Stratified Care Intervention for Suicidal Ideation, Depression, and Non-Suicidal Self-Injury in Adolescents (Reframe-IT+ & CARIBOU)

This is a quasi-experimental study without a control group, using a pre-post design with follow-up assessments at 3, 6, 9, and 12 months post-intervention. The study targets 10th, 11th, and 12th-grade students attending secondary schools with high socioeconomic vulnerability (≥50% on the School Vulnerability Index, IVE-SINAE) in the Metropolitan Region of Chile.

The intervention comprises two sequential components. First, all eligible students with suicidal ideation (C-SSRS score ≥3) receive CARIBOU-SITB, a four-session individual intervention based on dialectical behavior therapy and motivational interviewing, focused on safety planning and reducing the risk of self-harm. Following this component, students are stratified according to their depressive symptom severity on the PHQ-9: those with mild or moderate symptoms (PHQ-9 <20) are offered Reframe-IT+, a 13-session individual cognitive-behavioral intervention combining in-person and digital delivery; those with severe symptoms (PHQ-9 ≥20) are offered CARIBOU-CBT, a 16-session individual cognitive-behavioral intervention. Both programs are delivered at the schools by trained psychologists and target behavioral activation, cognitive restructuring, emotional regulation, and problem-solving skills, with CARIBOU-CBT additionally addressing communication skills.

The study is conducted in two phases. A preparatory phase includes translation and cultural adaptation of the CARIBOU-SITB manual, preparation of intervention and assessment materials, facilitator training, and development of protocols for managing critical risk situations. An implementation phase follows, encompassing school recruitment, parental informed consent, student screening and informed consent/assent, invitation interviews to confirm eligibility, program delivery, and post-intervention and follow-up assessments.

Primary outcomes includes the feasibility of implementing the stratified care plan (recruitment, attendance, response, and retention rates), the fidelity of implementation by facilitators (self-reported adherence to session protocols), and the acceptability of the CARIBOU-SITB component (assessed via acceptability questionnaires and the Client Satisfaction Questionnaire, CSQ-8). Secondary outcomes explore the preliminary efficacy of the interventions in reducing suicidal ideation (C-SSRS, SIQ-JR), non-suicidal self-injury, depressive symptoms (PHQ-9), anxiety (GAD-7), and hopelessness (BHS), as well as their efficacy in improving general functioning, quality of life, and cognitive-behavioral skills related to behavioral activation, emotional regulation, and problem-solving, assessed immediately post-intervention and at 3, 6, 9, and 12 months.

Inclusion criteria

• Schools

• Located in Santiago, Chile
• Secondary school (1st through 4th year of secondary school)
• At least two classes per grade level
• At least 30 students per class
• High vulnerability index (≥50%) as measured by the School Vulnerability Index - National Allocation System for Equality (IVE-SINAE)
• Students

• Students in grades 9, 10, and 11
• Suicidal ideation reported in the past month, defined as a score ≥3 on the Columbia Suicide Severity Rating Scale (C-SSRS)
• For the Reframe-IT+ Program: mild or moderate depressive symptoms, defined as a score <20 on the PHQ-9
• For the CARIBOU-CBT Program: severe depressive symptoms, defined as a score ≥20 on the PHQ-9

Exclusion criteria

• Participation in a manualized suicide prevention program (Reframe-IT+/CARIBOU) in 2025
• Severe psychotic symptoms, defined as clear perceptual disturbances and delusions identified during the invitation interview
• Suicide attempt(s) in the past 3 months, or active suicidal ideation requiring hospitalization, as determined during the screening interview
• History of a prior medical diagnosis of Bipolar Disorder I or II
• History of a prior medical diagnosis of a Severe Eating Disorder (e.g., Anorexia Nervosa or Bulimia)
• Severe substance use disorder, meeting any of the following patterns: daily cannabis use throughout the day; excessive alcohol or benzodiazepine use ≥3 times per week; cocaine or opioid use several days per month or more, as determined during the screening interview
• Intellectual disability
• Inability to speak, read, or write in Spanish