ASsuRED: Improving outcomes in patients who self-harm - Adapting and evaluating a brief pSychological inteRvention in Emergency Departments

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 £65,000) and could save 16 lives.