ASsuRED, version 1
Research type
Research Study
Full title
Improving outcomes in patients who self-harm - Adapting and evaluating a brief pSychological inteRvention in Emergency Department (ASsuRED)
IRAS ID
257373
Contact name
Rosemarie McCabe
Contact email
Sponsor organisation
Devon Partnership NHS Trust
Duration of Study in the UK
1 years, 9 months, 0 days
Research summary
Research Summary
When someone who has harmed themselves is seen in the Emergency Department, a clinican/ 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 “me as a person” but “as a list of problems”.
The interaction between the individual with self-harm and the practitioner is critical in engaging them in treatment and helping them cope. Studies in other countries have shown that an approach which trains practitioners in brief psychological techniques, reduces subsequent self-harm and deaths by suicide. We will test if this approach can help people seen in the NHS.
Our study has 5 interconnected parts:
• We will hold 6 focus groups to get the views on this approach from practitioners, people with a history of harming themselves and carers (friends or relatives).
• 16 practitioners from 4 Emergency Departments will each use the approach with up to 6 patients
• We will develop training for practitioners
• We will access Emergency Department records to identify people with self-harm and their healthcare contacts.
• We will share our findings widely and explore whether the approach could be helpful in other settings.This is a project which is part of a larger programme grant. Hence, this project will also involve preparatory work for a future trial. A separate ethics application would be submitted for the future trial.
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.
Summary of Results
Background In the UK, around 6000 people take their own life each year. The risk of suicide is 100s of times greater among people who self-harm than among the general population, with 15-43% of people attending the Emergency Department (ED) with self-harm in the year before death. This presents a crucial opportunity for intervention. An appropriate brief intervention which changes routine meetings with patients in the ED could reach around 220,000 patient contacts each year in England. This study forms part of a National Institute for Health Research (NIHR) funded research programme. In this study, we sought to develop a brief intervention for patients presenting to EDs with self-harm and to pilot it in four EDs.
Methods
Work Package 1: Intervention development We conducted focus groups with patients, carers and practitioners to seek their feedback on a proposed intervention (1), based on the best available international evidence for self-harm interventions (2). With this feedback, we developed the Assured intervention (3).
Work Package 2: Pilot study
We conducted a feasibility study of the intervention for a future clinical trial. This intervention was tested in four EDs. Practitioners in liaison psychiatry teams were trained to deliver the intervention. Patients (16 years or over) presenting to an ED with self-harm, defined as an intentional act of self-poisoning or self-injury, irrespective of the motivation or apparent purpose of the act, or suicidal ideation were recruited. Exclusion criteria were admission to a psychiatric hospital, cognitive (e.g. dementia) or other psychiatric difficulties interfering with ability to participate, experiencing a psychotic episode, no capacity to provide written informed consent, needing an interpreter, Ministry of Justice patients subject to a restriction order and receiving intensive psychological input that precluded receiving another psychological intervention (e.g. Dialectical Behaviour Therapy). Participants were recruited and assigned to the intervention or Treatment As Usual (TAU) arm based on the allocation of the practitioner they were assessed by in the ED (i.e. whether they were trained to deliver the intervention or note).Patients undertook two research assessments: the first of which took place as soon as possible after their assessment in ED; and the other at 6 months follow-up thereafter. They also received monthly surveys over this period asking about self-harm episodes over the past month. Both patients and practitioners were also given the option to take part in an interview about their experiences of the intervention and taking part in the study – of which 27 of the former and 13 of the latter did.
Work Package 3: Developing a training package for practitioners and assessing treatment adherence We worked with Binary Vision to create a training package to train practitioners in the intervention. We developed methods to assess adherence to the intervention.
Work Package 4: Preparatory work with electronic databases to extract data from ED systems We explored the hospital record systems to pilot extracting the primary outcome: repeat self-harm presentations to hospital over 6-months.
Results
Work Package 1
The Assured intervention consisted of the following four components: 1) an enhanced ED assessment including a narrative interview (whereby the patient was invited to tell their story of what lead up to the crisis) and a safety plan co-produced by the patient and practitioner together; 2) a telephone check-in within 72 hours of leaving the ED; 3) up to three follow-up sessions over 8 weeks utilising a solution-focused approach; 4) and three personalised letters over the 7 months thereafter.Work Package 2
23/20 practitioners were recruited (of which 7 were allocated to usual care and 16 to the intervention); and 61/60 patients were recruited (of which 46 were allocated to the intervention and 15 to usual care). 80 patients were identified as eligible and approached to take part in the study. 19 were not consented (17 declined and 2 were excluded by the practitioner due to them requiring a long stay admission). We recruited 61 participants in total, 46 of whom were allocated to the intervention arm and 15 to Treatment As Usual.We demonstrated the feasibility of conducting a trial in the ED to test this brief intervention for self-harm, as we were successfully able to recruit and follow up participants. The first research assessment (after the assessment in ED) was completed for 87% of participants. The second research assessment (at 6-months follow-up) was completed for 66% of participants. Interviews revealed research procedures were generally acceptable to participants, who took part in the study with a wish to improve care for others in the future.
Participants generally found the intervention acceptable, describing how they felt supported by practitioners, with the narrative interview providing the patient with the opportunity to express themselves and build rapport, and the safety plan and solution focus approach helped to provide them with strategies for moving beyond the crisis and for managing future potential crises.Work Package 3
Treatment adherence was measured by the number of follow up sessions attended. Participants most often attended no follow-up sessions or all three sessions, so engagement in the intervention was an issue for some participants. We developed an observer rated fidelity scale, used to rate recorded intervention sessions. We found that practitioners delivered the intervention with an acceptable level of fidelity to the intervention manual.Work Package 4
We were able to extract primary outcome data – repeat attendance to ED for self-harm – for all participants.Conclusions
This study demonstrates the acceptability of the intervention that has been developed for the NHS context. It demonstrates the feasibility of conducting a full-scale evaluation of the Assured intervention in EDs, to assess the clinical and cost effectiveness of the intervention. If effective, this would provide a lifesaving intervention to patients at risk of suicide. This study identifies that a full-scale evaluation of the Assured intervention in EDs is warranted. This will be undertaken in Work Package 5 of the Assured programme.References
1. O’Keeffe S, Suzuki M, Ryan M, Hunter J, McCabe R. Experiences of care for self-harm in the Emergency Department: a comparison of the perspectives of patients, carers and practitioners. BJPsych Open. 2021;7(5):e175.
2. McCabe R, Garside R, Backhouse A, Xanthopoulou P. Effectiveness of brief psychological interventions for suicidal presentations: a systematic review. BMC Psychiatry. 2018 May 3;18(1):120.
3. Currie CC, Walburn J, Hackett K, McCabe R, Sniehotta FF, O’Keeffe S, et al. Intervention Development for Health Behavior Change: Integrating Evidence and the Perspectives of Users and Stakeholders. In: Reference Module in Neuroscience and Biobehavioral Psychology. Elsevier; 2021.REC name
London - Surrey Borders Research Ethics Committee
REC reference
19/LO/0778
Date of REC Opinion
29 Jul 2019
REC opinion
Further Information Favourable Opinion