Title: ASsuRED: Improving outcomes in patients who self-harm - Adapting and evaluating a brief pSychological inteRvention in Emergency Departments
Funder: Department of Health and Social Care

Abstract: This programme aims to reduce self-harm and thereby reduce the risk of suicide. Self-harm incurs high personal suffering, poor mental health, poor quality of life, high informal and formal support needs and generates high costs. Self-harm is also the most important predictor of suicide. We will adapt a brief psychological intervention for routine contacts in NHS Emergency Departments (EDs), train ED teams in the intervention and provide an Online training package for wider implementation. Each year, there are ~220,000 self-harm episodes in EDs in England. Most episodes involve self-poisoning. Evidence from Switzerland, the U.S. and low/middle-income countries shows that brief psychological interventions in EDs are effective in reducing self-harm and suicide. However, these countries have different health care systems. Thus, such an intervention needs to be adapted for and evaluated in the NHS. Most EDs have a psychiatric liaison team staffed by specialist mental health practitioners. These teams conduct psychosocial assessments with patients who self-harm but do not yet provide an evidence based intervention. We will train liaison teams in a brief psychological intervention to conduct (a) enhanced psychosocial assessment to better engage patients (b) individualised safety planning to improve self-management of future self-harm (c) follow-ups with patients after ED attendance to improve integration with the patient s formal and informal support system and support crisis resolution. The programme will consist of 6 work packages (WPs). A Lived Experience Advisory Panel (LEAP) of 10 patients will contribute throughout. WP1 will conduct 6 focus groups with practitioners, patients and significant others to adapt existing evidence-based intervention components and write an intervention manual. WP2 will further adapt the intervention and test the feasibility of the study design for a trial. 16 clinicians from 2 EDs will implement the intervention with ~6 patients each. There will be 3 cycles of intervention implementation, feedback and iteration. WP3 will develop a training module and Online training package to train staff in the intervention. WP4 will involve preparatory data extraction from different IT systems across EDs to identify self-harm episodes, other healthcare contacts and resource use. WP5 will evaluate the intervention in a cluster randomised controlled trial assessing the effectiveness and cost-effectiveness of the intervention compared to treatment as usual in reducing self-harm and improving secondary outcomes, i.e., the therapeutic relationship, suicidality, depression, hope, quality of life, secondary mental health care use, costs and suicide. ED liaison teams will be randomised. Teams in the experimental arm will be trained to deliver the intervention. The trial will include 11 EDs and 693 participants in each arm. To ensure maximum impact, we will explore whether the intervention could be adapted for other settings and share findings with patients, practitioners, commissioners, academics and professional training bodies (WP6). We will run a workshop with the Zero Suicide Collaborative. If effective, the intervention will improve mental health and quality of life for people who self-harm and also benefit families, practitioners, the NHS and society: this programme of work would also avoid ~80 self-harm episodes (saving &pound;65,000) and could save 16 lives.

Lay abstract: The approach tested in this study has the potential to reduce the risk of suicide in the UK, which causes the death of about 6000 people every year. Self-harm is the most important risk factor for suicide. It occurs when someone deliberately poisons or injures themselves, often as a way of coping with difficult emotions, traumatic experiences and suicidal feelings. Accident and emergency departments in England manage about 220,000 self-harm contacts per year. 1-3% people attending the Emergency Department who harm themselves take their own life the following year. When someone who has harmed themselves is seen in the Emergency Department, a mental health practitioner (MHP) usually assesses their psychological state, social situation and needs for support. Although there are many examples of good care, the current approach is not evidence based. People often say that the assessment does not focus on &ldquo;me as a person&rdquo; but &ldquo;as a list of problems&rdquo;. The interaction between the individual with self-harm and the MHP is critical in engaging them in treatment and helping them cope. Studies in other countries have shown that an approach which trains MHPs in brief psychological techniques, in how to work with the person to create a personal plan for future crises and how to make contact with them after they leave the Emergency Department reduces subsequent self-harm and deaths by suicide. We will test if this approach can help people seen in the NHS. Our study has 6 interconnected parts: We will hold 6 focus groups to get the views on this approach from MHPs, people with a history of harming themselves and friends or relatives, adapting the approach accordingly. Initially, 16 MHPs from 4 Emergency Departments will each use it with up to 6 patients >16 years, with ongoing improvement and refinement of the approach. We will develop training for MHPs, including an interactive website and training videos. We will access Emergency Department computer records to accurately identify people with self-harm and their healthcare contacts. We will conduct a national study with 22 Emergency Departments and 1386 patients. All patients will continue with their normal care. In addition, half will receive the new approach and half will not. After 18 months, we will compare whether those receiving the new approach have less self-harm and better mental health and quality of life than those without the approach. We will share our findings widely, including with members of the South West Zero Suicide Collaborative, and explore whether the approach could be helpful in other settings. If effective, this new approach will improve the mental health of people who harm themselves, reduce their need for healthcare services and Emergency Department attendance, saving money and, most importantly, saving lives.

Research activity codes: 6.6 PSYCHOLOGICAL AND BEHAVIOURAL
Health categories: MENTAL HEALTH