Suicide attempt rates have increased over the past decade, and it is the second leading cause of death among youth aged 10 to 18 years in the United States (CDC, 2020; Ivey-Stephenson et al., 2020; Sheridan et al., 2022). According to the 2021 Youth Risk Behavior Survey, between 2019 and 2021, the rates of youth who seriously considered suicide in high school increased from 24.1% to 30.0% for females and from 13.3% to 14.3% for males. Similar gendered increases and stability were seen in the rates of those who made a suicide plan (19.9% to 23.6% for females, 11.3% to 11.6% for males) and of those who attempted suicide (11.0% to 13.3% for females, stable for males) (Gaylor et al., 2023). Since 2007, the rate of death by suicide for youth aged 10 to 24 has increased by 62% (Curtin & Garnett, 2023). In 2018, suicide accounted for one in three injury-related deaths in American youth (CDC, 2020a). While suicide rates were on the rise prior to the COVID-19 pandemic, rates of visits to emergency departments for suicidal thoughts and behaviors more than doubled after the onset of the pandemic (Yard, el al., 2021). Furthermore, rates of youth hospitalized for suicidal thoughts and behaviors increased from 30.7% in 2009 to 64.2% in 2019 (Arakelyan et al., 2023). Adolescents are at greater risk for suicidal behaviors when they have a mental disorder, previous suicide attempt, stressors related to interpersonal losses, school, or family, personality characteristics like impulsivity, and access to lethal means (Bilsen, 2018; Rufino & Patriquin, 2019; Shain, 2016). Furthermore, minoritized populations such as Latinx youth, have higher rates of suicidal thoughts and behaviors compared to White youth (Grunin et al., 2022; Gaylor et al., 2023).

Minority youth face more numerous, more frequent, and more severe problems than their majority peers because of documented health disparities (Marks et al., 2020). Latinx are the largest minoritized ethnocultural group in the United States, comprising about 18.5% of the population, and 32% of Latinx are under 18 years of age (Raymond-Flesch, 2017, U.S. Census Bureau, 2019). Latinx youth are significantly less likely to receive and to utilize mental health treatment (Mennies et al., 2021). Recent studies have shown that Latinx adolescents have a higher prevalence of depression compared to non-Hispanic youth (Céspedes & Huey, 2008; Knopf et al., 2008; Twenge and Nolen-Hoeksema, 2002). Suicidal thoughts and behaviors are common in this population, with about 17.2% of Latinx high school students reported seriously considered suicide, 14.7% reported making a suicide plan, and 8.9% reported attempting suicide in 2019, with 3% of these youth who made an attempt requiring medical care (CDC, 2020b; Ivey-Stephenson et al., 2020).

Latinx adolescent suicidal behaviors are influenced by individual, familial, and sociocultural factors (Boyas et al., 2019; Gulbas et al., 2019; Rodriguez et al., 2019; Romero et al., 2014; Vega, 2014). Racial and ethnic minority youth face discrimination, which is associated with suicidal ideation among Black and Latinx youth (Madubata et al., 2019). Much of the research on Latinx adolescent suicidality has predominantly focused on Latinx females (Villarreal-Otálora et al., 2019), but Latinx males have a higher rate of death by suicide (Miranda-Mendizabal et al., 2019). Depressed mood has been found to influence suicidality in Latinx adolescents (Villarreal-Otálora et al., 2020). Latinx youth have been found to be at greater suicide risk when they report lower levels of ethnic identity attachment (Oakey-Frost et al., 2019). Bicultural stress in families (that is, the stress associated with negotiating two cultures and accompanying sociocultural elements) is associated with the development of depression and suicidal ideation for Latinx adolescents (Gillig et al., 2020; Rodriguez et al., 2019; Romero et al., 2020).

Youth suicide is a serious public health concern that requires evidence-based treatment programs (Arango et al., 2021). Suicide risk screening and raising awareness through education are considered critical prevention strategies occurring across a wide array of settings, including health care and secondary schools (Arango et al., 2021). Gatekeeper training for suicide prevention educates individuals to recognize and support at-risk youth to better connect them to mental health services. Such training in schools has been associated with increased knowledge and self-efficacy, improved attitudes toward intervention, and improved personal ability to intervene (Mo et al., 2018). Once at-risk youth are identified, they may receive psychotherapy, psychoeducational support, psychopharmaceutical treatment, or, when applicable, crisis intervention services (Arango et al., 2021). The treatment of suicidal thoughts and behaviors in adolescents has advanced through several clinical trials, yet these interventions while effective are not durable (Spirito el al., 2021). Treatments with demonstrated efficacy include family-integrated cognitive-behavior therapy (Esposito-Smythers et al., 2019; Asarnow et al., 2011), attachment-based family therapy (Diamond et al., 2016), dialectical behavior therapy (DBT; Mehlum et al., 2014; McCauley et al., 2018), and mentalization-based therapy (Rossouw et al., 2012). Collaborative assessment and management of suicidality has also been suggested as a promising intervention strategy for this population (Adrian et al., 2022; O’Connor et al., 2014). Yet, only DBT with 2 independent trials supporting efficacy, is considered to be a well-established treatment for adolescents with suicidality (Hughes and Asarnow, 2013; Berk 2022; McCauley et al., 2018). However, the advantages of DBT over a comparator condition decreased at 12-month follow-up (McCauley et al., 2018).

The present study is based on an adaptation of the Suicide Prevention and Resilience at Children’s (SPARC), an intensive outpatient program (IOP) intervention developed by Kennard et al. (2014) that aims to reduce suicidal thoughts and behaviors by identifying and mitigating risk factors associated with suicidality. SPARC utilizes a cognitive behavior therapy approach (CBT; Stanley et al., 2009) and includes aspects of DBT and DBT-A (McCauley et al., 2018; Mehlum et al., 2014), Mindfulness CBT (Teasdale et al., 2000), and Relapse Prevention CBT (Kennard et al., 2014). The program’s model focuses on identifying risk factors (poor distress tolerance, difficulties regulating emotion, unhelpful thinking, limited problem solving and interpersonal skills) related to suicidal behavior and on the treatment strategies to mitigate these risk factors (Brent et al., 2023). In a hospital-based setting, the program has been found to have significant improvements in depression severity and suicidal thoughts and behaviors (Kennard et al., 2019). Recent program results suggest significant reductions in depression severity and suicidal ideation and low rates of reattempt in the 6-month period following program completion (Kennard et al., 2023). Though these interventions have evidence of efficacy based in controlled study settings, further research is needed on therapeutic interventions in real-life community settings with cross-cultural adaptations (Arango et al., 2021; Lee & Wong, 2020).

Cultural adaptations of evidence-based practices for high-risk communities that address the unique needs and the barriers associated with marginalization are critical (Bernal et al., 2009). Interventions adapted for subcultural groups have been found to be effective in improving health outcomes and psychopathology (Barrera et al., 2013; Hall et al., 2016). There is a demand for mental health treatments that are culturally tailored for youth in Latinx communities (Boyas et al., 2019). And, given the increasing rates of suicidal youth, the adaptation of suicide-specific intervention programs to address the needs and disparities of Latinx youth are warranted (Ford-Paz et al., 2015; Silva & Van Orden, 2018).

We examined the treatment outcomes of a Suicide Prevention Treatment adapted (SPT-A) for a community mental health center in North Texas, United States. The SPT-A, which included a majority of Latinx youth and their caregivers, was culturally adapted for this setting (Kennard et al., 2019; Kennard et al., 2020). Adaptations were developed based on qualitative data gathered from structured interviews of youth, parents/caretakers, and clinical staff to inform the adaptation of the parent IOP program. Specific adaptations included reducing identified barriers to treatment by shifting appointments to evenings, shortening the group sessions to 1.5 h weekly for 8 weeks, and allowing other siblings to attend multifamily groups with parents. The multifamily groups were conducted in English and Spanish, with psychoeducation on depression and suicidality included as core components. Additionally, interactive content, storytelling, and multifamily potlucks where taught skills were reviewed to facilitate engagement. Other content added based on qualitative analysis included wellness content discussing the importance of spirituality and religiosity in families and communication strategies like validation and perspective taking via role-plays (Kennard et al., 2020). Finally, given identification as a protective factor (Serrano-Villar & Calzada, 2016), we added a family history project where the teen interviewed a parent/caretaker about their childhood to reduce intergenerational divide, strengthen listening skills and appreciation of each other’s experiences. In the present project, we examined suicidal thoughts and risk, depressive symptoms, suicide attempts, and NSSI in youth before and after participation in the community-based suicide treatment program.

Method

Study Setting and Participants

The project was launched at a large urban community mental health center at three clinic locations that provide child and adolescent mental health services, including evaluation, counseling, skills development, and medication management. Providers include qualified mental health professionals (QMHPs), psychiatrists, and nurses. Providers in this program included masters-level providers who paired with the SPT-A’s QMHPs to lead the group sessions. Community mental health clinicians referred adolescents (aged 12 to 17 years) from the three clinics. Eligibility for the study was determined by the adolescent’s provider and included either a worsening in suicidal ideation or a recent suicide attempt. The UT Southwestern Medical Center Institutional Review Board and the Altshuler Center for Education and Research (ACER; Research Committee) reviewed and approved the study to ensure ethical standards were followed. Informed consent and assent were obtained from legal guardians and participants, respectively.

Of the 81 youth, 79.01% were females (sex assigned at birth) and the mean age was 14.71 ± 1.53 years (age range = 12 to 18 years). Over 65% were Hispanic/Latinx, with 22.2% African American, and 28.4% White. The incidence of a lifetime suicide attempt upon entering the SPT-A was 68.75%. Over 75% of the sample had a history of NSSI. Mean baseline (at entry) QIDS-A17-SR total and CHRT-SR Risk scores were 13.47 ± 5.50 and 3.93 ± 3.04, respectively, indicating moderate level of depressive symptoms and suicide risk. Demographic and clinical characteristics of the youth, overall and by attempt status, are shown in Table 3. As this intervention was a transdiagnostic intervention, we had the following inclusion criteria: currently in treatment for suicidal ideation/behavior at the community clinic, referred by a clinic provider, and were ages 12–17. The exclusion criteria of this study were history of psychosis, intellectual disability, and ASD.

Youth Suicide Prevention Treatment Program Adapted for Community Mental Health Center (SPT-A)

The parent program of SPT-A is an intensive outpatient program based in CBT with DBT components, including distress tolerance and emotional regulation strategies to reduce suicidal thoughts and behaviors in adolescents. The program has been found to be acceptable, feasible, and may be more cost-effective than higher levels of care (Kennard et al., 2019). Recent analyses of the program continue to demonstrate its effectiveness, with significant reductions in depression and suicidal ideation at program completion (Kennard et al., 2023).

Kennard et al. (2020) examined the treatment needs of low-income Latinx suicidal youth in a community mental health clinic. Qualitative interviews with Latinx youth, parents, and clinical staff revealed that common barriers to care included transportation, unstable housing, scheduling issues, and unmet childcare needs. Furthermore, differences in acculturation in families was a risk factor. The SPT-A program was thus developed for community mental health clinics that mainly serve Latinx patients and was provided as an adjunctive treatment for youth who were being treated by QMHPs in the clinics. The in-person program included 8 weekly sessions of skills-based group sessions that focused on reducing suicidality (e.g., reasons for living, behavioral activation, family communication). Group therapy sessions were 1.5 h a week for 8 weeks and utilized CBT and DBT modules focusing on skills to reduce risk factors (Bridge et al., 2006; Brent et al., 2009). Parents also attended 4 of the 8 weeks for psychoeducation and multifamily treatment. See Table 1 for skill modules provided.

Table 1 Skills Curriculum
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Outcome Measures

The primary outcomes for the current study were suicidal behavior and depressive symptoms, which were measured at baseline (upon entry into the program before treatment) and at exit/discharge (at completion of the treatment program). Information about past and current suicidal behavior and non-suicidal self-injury (NSSI) was assessed by the clinician using the Columbia Suicide Severity Rating Scale (C-SSRS) (Posner et al., 2011). The C-SSRS is a semi-structured clinician-rated interview created to assess severity of suicidal behavior and ideation for those aged 11 years and older in community, clinical, and research settings (Brent et al., 2009; Posner et al., 2011). Suicidal behavior was assessed based on number of interrupted, aborted, and actual suicide attempts.

The Concise Health Risk Tracking (CHRT) is a 14-item self-report scale, was also used as a outcome measure of suicidal ideation, suicidal severity, and suicide risk in adolescents (Mayes et al., 2018; Trivedi et al., 2011). Items 1–9 represent the Propensity score which encompasses risk factors such as “pessimism” (items 1 and 2), “helplessness” (items 3 and 4), “perceived lack of social support” (items 5 and 6), and “despair” (items 7, 8, and 9), while items 12, 13 and 14 represent “Active Suicidal Thoughts or Suicide Risk.” Items 10 and 11 measure “impulsivity.” The items were rated on 5-point Likert-type scales, which ranged from strongly disagree (0) to strongly agree (4), with a total Propensity score ranging from 0 to 56 and higher scores indicative of greater severity. Suicide Risk scores range from 0 to 12, with a score of 4 or greater being indicative of higher risk.

Depressive symptoms were measured using the Quick Inventory of Depressive Symptomatology, Adolescent self-report version (QIDS-A17-SR; Bernstein et al., 2010) which is a 17-item self-administered screening instrument. The QIDS-A17-SR score ranges from 0 to 27, with a greater score representing greater depression severity. Score interpretation ranges include: 6–10 is mild depression, 11–15 is moderate, 16–20 is severe, and 21–27 is very severe.

Measures of feasibility included the ability to enroll and retain patients (completion of at least five sessions) as based on other studies of interventions (Chew-Graham et al., 2022; Donovan et al., 2023). Acceptability was measured through assessment of teen satisfaction at the end of treatment using the Client Satisfaction Questionnaire (CSQ-8; Nguyen et al., 1983). The CSQ-8 is an eight-item scale rating satisfaction with treatment on a scale of 1–4, with higher ratings indicating greater satisfaction (scores range from 8–32). The CSQ-8 has good internal consistency with an alpha of .93 (Nguyen et al., 1983). Satisfaction as measured by the CSQ-8 was selected as it has been used in a variety of health and human services, including outpatient psychotherapy.

Statistical Analysis

Demographic and clinical characteristics for the sample of evaluable patients were described using the sample mean and standard deviation for continuous variables and the frequency and percentage for categorical variables. Two-independent sample t-test with the Satterthwaite method for unequal variances (continuous variables) and Fisher’s exact test (categorical variables) were used to identify any differences between characteristics of the two groups (suicide attempt during lifetime vs. no suicide attempt).

The incidence and risk difference for lifetime suicide attempt and for NSSI in youth were calculated following treatment in SPT-A (at exit) compared to baseline (at entry before treatment). Simple within-subjects logistic regression, with penalized maximum likelihood estimation along with Firth’s bias correction, was implemented to estimate the odds of a suicide attempt and a NSSI, respectively, for youth following treatment in SPT-A compared to youth before entering SPT-A treatment. Separate logistic models were implemented. Finally, the change over time (baseline to exit) in depressive symptoms (QIDS-A17-SR) and suicidal risk (CHRT-SR), respectively, was examined using a linear mixed model analysis of repeated measures. The mixed model contained fixed effects terms for attempt status (lifetime attempt vs. no attempt), time, and attempt status × time interaction. Restricted maximum likelihood estimation along with Type 3 tests of fixed effects were used with the Kenward-Roger correction applied to the compound symmetry covariance structure. Least squares means (LSM) were estimated as part of the mixed model. Simple group (attempt status) effects at each time period as well as within-group contrasts (change) from baseline (entry) to exit were also assessed. Cohen’s d was calculated and interpreted as the effect size estimator.

Statistical analyses were carried out using SAS software, version 9.4 (SAS Institute, Inc., Cary, NC). The level of significance was set at α = 0.05 (two-tailed).

Results

Lifetime Incidence of Suicide Attempt and NSSI

Among the youth who entered the SPT-A, the incidence of a lifetime suicide attempt was 68.75% and upon completing SPT-A, at exit, the incidence of an attempt was reduced to 5.56% (risk difference: 63.19% decrease in the incidence of attempts, 95% CI: −74.11% to −50.27%, p < 0.0001). In other words, there was a 63.19% decrease in the incidence of attempts in youth following treatment SPT-A (at exit) compared to when youth entered at baseline (before treatment), given lifetime incidence of attempts. Logistic regression results also revealed that there were lower predicted odds of having a suicide attempt for youth following SPT-A compared to youth before entering SPT-A, given lifetime incidence of attempts (OR = 0.030; 95% CI: 0.010 to 0.088, p < 0.0001; AUC = 0.832).

For the youth who entered the SPT-A, the incidence of a lifetime NSSI was 75.64% and upon completing SPT-A, at exit, the incidence of a NSSI was reduced to 22.22% (risk difference: 53.42% decrease in the incidence of NSSI, 95% CI: −66.08% to −37.98%, p < 0.0001). In other words, there was a 53.42% decrease in the incidence of a NSSI in youth following treatment in SPT-A (at exit) compared to when youth entered at baseline (before treatment), given lifetime incidence of NSSI. Logistic regression results also revealed that there were lower predicted odds of NSSI for youth following treatment in SPT-A compared to youth before entering SPT-A, given lifetime incidence of NSSI (OR = 0.096; 95% CI: 0.045 to 0.204, p < 0.0001; AUC = 0.767).

Depressive Symptoms

The mixed model repeated measures analysis revealed no significant attempt status by period interaction effect (p = 0.1711) or main effect of attempt status upon entry (p = 0.1106), but there was a significant period main effect (p < 0.0001). As shown in Table 2 and Fig. 1, the pattern of the least squares means revealed a significant improvement (decrease) in depressive symptoms (QIDS-A17-SR Total scores) from baseline QIDS-A17-SR to exit QIDS-A17-SR for those who had no lifetime suicide attempt upon entering SPT-A [11.600 (SE = 1.079) at baseline vs. 9.069 (SE = 1.117) at exit, LSM decrease = −2.530 (SE = 1.176), mean percent change = 21.81% decrease, p = 0.0351; d = 0.240] and for those who had a suicide attempt during the lifetime [14.418 (SE = 0.727) at baseline vs. 9.891 (SE = 0.799) at exit, LSM decrease = −4.527 (SE = 0.836), mean percent change = 31.39% decrease, p < 0.0001; d = 0.604]. Although those who had a lifetime attempt had significantly greater depressive symptoms (QIDS-A17-SR total) upon entry into SPT-A than those who had no lifetime attempt (14.418 vs. 11.600, p = 0.0324), the two groups of youth (attempt vs. no attempt) converged to similar mild levels of depressive symptoms (QIDS-A17-SR total) following treatment in SPT-A at exit (9.891 vs. 9.069, p = 0.5511).

Table 2 The effect of attempt status on depressive symptoms and suicidal risk before and after treatment in SPT-A
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Fig. 1
figure 1

Least squares means (LSM ± SE) for depressive symptoms (QIDS-A17-SR) from the Attempt Status by Time Period tests of simple effects from the linear mixed model. Significant Group (attempt status) differences were observed at baseline (p = 0.032), but not at exit (p = 0.551). A significant improvement (decrease) was observed in depressive symptoms from baseline to exit for both those who had a suicide attempt during the lifetime (p < 0.0001) and those who had no lifetime attempt (p = 0.035). A higher QIDS-A17-SR score represents worse depressive symptoms

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Suicidal Ideation and Risk (CHRT-SR Risk)

The mixed model repeated measures analysis revealed no significant main effect of attempt status upon entry (p = 0.4758), but a significant period main effect (p < 0.0001) and a significant attempt status by period interaction effect (p = 0.0498). As shown in Table 2 and Fig. 2, the pattern of the least squares means revealed a significant improvement (decrease) in suicidal risk (CHRT-SR) from baseline CHRT-SR to exit CHRT-SR for those who had a suicide attempt during the lifetime [4.345 (SE = 0.385) at baseline vs. 1.977 (SE = 0.419) at exit, LSM decrease = −2.368 (SE = 0.411), mean percent change = 54.49% decrease, p < 0.0001; d = 0.644], but not for those who had no lifetime suicide attempt upon entering SPT-A [3.200 (SE = 0.572) at baseline vs. 2.245 (SE = 0.5902) at exit, LSM decrease = −0.954 (SE = 0.576), mean percent change = 29.83% decrease, p = 0.1023; d = 0.185]. Although those who had a lifetime attempt had higher suicidal risk (CHRT-SR) upon entry into the SPT-A program than those who had no lifetime attempt (4.345 vs. 3.200, p = 0.0996), the two groups of youth (attempt vs. no attempt) converged to a similar level of risk (CHRT-SR) following treatment in SPT-A at exit (1.977 vs. 2.245, p = 0.7121). The interaction effect also revealed that the change in suicidal risk (exit-CHRT-SR minus baseline-CHRT-SR) was significantly different between those who had a lifetime attempt and those who had no lifetime attempt (ΔLSM = −1.413, SE = 0.708, p = 0.0498). In other words, attempt status moderated the change in suicidal risk from baseline (entry) to exit.

Fig. 2
figure 2

Least squares means (LSM ± SE) for suicidal risk (CHRT-SR Risk) from the Attempt Status by Time Period tests of simple effects from the linear mixed model. No significant Group (attempt status) differences were observed at baseline (p = 0.096) and at exit (p = 0.712). A significant improvement (decrease) was observed in suicidal risk from baseline to exit for those who had a suicide attempt during the lifetime (p < 0.0001), but not for those who had no lifetime attempt (p = 0.102). A higher CHRT-SR score represents greater suicidal risk

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Feasibility, Acceptability, & Patient Satisfaction

Over 87% of participants completed the program, with an average of 6.71 ± 1.91 sessions attended indicating good feasibility and acceptability. 82.7% of the youth program completers completed CSQ-8 at exit from the program, which indicated high mean levels of satisfaction 27.94 ± 3.77. Also, regarding CSQ Item 8 at exit, when asked “If you were to seek help again, would you come back to our service, “over 21% and 72% responded by saying “yes, I think so” and “yes, definitely,” respectively. Mean levels of overall satisfaction did not differ based on history of lifetime attempt vs. those without an attempt history (28.29 ± 3.29 vs. 27.04 + , p < .2589, FDR 0.3884; Table 3).

Table 3 Demographic and clinical characteristics of the overall sample and by lifetime suicide attempt status
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Discussion

Tailoring treatment interventions to culturally diverse populations is important in delivering optimal care. In a prior study, we outlined qualitative methods used to adapt an intensive outpatient program for suicidal youth to community mental health center clinics serving a majority of Latinx youth (Kennard et al., 2020). Specifically, we developed a transdiagnostic, suicide specific treatment program for Latinx youth. In this study, we examined the acute outcomes of the participants in this program. Participants in this program, referred by clinic providers, were largely Latinx (over 65%), female sex assigned at birth (79%) and entered the program with moderate levels of depression and suicidal thoughts and behaviors. Over 68% of the youth had a history of suicide attempt and over 75% had a history of NSSI. Given the acuity of this population, it is important to assess whether the adapted program is feasible, acceptable, and effective.

We found the feasibility and acceptability outcomes encouraging, with more than 87% completing the program, and the average number of sessions attended was just over 6 sessions of the 8-session program. Teen satisfaction with the treatment program was high (Total score of 27.94 out of 32 possible points). Together, these factors suggest that the adaptations made benefited the population; however, further exploration and qualitative review may increase suitability of specific adaptations. Further consideration of differences in dropout rates for individuals who have attempted previously, and individuals referred for ideation only may be warranted. Past meta-analyses suggest that SPT-A type treatments benefit youth who engage and indicate the individual-level factors regarding treatment participation are needed (Ougrin et al., 2015; Yuan et al., 2019).

Youth enrolled in the program had a significant decrease in suicide attempt risk at the completion of the program. More than 63% of participants had a decreased attempt risk compared to incidence of attempt before entering SPT-A treatment—including lower predicted odds of having an attempt following SPT-A compared to youth before entering SPT-A. We found a similar decreased risk of incidence of NSSI following treatment from the program. This result demonstrates the effectiveness of the adapted intervention, given that lifetime history of attempts has been indicated as a predictor of future suicide attempts (Bilsen, 2018; Bostwick et al., 2016; Brent et al., 2023; Horwitz et al., 2015). Taken together, these results indicate that the adapted intervention did target suicidality and NSSI as intended, suggesting potential effectiveness; however, a larger scale randomized clinical trial would be necessary to speak more towards this point.

While lifetime attempters had significantly greater depressive symptoms upon entry into SPT-A than youth who had no lifetime attempt, the two groups (attempt vs. no attempt) converged to similar mild levels of depressive symptoms following treatment in SPT-A at exit. This was also true for suicidal thoughts and risk on the CHRT, where those with a lifetime attempt had higher levels of suicidal risk at program entry than those with no history of attempt, but both groups had similar levels of suicide risk at discharge. Attempt status moderated the change in suicidal risk from baseline (entry) to exit with change in suicidal risk significantly different between those who had a lifetime attempt and those who had no lifetime attempt.

The findings of this study are promising, yet preliminary due to its limitations. This was an open trial without a comparison and control condition. The sample size was small and predominately female. Furthermore, we followed these participants from enrollment to exit, with no long-term follow-up data. There was also a reliance on adolescent self-report measures and a lack of data obtained from parents. On the teen self-report satisfaction measure, we had 14 missing observations, so caution may be warranted; however, 67 teens did complete the satisfaction measure. Additionally, we did not collect information from participants regarding any external concurrent treatment. Future research should consider a randomized clinical trial to establish effectiveness of this community-based treatment.

In conclusion, the outcomes indicate that a culturally tailored adaptation of a suicide prevention program can be implemented successfully in a community-based setting. Given the rise in suicide rates and health disparities for specific populations, removing barriers to critical treatment access and adapting similar interventions for suicidal youth is critical. The primary focus of the program was to reduce the risk of suicide attempt and self-harm, and the reduction in risk for attempt and future NSSI outcomes are favorable. Further, irrespective of history of attempt, the outcomes related to depressive symptoms were similar at completion of the program.