Caring Contacts and Suicidality Among American Indian and Alaska Native Communities

Importance: For American Indian and Alaska Native communities, connectedness and belonging are strengths that may reduce suicide risk. Objective: To evaluate the effectiveness of culturally-adapted Caring Contacts combined with optimal available resources (intervention) compared with optimal available resources alone (control) in reducing suicidal ideation, suicide attempts, and suicide-related hospitalizations. Design, Setting, and Participants: The CARE study was a blinded, 2-group randomized clinical trial conducted between May 2018 and September 2023 among 5 American Indian and Alaska Native communities in Alaska, the Northern Plains, and the Southern Plains, including 4 tribal communities and 1 tribal health organization. Participants were English-speaking adults (age ≥18 years) self-identifying as American Indian or Alaska Native with active suicidality. Analysis was conducted January through April 2024. Intervention: Caring Contacts is a low-cost intervention via brief, nondemanding messages exclusively focused on expressing care and interest sent by text message or greeting card on a pre-determined schedule over 12 months. Main Outcomes and Measures: Outcomes included suicidal ideation in the past month (measured using the Suicidal Ideation Questionnaire-Junior [SIQ-Jr]), number of suicide attempts, and suicide-related hospitalizations over 12 months. Retention of active suicidality at follow-up was added as an additional outcome. Results: Of 1390 individuals prescreened for eligibility, 1202 consented and were screened for eligibility, and 709 (457 [64.5%] female; mean [SD] age, 35.4 [11.5] years) were enrolled and randomized, including 357 participants in the control group and 352 participants in the Caring Contacts intervention. Most participants (549 [77.4%]) self-identified as American Indian or Alaska Native only, and 160 participants (22.6%) as American Indian or Alaska Native plus another racial group. More than half of participants (392 [55.3%]) were never married. The mean (SD) SIQ-Jr score at baseline was 42.0 (13.8), and 604 participants (85.2%) had ever made a suicide attempt. Overall, 454 participants (64.0%) provided 12-month follow-up data. Between baseline and the 12-month follow-up, both groups showed significant reductions in suicidal ideation (mean [SD] score: Caring Contacts, 41.4 [13.7] vs 22.7 [15.3]; enhanced usual care, 42.5 [13.9] vs 23.1 [14.5]) and participants with a past-year suicide attempt (Caring Contacts, 169 of 352 participants [48.0%] vs 34/240 participants [14.2%]; enhanced usual care 155 of 357 participants [43.4%] vs 39 of 238 participants [16.4%]); however, no statistically significant between-group differences were found. Conclusions and Relevance: In this randomized clinical trial of culturally adapted Caring Contacts among American Indian or Alaska Native adults with active suicidality, Caring Contacts did not improve suicidal outcomes beyond optimal available resources alone. Similar improvements in both groups may reflect regression to the mean, the therapeutic impact of compassionate baseline engagement with supportive community staff, or the active components of optimal available resources. Further research should explore these dynamics and other culturally grounded interventions. Trial Registration: ClinicalTrials.gov Identifier: NCT02825771.