Safety Planning vs Standard Care for Suicide Prevention After Pretrial Jail Detention: A Randomized Clinical Trial.

Importance: In the US, 1 in 5 adult suicide decedents has spent at least 1 night in jail in the year prior to death. Objective: To evaluate the effectiveness of the Safety Planning Intervention (SPI) with telephone follow-up as an adjunct to enhanced standard care (ESC) compared with ESC alone for reducing suicide events in the 12 months following release from pretrial jail detention. Design, Setting, and Participants: This randomized clinical trial included individuals with past 30-day suicide risk (suicide ideation with intent and/or suicide attempt) in pretrial jail detention who were recruited from 2 jails from May 11, 2016, to November 13, 2018, with a 12-month follow-up after release. Data analysis was completed from April 2023 to May 2025. Interventions: All participants received ESC. The SPI included a safety planning session in jail followed by 4 to 8 telephone calls 6 months after jail release. Main Outcomes and Measures: The primary outcome was the number of suicide events (a composite of suicide attempts and behaviors, suicide-related hospitalizations, and suicide deaths). Secondary outcomes included the number of suicide attempts, weeks and severity of active suicidal ideation, time to first suicide event, psychiatric symptoms, functioning, and hypothesized mediators. Suicidal ideation and behaviors were assessed using the Columbia-Suicide Severity Rating Scale, the Longitudinal Interval Follow-Up Evaluation, and record reviews from area hospitals. Deaths were identified through hospital, state, and national death records. Hospitalizations were measured with the Treatment History Interview and hospital records. Results: Of 800 participants randomized in jail, 655 (mean [SD] age, 33.0 [10.4] years; 473 males [72%]) were released to the community and included in analyses. Of those, 593 (91%) completed at least 1 follow-up interview. Medical records were available for all 655 participants (100%). Per person-year of follow-up over 12 months, those in the SPI group compared with those in the ESC group had 42% fewer suicide events (mean [SE], 1.82 [0.18] vs 3.11 [0.32]; mean [SE] difference, -1.30 [0.37]; P < .001), 55% fewer suicide attempts (mean [SE], 1.06 [0.14] vs 2.35 [0.33]; mean [SE] difference, -1.33 [0.38]; P < .001). Differences in weeks of suicidal ideation were not statistically significant (mean [SE], 10.39 [0.78] vs 12.86 [1.02]; mean [SE] difference, -2.47 [1.28]; P = .06). There were no other observed differences in outcomes. Conclusions and Relevance: In this randomized clinical trial of the SPI compared with ESC, those in the SPI group experienced reduced suicide risk by 42% in the year after jail release. These results suggest that SPI is effective for reducing suicide risk during this high-risk period. Trial Registration: ClinicalTrials.gov Identifier: NCT02759172.