drs. Jonah Meyerhoff and Emily Letty. Just a brief funding notice here, the Suicide Prevention Resource Center, which is based at the University of Oklahoma Health Sciences Center, is supported by a grant from the Substance Abuse and Mental Health Services Administration. The views and opinions and content expressed in this webinar do not necessarily reflect the opinions, views, or policies of SAMHSA, HHS, or CMHS. Next slide, please. There are no financial relationships or conflicts of interest to report for this webinar. Next slide, please. If you're unfamiliar, just a bit of background here about the Suicide Prevention Resource Center, or SPRC. SPRC is the only federally funded resource center devoted to advancing implementation of the National Strategy for Suicide Prevention. As I mentioned before, SPRC is supported by a grant from SAMHSA. And so SPRC fulfills its goal of advancing the National Strategy for Suicide Prevention by building capacity and infrastructure for effective suicide prevention across the country through training, consultation, and developing resources for a variety of settings from states, tribal communities, and health systems, and that reach individuals across the lifespan. SPRC also fosters key national partnerships that engage a wide range of stakeholders and also serves as the Secretariat of the National Action Alliance for Suicide Prevention. Next slide, please. This webinar offers one AMA PRA Category 1 credit and information about claiming this credit will be displayed at the conclusion of this webinar. Next slide, please. Just a few technical pointers for you here. If you join from the desktop application of GoToWebinar, you can access handouts such as the PDF of these slides by navigating to the handouts area of the control panel. And if you use the instant join viewer, you can do the same by clicking the page icon or symbol that's on your display. Next slide, please. We'll be compiling and holding questions for the Q&A period toward the end of today's webinar, but feel free to submit questions throughout the presentations. You can do this by using the attendee control panel. Again, there's a questions pane where you can enter those questions and we'll be collecting them throughout. If you use the instant join viewer, you can do the same by clicking the question mark icon and entering your questions that way. Next slide, please. So learning objectives for today's webinar. We're going to describe the rates of suicide ideation and intentions in different subpopulations within the United States, discuss challenges to current suicide-specific care delivery models and opportunities and challenges of digital mental health tools to address this treatment gap, examine the use of digital mental health tools or DMHTs for the treatment of suicidal ideation and the prevention of suicide, and evaluate strengths and limitations of different digital mental health interventions for addressing suicidal thoughts and behaviors. And with that, I'm going to turn it over to you, Dr. Myhoff, to take it away. Thank you very much, Adam, and thank you, Ebony, and to the Suicide Prevention Resource Center, as well as the APA. We're excited to be here. So today, we will talk about suicidal thoughts and behaviors among young adults, and we'll go into some detail around some of the current interventions for suicide. We'll talk a little bit about some of the treatment gaps and opportunities for prevention, and then we'll move into how digital mental health interventions or DMHIs fit into this opportunity and can address some of these gaps. And then we'll talk a little bit about what things look like moving forward. How do we move towards better dissemination and implementation of preventive interventions? So first, we'll touch on suicidal thoughts and behaviors among young adults, and I'll turn this over to Dr. Emily Latty. All right. Next slide. So we know that young adulthood is a really developmentally sensitive time for mental health. Half of all mental health disorders that get diagnosed over the lifetime occur while individuals are 24 years old or younger. And so if we think about young adulthood as the 18 to 25 age group, this is really crucial, and there's a lot of folks who are having symptoms for the first time during this phase. And I think the thing that's really valuable and interesting about young adulthood is that it's typically, not always, but typically, marked as this period of emerging independence. Individuals are experiencing the numerous stresses of adulthood for the first time, and this includes responsibility not just over one's health and self-management, but also responsibility for seeking and maintaining their own kind of health care services. Next slide. So unfortunately, young adults and suicide is a growing problem. The young adult age group has the highest and fastest growing rate of suicide-related thoughts and behaviors. The graph on this slide shows how much higher the suicidal ideation prevalence is in 18 to 25-year-olds compared to older age groups. Next slide. And here we see a little bit more differentiation between ideation plans, attempts, and deaths among 18 to 25-year-olds. So we can see that everything is growing, and ideation is kind of growing the most and is the highest among this group. Next slide. And over time, suicidal thoughts and behaviors have been growing in the last decade, and, you know, this is a really valuable subpopulation to be looking at and figuring out kind of how we could do better for them. Unfortunately, this is the subpopulation with the lowest rates of outpatient mental health care utilization as well. So among 18 to 25-year-olds, 24.5% with past year mental illness sought outpatient mental health care. So just about one in four of individuals with a mental health illness sought any kind of outpatient health care, and just a little bit more, 28.6% sought psychopharmacological care. So we're missing a lot of young adults who could really likely benefit from treatment. They do have the highest rates of inpatient mental health care with about 4.6%. But what I'm really interested in is kind of the folks that aren't going to get any kind of treatment. And reasons cited for not getting treatment often include stigma. So while stigma seems to be decreasing among this age group, it's still very much there. And another big reason is often a preference for self-management. Of course, young adults face structural and financial barriers to mental health care, but we see that attitudinal barriers, things like stigma and preferences for self-management are far more prevalent among this group. Next slide. Next, I want to touch on some of the current interventions for suicide and preventive interventions for suicide. We'll talk about them or I'll talk about them in two different groups. The first is sort of brief interventions, which often focus on prevention of and survival of suicidal crises. And there's a variety of different flavors of this type of intervention, but the most well-studied is the safety planning intervention, which was developed by Barbara Stanley and Greg Brown. And the goal with the safety planning intervention is to help reduce suicidal behavior before an individual gets to a crisis state or while they're in a crisis state, what they can do to help kind of turn down the volume a little bit on that crisis or cope more effectively. And a similar intervention is called the crisis response plan, which was developed out of brief cognitive behavioral therapy for suicide prevention by Craig Bryan, David Rudd, and colleagues. And these kinds of brief interventions differ from other types of suicide specific psychosocial interventions in that they are very brief and they are focused on increasing suicide-related coping and thereby facilitating sort of the survival of a suicidal crisis and a reduction in suicidal behaviors. They're not necessarily designed to address some of the upstream causes of suicidal behavior or ideation. And so to address some of those more upstream causes or psychosocial factors contributing to suicide-related thoughts and behaviors, contributing to suicide-related thoughts and behaviors, other interventions have been shown to be effective. These are things like the collaborative assessment and management of suicide or CAMS developed by David Jobes, cognitive behavioral therapy for suicide prevention developed by Amy Wenzel, Greg Brown, Aaron Beck, others, and brief cognitive behavioral therapy developed by David Rudd and Craig Bryan and colleagues. And then finally, many people are familiar with dialectical behavior therapy by Marshall Linehan. So safety planning is often incorporated into a variety of different therapeutic modalities or settings, things like emergency departments. They're incorporated into existing therapy relationships. And essentially they consist of a step-by-step guide that walks a patient through methods of identifying warning signs or identifying suicidal crises and specific personalized coping plans. And importantly, it is about the process of developing this awareness and also knowledge and perceived self-efficacy around coping effectively with a suicidal crisis. And it's about that process of developing personalized coping plans that is most important. Sometimes these forms, unfortunately, can be used just as forms, sort of in a perfunctory kind of checklist kind of way. And it is important just to acknowledge here that it is about that process. These are typically co-developed in collaboration with a counselor or a therapist. So a patient would develop this, you know, in a brief session or over a couple of brief sessions with another health care, mental health care provider. And they're designed to be living documents. So they change over time as individuals, either warning signs change or their coping needs change or their environmental circumstances shift. And they've shown to be really effective for reducing suicidal behavior, especially in situations like post-discharge and also reducing repeat hospitalizations. And they're especially effective when they're combined with follow-up telephone calls. So a 2018 study looked at the safety planning intervention and follow-up calls and found that safety planning plus follow-up was associated with a 45% reduction or fewer suicidal behaviors than for individuals who received usual care at six months post-discharge. Another intervention that we know works is CAMHS. So CAMHS is a flexible framework, and it's a framework in which the patient and clinician collaborate to assess and address some of the patient-identified drivers of suicide. And that's the key here, is that it is about what the patient identifies as what ends up driving that suicidal ideation behavior, which ends up being the target. And so it's highly individualized, and it's rooted in a patient's own understanding of their own drivers of suicide. CAMHS includes the CAMH stabilization plan, which is designed to increase coping and reduce access to lethal means. It's kind of similar to safety planning, but it's not identical. And it uses some of the existing clinical interventions that we know work to treat drivers of suicide. So for example, if PTSD symptoms end up being a key driver for an individual, a clinician can treat those PTSD symptoms with existing tools, prolonged exposure, cognitive processing therapy, that ends up fitting within the CAMHS framework. And it's really effective for reducing suicidal ideation and increasing some protective factors, things like hope. And it is used across settings, inpatient, outpatient, military, civilian. And it typically is designed to last until suicidal ideation or behavior is effectively managed for about three sessions. And I'll turn it over to Emily. Okay. So another treatment that has a good evidence base is cognitive behavioral therapy for suicide prevention. And when we're talking about cognitive behavioral therapy for suicide prevention, this is usually about a 10 to 12 session protocol that consists of three core phases. So the first phase is assessing risk, making a plan for treatment, doing some crisis response planning and safety planning, and then moving into working on emotion regulation and crisis management skills. Now this protocol is in phases. And so one person might get through phase one within a first couple of sessions. Another person might be spending about half their sessions here. Phase two is focused really on kind of the core of CBT of identifying, challenging and restructuring thoughts and beliefs that drive suicidal thoughts and behaviors. So clinicians working with a patient to identify these to do that kind of exploration and to keep practicing at it. After an individual is relatively stable there, phase three is relapse prevention. And so relapse prevention focuses on identifying the skills that somebody will continue to use beyond the course of therapy to prevent relapse of suicidal ideation or suicidal behaviors. And research studies have shown that patients are about half as likely to experience a suicide attempt in two years following treatment with cognitive behavioral therapy for suicide prevention. And so it's a good one. Moving on to the next slide. So dialectical behavioral therapy, there could very easily be a one-hour workshop, a day-long workshop on DBT. So I'm not going to get into this in depth, recognizing that a lot of folks on this call are probably at least somewhat familiar with DBT. A course of DBT typically runs somebody about six to 12 months. And for it to be true DBT, the individual would be engaged in individual therapy. They would be attending a skills group with other folks who are engaged in individual therapy. They would have access to in-the-moment telephone coaching with their therapist. And their therapist would be attending a consult group with other therapists who are providing DBT. So this is a more intensive treatment that has a really good evidence base. Over the course of DBT, individuals cover the following topics. They go through mindfulness exercises. They work on their distress tolerance. They engage in exercises on interpersonal effectiveness and on emotion regulation. And there's been a number of research studies that have demonstrated that DBT is associated with reductions in suicidal ideation severity, in suicide attempts, in emergency department visits, and in non-suicidal self-injury. Next slide. So across settings, the National Action Alliance for Suicide Prevention recommends that the following elements are a part of standard care. The first is assessment. So we need to be assessing all patients for suicide risk using a standardized instrument or scale. And then we should be stratifying patients according to the level of risk that's detected through the assessment. We should be doing safety planning for patients with elevated risk. So this is completing a collaborative safety plan during the same visit that risk is identified. We should be engaging in lethal means reduction. So carrying out steps to reduce access to lethal means, which can include asking family members or significant others to assist. And then finally, we should be providing And then finally, we should be providing caring contacts or follow-up. And so these are timely supportive calls, texts, letters, messages, visits for people who have significant suicide risk, especially after acute care episodes or when ongoing services are interrupted. So if a scheduled visit is missed, a caring contact or follow-up should be provided. Next slide. Okay. So I want to move into talking a little bit about some of the challenges to the current prevention infrastructure. And as we touched on a little bit earlier, some of the key barriers to mental health care broadly fall into two categories, sort of structural barriers and attitudinal barriers. And structural barriers end up being those things that are structural in nature. So financial difficulties, the availability of clinicians and treatments, difficulty getting to places where care is offered. So transportation challenges, as well as just the general inconvenience that is required when you ask somebody to take time out of their day, their life to address a particular need that might have a lot of difficulty actually kind of enabling somebody to get to that point. So maybe they are engaged in other tasks that are valuable to them and it's hard for them to step away. Other kinds of barriers end up being attitudinal in nature. So these are, as we mentioned a little earlier, wanting to handle problems on their own. So this is this preference for self-management. Sometimes there can be a perception that treatments are ineffective, and that can be a huge barrier to people reaching out for care. Stigma, either self-stigma or social stigma can be a really major barrier to somebody actually engaging or wanting to engage in care, as well as an attitude that somebody's problems, if they can wait them out, they will resolve on their own. Certainly sometimes that can be true, but it is really important that this ends up being addressed because getting the proper care to meet a particular difficulty ends up being a really important reduction in risk. So this attitude can be a really big barrier. And finally, sometimes the perception that somebody's problems are not severe enough to warrant care or to warrant help-seeking is another really big barrier or blocker for somebody accessing or wanting to access care. And specifically in young adults, there are added barriers. If we think about college campuses where mental health services are sometimes offered and might ordinarily be more accessible than in other parts of the community, these mental health services often have limited hours and they have tremendously long waiting lists, making care really hard to get to. And sometimes they have inaccessible locations that require a car or bus routes that don't actually run near where they're going. And then stigma and social stigma in particular can be really prevalent on college campuses and among young adults. And across different treatment settings, many young adults struggle to recognize some of their symptoms as severe or problematic or difficult. Sometimes this is termed in the literature low mental health literacy, and it can reduce somebody's help-seeking. The belief that somebody's mental health difficulties are developmentally appropriate is also a big barrier that comes into play. So if somebody believes that they are supposed to be struggling at a particular point, that's going to be perceived as, that's gonna be a barrier that ends up preventing somebody from looking for help in certain instances. And then as we talked about, stigma and embarrassment can also be a really prevalent issue. And there is a strong preference among young adults, especially for self-reliance or self-management. The other thing that we know is that there are limited clinicians in training and that clinicians across different mental health spheres are often underprepared to assess suicidal ideation and address suicidal behaviors and ideation, as well as underprepared to deliver evidence-based suicide prevention interventions that we know to be effective. There is a longstanding lack of required trainings, either in certain graduate institutions or certain licensing institutions. And this is true across fields. And when training is present, sometimes, unfortunately, it can be kind of perfunctory or surface-level in nature. And current models of care are typically rooted in an in-person visit. So somebody has to actually desire and access in-person care, which is unrealistic and frankly, unattainable for a lot of people. We know that less than half of individuals with some mental health concerns over the past 12 months saw a provider for mental health-related treatment, which means more than half of individuals who could benefit from some care are not receiving it, which means that individuals, specifically individuals with suicidal thoughts and behaviors, most people are not going to be accessing this kind of care. And the other thing that plays a really important role is it is really difficult to target these kinds of preventive interventions. So one of the things that we know has been helpful in other kinds of diseases, disorders, is targeted interventions. So finding people who are at risk and delivering a preventive intervention. And certainly that is true also with suicide. However, we also know that the prediction of suicide in particular hasn't improved over 50 years of research. So right now, across 50 years, prediction of suicidal outcomes, so that is thoughts, attempts, deaths, tends to be only slightly better than chance. And the risk factors that are frequently studied, they're studied in isolation and not in combination. So these risk factors are typically studied over and over and over again. And it tends to be the same five rough risk factors across 50 years of research, meaning that we're not necessarily finding new things or studying combinations of risk factors that end up enabling us to target interventions more effectively or broadening kind of our public health interventions. And so although we do have interventions that are effective, they're limited in number. And furthermore, they produce relatively small effect sizes. And some of the reasons for our stalled progress on this is that randomized controlled trials that examine suicide outcomes, so that is thoughts and behaviors, tend to have minimal differentiation between the types of interventions or the types of outcomes that are delivered. As well as randomized controlled trials, sometimes often ones that are not specifically focused on suicide don't include suicide-related thoughts and behaviors as primary outcomes, which means that we lose access to understanding what the effects of certain interventions are on suicide-related thoughts and behaviors. And so what we need is improved study of suicide prevention outcomes in well-powered, and that's critical, well-powered randomized controlled trials and interventions that address common causes of suicide-related thoughts and behaviors. There's a huge opportunity, many huge opportunities, for digital interventions in this space. So smartphone-based digital interventions we know are effective for a lot of different challenges. So they offer an opportunity for increased autonomy. They enable people to use tools privately in the course of their own lives. And enable people to use these tools privately in the course of their own lives. And they can help people use these tools when they're needed. It also enables new ways of engaging people in the process of recovery. So smartphones tend to offer dynamic tools. They can be social, they can be game-like, they can be informational. They're highly, highly flexible and have tremendous potential to engage users in lots of different ways, and specifically at opportune moments in the recovery process. And digital mental health interventions can effectively address many mental health diagnoses comparably to face-to-face interventions. So previous effect sizes for depression and anxiety have ranged in the small to medium effect size. So if you're familiar with Hedges-G, roughly 0.39 to 0.41. And the other thing that I think is critical for the population we're interested in today is that young adults are really interested in accessing interventions through their smartphones. 96% of US-based young adults own a smartphone and they're the age group that is most likely to access the internet only through their smartphone. And currently, digital mental health interventions can circumvent the need to disclose to others. They can circumvent the need to access vast financial resources to seek care. They circumvent, or they actually also enable people to explore different treatment options with really low barriers to entry and can enable symptom self-management through ease of access to lots of different intervention types. There are lots of different tools right now for suicide prevention, digital tools for suicide prevention. Most of them are longitudinal and modular in nature. So for example, there are multi-week DBT skills training tools. I'm thinking of pocket skills in particular. There are eclectic, so CBT, DBT, ACT-based online apps that address depression, anxiety. There are safety planning tools and coping skill aggregation apps. Things like Virtual Hope Box, or in the VA's PTSD Coach, there is a safety planning tool built in. There are also really interesting text-based supportive messaging tools and reminders. There are narrative writing-based or kind of journal or reflection exercises that are sometimes delivered to people via their smart devices. And then there are also digital interventions that work on a relatively newer area, therapeutic evaluative conditioning, which is developed by Joe Franklin and is essentially meant to target the fear of death and increase fear of self-injury, as well as increase positive views of oneself, so reducing self-criticism. And there are tools being developed in all of these different domains. And there's also an emerging evidence base for some of these kinds of tools. So digital mental health interventions for suicide thoughts and behaviors are starting to accumulate. Trials of these are starting to accumulate, and there was a recent systematic review that looked at 22 of these, and roughly half of them were randomized controlled trials. Unfortunately, there were limited study of certain outcomes. So suicidal ideation was the most studied in most of these trials. And what they found was that the meta-analysis showed that there was small but promising effect sizes for suicidal ideation specifically. So there were hedges of relatively negative 0.12 to 0.26, relatively negative 0.12 to 0.26, and there were better effects when treatment as usual was used as a comparator rather than some other type of active control. And perhaps more importantly for our discussion today, acceptability of these tools is generally really high. So for SMS studies, so text-based studies, roughly 80 to 93% found these interventions to be helpful generally. And across studies, there was a lot of variability with regard to the perceived usefulness of a tool for managing suicidal thoughts and behaviors specifically, but roughly 40 to 80% found that these tools were helpful for managing suicide-related thoughts and behaviors. Now, again, that's a lot of variability, but there's good engagement across these kinds of tools. So where it was reported, and it wasn't always reported, there were roughly good engagement numbers across the length of use, although we see something that we see in all digital mental health intervention studies, and that is a declining engagement over time. And what this says to me is that there is a clear need for improved user-centered design. And what user-centered design can do is help match interventions to specific needs and preferences of certain users and minimize gaps in acceptability, minimize gaps in engagement, and support good treatment to target matches. And it's really imperative when we're thinking about how to effectively engage people in user-centered design and develop these kinds of tools, it is incredibly important that we involve those with lived experience in the design of these tools, because ultimately, we are designing for individuals experiencing these kinds of challenges, and we wanna make sure that, one, we have a good treatment target match, two, that these end up being useful for people, and that we can address early on some of the challenges that we see arising from the development of these kinds of tools. So I'll turn this over to Emily. So there is a good evidence base. People who are participating in research studies on these types of tools find them generally acceptable. Broader studies indicate people want these kinds, young adults particularly, want these kinds of tools. Yet there remains this research-to-practice gap for a number of reasons. So one of the things that always stands out to me here is reading a good research study on a new digital mental health intervention that participants in the study found very useful, found very acceptable, and then thinking, okay, where can I get this myself, or where can I refer people that I'm working with to this? And some of these programs are only available in the research, for participants in the research studies, so they just haven't been accessible to general practice yet. So that's kind of one subset of problems. But there are other issues within kind of the research-to-practice gap that I think demand a little bit of exploration and kind of better future directions for our field. Next slide, Jonah. So I think that we need to be really focusing on the implementation of these kinds of tools. And as we are focusing on the design-to-implementation pathway for digital mental health interventions for the reduction of suicidal ideation, thoughts, and behaviors, we need to be paying special attention to existing digital inequities. So we know that most young people have cell phones. We know that a lot of them have smartphones too. But things like smartphone access can vary dramatically too. So just having a smartphone doesn't mean that somebody is confident in their ability to use their smartphone for health purposes. It doesn't mean that they have consistent access to Wi-Fi to be able to download and use programs. And it doesn't mean that they have trust in the kinds of programs that we're pushing out to them either. There's a number of ways in which individual characteristics can lead to digital inequities. So of course there's socioeconomic status in that a lot of these personal technologies are becoming less expensive, more ubiquitous, but there's still definite issues there. Jonah and I have been focusing in this presentation on young adults who are kind of higher users of these sorts of technologies, but we know that across the age span for adulthood, age can lead to digital inequities. We know that education level can play a role. The quality of individuals, social support networks can play a role. When we're looking at the immigration status of some populations, that can really influence people's kind of willingness and trust to use different kinds of digital mental health care devices, especially those that might be monitoring where people are or may have identifying information in them. We know that location that folks are living in, working in, playing in, wherever, it can lead to digital inequities in terms of access to the internet connection. And then we know that folks' health literacy can influence their willingness to engage and their ability to engage in different programs that we might have. And so as reliance on digital health approaches increases, these kinds of inequities might further exacerbate existing health disparities and reduce healthcare access to those who are most likely to be affected by ongoing crises. And so as we're talking about the importance of user-centered design and the importance of including individuals with lived experience in plans to not just design, but implement these types of programs, we really need to be thinking about engaging diverse audiences in that pipeline. Next slide. So to improve digital mental health access and quality, Friese-Healy and colleagues developed this set of recommendations that I really like. It was published earlier this year. And first, they note that real-world evidence is key. We really need to increase transparency and reduce the time to market for digital mental health tools. And so traditionally, a lot of psychological and medical interventions have been studied in these really tightly controlled settings and then scaled up after efficacy is determined, efficacy is tested, and then there may be implementation studies from there. And this can take several years. And we know that having a several-year time to market for digital mental health tools can mean that the tools that are originally tested are going to be relatively obsolete if they're not being continuously updated, optimized, changed. And so we have to figure out how to better take hold of real-world evidence so that we're able to give end users, consumers, patients, whatever term we want to use, tools and services that are desirable and are going to be effective and based in evidence-based practices. We also need to educate providers and consumers on digital mental health tools, which is part of why Joan and I are joining you all here today. And we need to build and support adaptive interventions that are capable of increasing the effectiveness of an intervention and reducing the length of treatment. So we know that people have so many barriers to getting mental health care, and we're generally not of the mindset that we need to take what's working in real life and translate it into a digital tool, but rather we know there's a lot of things that kind of work in real life or face-to-face life that can really be optimized in better ways to increase the effectiveness and reduce the length of time of treatment. As I noted earlier, we need to be specifically creating for diverse populations. So far too often in the digital mental health research world and in kind of the psychological research community and psychiatric research community at large, we design and evaluate tools and protocols with nearly all non-Hispanic white samples and then claim that the results will generalize to more diverse samples. But to increase access, uptake, engagement, effectiveness, we really need to be creating both for diverse populations and actively working to build trust with those communities that have been historically underserved by mental health care. Because if people aren't interested, if they don't trust the kinds of mental health care services we want to provide, they're not going to be using them. Next slide. So one of the ways that our research team has been trying to address these issues is through the development and evaluation of this accelerated creation to sustainment, or we call it an ACTS model. And so this is a model that we're using to try to speed up kind of the process of design to implementation. And so in the create phase here, we're highlighting that digital mental health interventions are not just standalone technologies, but rather there's always some sort of service attached to it. So we have to be defining and producing protocols for the people who are going to have touch points with the technology from the get-go. And we also need to be thinking about implementation plans from the very beginning and designing not just a technology and service for implementation, but designing what the implementation strategies will be early on so that we can identify failure points before we start investing a lot of resources into it. After versions are available for the service, the technology, and the implementation, we would move into a hybrid trial. And OEI here stands for Optimization Effectiveness Implementation Trial. And so in the implementation science literature, there's been a big push in recent years to run implementation effectiveness trials, where you're testing both implementation strategies and you're also assessing the effectiveness on clinical outcomes. And here we're proposing adding elements of optimization, knowing that both technologies and service lines are going to need to be adapted and optimized as the world around us is changing. And so there are ways to be doing that in systematic ways where we can be assessing kind of the same core technology-enabled service over the course of it. And then we see that many studies prove some sort of efficacy or effectiveness and then get dropped. And so we're really advocating here that these types of studies should be including a sustainment period where we are leaving a functioning technology-enabled service in place after research support is removed so that we can be assessing how that type of service is sustained in the care environment, in the community organization, in wherever it was being implemented so that we can hopefully learn and plan better for the next times and realize what kind of ongoing support or engagement needs to be used. Next slide. So I know this slide is a little busy. This just gives a little bit of an overview of the types of things that are done in each of these phases. And the arrows here are really meant to show that this process is iterative. And so when we're creating a technology-enabled service, we're designing the service technology implementation plan, evaluating it through qualitative assessments and usability evaluations, potentially redesigning until we get to something that's being evaluated fairly well. And then we can move into a trial phase where there continues to be some redesign and evaluation. If things really aren't working, we can move back to the creation or the create phase. And if things go well, then we move forward into a sustainment phase after. Next slide. So I know that when I tend to talk about more of the kind of research methods that we should be using, oftentimes folks wonder, rightfully so, okay, that's cool. But what is available now? What could I be using in my day to day? And so earlier in this presentation, Jonah was going through some kind of high level descriptions of the types of programs, projects, product services that are available now. And knowing that everyone has access to our slide deck as a handout, we wanted to put together a brief list of things that are available now with web links on how you could access them. So I'm not going to go in depth about each one of these here, but know that this is a resource list for you that you can be taking back to your day to day lives. And next slide. So we'll start to wrap up. And in doing so, I just want to highlight a couple of different points. The first is that digital suicide prevention tools are aimed at engaging people in their own recovery and leveraging and increasing people's autonomy. They can help people choose how they want to engage in their recovery and are aimed at really kind of empowering individuals. The second point here is that the evidence base is still emerging. It is early on. And while there are promising signs for these kinds of tools, it's important to remember that these tools right now are part of a larger suicide prevention package of care. They're not necessarily meant to be used without guidance yet. They're not necessarily meant to be used in isolation or without other kinds of wraparound care systems. In fact, many of these rely on some of the wraparound care systems such as the National Suicide Prevention Lifeline or other emergency or crisis services. And finally, these tools are starting points. They are meant to facilitate processes that we know work. For example, safety planning is a great example of this. Safety planning is much more about the process of safety planning than the specific form. The form is useful, it is important, but it is much more about the processes that the form suggests. And so all of this is to say that these tools can have the potential to be tremendously powerful and can help reduce barriers to care and engage people in their own recovery. And we need more research. We need more work first. I'll show you some of our references. You'll have a copy of all of these, I believe, through the handout section. So if you are interested in some further reading, we have an awful lot of references in here. And feel free to explore it on your own. Thank you. Great, thanks very much. Let me just turn my webcam back on here. Thanks, Dr. Ladi and Dr. Maya for your really insightful presentation and for sharing your expertise. And you know, I really appreciated how you incorporated the importance of considering equity or I guess, as opposed to working against inequity that's present in the current way that digital interventions may be used or studied or developed. You know, especially considering some of the attitudinal and structural barriers you mentioned to access and care that are going to be different, depending on the individual that you talked about earlier in the presentation. And also just at the end there, I just thought it was great that, you know, you really emphasized why and how you use particular tools rather than the tools themselves, which I think is just so important when thinking about looking for solutions that are really tailored to folks who are at risk for suicide. So just some questions that came in. One, I think I can probably pitch to the both of you here is, you know, as we're still facing the impacts of the pandemic on the delivery of care, and I don't think any of us think telehealth is going anywhere, even as the pandemic shifts and changes over time. How do you see the interaction of telehealth care and digital interventions? Do you think the barriers to access, whether attitudinal or structural, are something we need to consider differently in that space? How do the digital interventions fit in? Is it a different playing field? Yeah, I can start off. Emily, I can't see you, so jump in. But, you know, I think this is a real opportunity. I think we've seen from the provider end that telehealth has dramatically increased, I think, the ability of people to access certain kinds of care. We know telehealth is, or teletherapy in particular, is effective. We know it is similarly effective to face-to-face care. And it opens up tremendous opportunities in terms of reducing barriers to access. So transportation issues, as we've talked about it, it allows people to really take ownership over how and when they're able to meet with people. And I think similarly, the digital mental health tools that we've talked a little bit about can do a similar kind of thing. It is really about putting treatment tools in individuals' hands and enabling them to control or titrate kind of what they need when they need it. And I think they can be easily used in conjunction with teletherapy or other kinds of, I mean, certainly they're used right now in teletherapy and in conjunction with face-to-face therapy. So I think this actually will translate really nicely. And I think they can, right now, augment some of the care delivery models that exist. But I think we've seen that there is a real demand for it. And I'll, Emily, anything else on that? Yeah, I mean, I feel like the only thing that I have to add is one of the, I hate to say hidden benefits, because everything about the pandemic has been terrible. But one of the, I think, benefits of this rapid expansion of telehealth services is that there are so many more people who are now engaging and using some types of technology as part of their kind of mental health care and support that has opened up kind of a window of willingness to use other types of tools. And so people who were previously not interested in connecting with a mental health clinician by videoconference or by phone, when it became the only option for a while, and when it became standard, opened some people up to the other kinds of tools that they could be using. And so I think that telehealth is here to stay in a number of different ways. And that I think digital mental health tools and interventions can be used alongside that to hopefully be engaging people who may not have been as interested in it a few years ago. Great, thank you. I think another question was, and you mentioned it right when the slide was being displayed of the what all is out there. So towards the end of the presentation, you sort of showed the list of some specific programs. And I wondered if from your experience or working with colleagues or others, could you say a bit more about among those that are available, and that perhaps you listed that you have some experience with? Are there any highlights or things you want to say a bit more about about particular ones that you've seen put into play or implemented or used with individuals yourselves? Let's say I think folks would be curious about just, you know, how to navigate how many options there are. And so there's less of the just pick one and more of the think about how you and why you might use it mindset. Yeah, so I think the first challenge here is that there are a lot that is totally true. Where it becomes a little tricky is that there is not totally enough evidence yet for any one of these tools. But I think it is important to explore whenever you whenever a clinician is recommending a particular tool, it's important for them, I think, to get experience using it themselves or trying it out themselves. That being said, I think a couple that I can point to around ones that I think are useful in different capacities. The crisis text line is a great way. It is very similar to the National Prevention Lifeline in that it is a crisis service that is delivered in a in a more accessible medium for certain people. And so it is live, it's an actual person, it's not an automated tool. But there are automated tools that are similarly on demand, I think, thinking about what an individual needs is really important. So just moving down the list, lock to live is a really nice tool to help support lethal means counseling. And there are others on here that I think are really tremendously excellent, but I'm not sure that any one of them has enough of a concrete evidence base to kind of recommend one over others. I think I encourage people, not all of them are also available in different regions. For example, the bottom two, iBobbly and Blue Ice are only available in certain geographic regions. So I think it's important to try these things out, get familiar with them, see what you as a clinician like about different ones. And I think that's where I'll end that. Yeah. Emily, any other thoughts on this? The only kind of note that I always like to include is, I think, as a clinician who did most of my clinical training before apps were becoming so commonplace, there was so much that we relied on people to keep track of on handouts and worksheets. And so while there may not be a ton of in-depth, well-designed trials on some of the tools that are out there that take what we would have already kind of been doing on paper and pencil processes and putting it onto people's phones or putting it onto websites. I just really think through the utility of having those tools really accessible to people in their day-to-day lives. And so I know that if I were to see a therapist myself and make a safety plan on a piece of paper, there's a really good chance that paper is going to get filed away somewhere in my house or lost in a backpack or whatever it may be. Whereas if it's on an app on my phone or if it's saved on a website that I can log into and I have the link to that, I'm a lot more likely to be able to go back and review it easily. And so part of this is thinking through kind of the pure convenience for folks as well. I think one other question I had in mind that comments both of you made just now made me think of is with respect to training, and you talked about some still being a training need, certainly with respect to suicide prevention and specific among professional training. But, you know, as you mentioned, there's a lot of people who are not trained to do that. And so I'm wondering if there's But, you know, as you mentioned, Dr. Meyerhoff, being familiar with these apps before you go and use them, it feels like this is a, you know, there's a core set of training and skills needed. You could argue for folks who are going to work and who already are likely probably working with individuals at risk of suicide. But from a systems perspective, you know, embedding this additional training and which tools in the digital intervention space am I expected to use in the system and context that I work in, seems like something that could get built in at a systems level, as opposed to I need to make this individual decision based on my clinical judgment when I'm sitting across from or in the other side of a video from this person, which digital tool do I use? It feels like that kind of support is really key in this space, given that there are so many options. I wonder if it's a bit of different expectation setting from a systems level, in addition to having an individual experience of what my client is going to see and using this app to Absolutely. I mean, I think we see versions of this in a couple of different ways. One is when providers of any sort, you know, I think Emily in particular has done a lot of work and she, I'll let you talk about care manager training, but I think this can often be a really wonderful area where when people are trained appropriately, the tools can be more effective. We see this also also with digital coaching, when individuals have a coach they can rely on, or that can provide, can bridge some of the gaps in whether it's usability, whether it's engagement or adherence, we see these tools become more effective. And so I think there is a real opportunity at a systems level to engage people in, in training how to use these tools. Great, well, thank you very much. I do want to recognize we're getting close to time, but want to spend a minute just reviewing how to claim credits. But I want to thank you both, Dr. Myroff and Dr. Letty again for the excellent presentations, and for filling in the questions from our participants. For those of you who are interested, information about how to claim credit is available on the screen here. You can go to the, you can email the Learning Center with questions, but if you go back into the APA website, you can do the evaluation, claim your credits that way, and you should be all set. So last slide please, just want to thank you all for taking the time this afternoon or morning, wherever you are for attending the event, and we'll be sure to catch you the next time for another one of our webinars. So thank you again to our presenters, thank you all to our organizers, and Dr. Myroff, we can just flip to the very last slide, where I believe your contact information is displayed, and we'll close out for the day. Thanks everyone, take care.

Digital Mental Health Interventions

Suicide Prevention

Young Adults

Dr. Jonah Meyerhoff

Dr. Emily Letty

Suicide Prevention Resource Center

Substance Abuse and Mental Health Services Administration

Suicide Ideation

Care Delivery Models

Digital Mental Health Tools