Adapting a Telehealth Intervention for Suicide Prevention Among Patients With Alcohol Use Disorder in Tanzania

Globally, alcohol use disorders (AUD) cause 3.3 million deaths each year and account for nearly 100 million disability-adjusted life years (DALYs). Alcohol use is also one of the most prominent risk factors for death by suicide, as people with AUD have a lifetime risk of suicide more than 7 times higher than the general population. In preliminary studies at Kilimanjaro Christian Medical Centre (KCMC) in Tanzania, 7% of patients with AUD met criteria for comorbid depression, 7% were experiencing suicidal thoughts or behavior, and nearly half reported challenges in social support. Unfortunately, Tanzania is also among the most underserved nations in the world for mental health treatment, with fewer than 1 psychologist or psychiatrist per 1 million people and very little capacity to intervene for suicide risk or AUD. Given this shortage in treatment, there is a critical need for innovative, resource-efficient treatments for suicide prevention among people with AUD. In Tanzania, 91% of the population owns a cellular phone and nearly 50% use mobile internet, yet telehealth interventions have been largely unexplored, representing a major missed opportunity for delivering evidence-based interventions. By adapting an evidence-based Motivational Interviewing intervention, MI-SafeCope, the team developed IDEAS for Hope, a telehealth intervention for suicide prevention in HIV care in Tanzania. In the current grant, the researchers propose to revisit this process by adapting MI-SafeCope, with lessons learned from the HIV study, to reduce suicide risk among people with AUD who are presenting for care in the KCMC Emergency Department (ED). The resulting intervention, IDEAS-AUD, will address suicide risk with a four-pillared approach: reducing alcohol-related harm, building social support, enhancing emotional health, and addressing social determinants of health. The pillars are integrated with Motivational Interviewing-enhanced safety planning and referral for local psychiatric care as appropriate. The long-term goal is to create evidence-based, accessible, and cost-effective treatments for mental health and substance use treatment in low-resource settings. The objectives of this proposal are to: 1) adapt IDEAS-AUD for the AUD population in Kilimanjaro, Tanzania; 2) rigorously evaluate the acceptability and feasibility of IDEAS-AUD; and 3) develop the intervention package, along with a trialability evaluation, for a future implementation evaluation and clinical trial. In Aim 1 of the current study, the researchers will identify drivers of suicide risk and desired intervention characteristics to prevent suicide in the AUD population at KCMC. In Aim 2, the study team will adapt an evidence-based suicide prevention intervention to existing AUD care, guided by a community coalition. In Aim 3, the investigators will pilot test the telehealth intervention to assess its feasibility and acceptability for reducing suicide risk in the KCMC AUD population. By the end of this proposed project, the researchers will have a framework-guided, culturally- and resource-adapted, piloted protocol for IDEAS-AUD, including screening tools, programmatic, and implementation components.

• IDEAS-AUD (Behavioral): Telehealth-delivered counseling to reduce suicide risk among people with Alcohol Use Disorder (AUD) who are presenting for care in the KCMC Emergency Department (ED).

Primary outcomes

• Acceptability of intervention [3 months]: Acceptability of Intervention Measure (AIM). Four items scored from 1-Completely disagree to 5-Completely agree. Scores are summed for a total score of 4 to 20, with higher scores indicating greater acceptability.
• Enrollment feasibility as measured by the percentage of ED patients with documented screening for study eligibility [up to 1 year]
• Enrollment feasibility as measured by the number of eligible participants who declined enrollment [up to 1 year]
• Enrollment feasibility as measured by the time needed to enroll 30 eligible participants [up to 1 year]
• Retention feasibility as measured by the number of participants retained for follow-up [session 2 (2 weeks), session 3 (4 weeks), and 3 months]

Sex: All, ages: 18 Years to any

Inclusion Criteria:

* 18 years of age or older
* screen positive for alcohol use disorder (AUDIT >=8)
* have had suicidal thinking (C-SSRS item indicating "actual thoughts of suicide") in last 30 days
* clinically sober
* medically stable
* have the physical and cognitive capacity to provide consent and complete study procedures
* able to communicate in Swahili or English

Exclusion Criteria:

* prisoners
* decline or unable to complete informed consent

• Brandon Knettel, PhD, Principal investigator, Duke University