Conference Agenda
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PS23: Clinical and Emergency Care for Self-Harm
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Umbrella review of psychosocial and ward-based interventions to reduce self-harm and suicide risks in inpatient mental health settings 1: National Institute for Health and Care Research (NIHR GM PSRC) Greater Manchester Patient Safety Research Collaboration, University of Manchester, UK; 2: School of Medicine, Keele University, Keele, UK Background: Understanding what psychosocial interventions can reduce self-harm and suicide within in-patient mental health settings can be challenging, due to clinical demands and the large volume of published reviews. Aims: To summarise evidence from systematic reviews on psychosocial and ward-level interventions (excluding environmental modifications) for self-harm and suicide that may enhance patient safety in in-patient mental health settings. Method: We systematically searched Medline, Embase, CINAHL, PsycINFO and CDSR (2013-2023) for systematic reviews on self-harm and suicide prevention interventions that included in-patient data. Review quality was assessed using AMSTAR-2, primary study overlap via an evidence matrix, and evidence strength evaluated (GRADE algorithm). Findings were narratively synthesised, with input from experts-by-experience throughout (PROSPERO ID: CRD42023442639). Results: Thirteen systematic reviews (seven meta-analyses, six narrative), comprising over 160 000 participants, were identified. Based on quantitative reviews, cognitive-behavioural therapy reduces repeat self-harm by follow-up, and dialectical behaviour therapy decreases the frequency of self-harm. Narrative review evidence suggested that post-discharge follow-up, as well as system and ward-based interventions (e.g. staff training) may reduce suicide and/or self-harm. However, review quality varied, patient involvement was lacking and methodological quality of trials informing reviews was predominately low. Overlap was slight (covered area 12.4%). Conclusions: The effectiveness of interventions to prevent self-harm and suicide in in-patient settings remains uncertain due to variable quality reviews, evidence gaps, poor methodological quality of primary studies and a lack of pragmatic trials and co-production. There is an urgent need for better, co-designed research within in-patient mental health settings. Findings from an RCT of a brief solution-focused psychological intervention for self-harming adolescents (and their carers) presenting to Emergency Departments in England City St George’s, University of London, United Kingdom Suicide is a leading cause of death in children and young people (CYP) globally and the strongest predictor is self-harm. Visits to the Emergency Department (ED) are associated with a higher risk of repeat self-harm and suicide. Supporting CYP after presentation at ED offers a unique opportunity to intervene to prevent self-harm becoming entrenched, however effective interventions are lacking. Evidence in adults and a non-randomised study in CYP suggest promising results for Therapeutic Assessment (TA) and Safety Planning (SP) with rapid follow-up in reducing self-harm and increasing engagement with care after ED attendance. Solution-focused (SF) therapy is a brief, strengths-based approach with promising results in other settings but achieved in fewer sessions. Methods: We designed the SASH approach with input from CYP with lived experience and clinicians. SASH is a brief psychological intervention for CYP and their carers including TA, SP, SF follow-ups and letters, delivered by CAMHS practitioners within 1-2 weeks of young people presenting at the ED. We evaluated its clinical and cost-effectiveness at 6-month follow-up in addition to Treatment As Usual (TAU) care in a randomised controlled trial (RCT) across three public health care organisations in London, England, compared with TAU only. CYP self-reported self-harm in the past month at 6-month follow-up is the primary outcome; secondary outcomes include symptoms of depression and anxiety, repeat ED attendance, school attendance and wellbeing. Results and Discussion: We will report on the development and evaluation of SASH with 154 participants who presented to the ED with self-harm or suicidal thoughts (with recent self-harm). Along with the quantitative findings of the trial, we will present experiences of receiving and delivering the intervention from young person, carer and practitioner perspectives gathered as part of the qualitative process evaluation. Conclusion: We will discuss possibilities and next steps for implementation in CYP crisis services. Do hospital referrals for admission in patients with recurrent mental health crises reduce risk of self-harm? A nationwide trial emulation using Norwegian registry data 1: NTNU, Norway; 2: UCL, UK Introduction Evaluations of whether hospital admission benefits patients in mental health crisis are hampered by the potential for confounding by indication. Robust research designs are therefore essential to isolate the effect of crisis referrals for hospital admission and of different types of admission on subsequent risk of self-harm among people experiencing recurrent crises. Methods Analysing Norwegian registry data for 72,328 patients with recurrent acute mental health crises presenting to out-of-hours primary care services, we emulated a pragmatic cross-over target trial using within-patient Poisson regression and instrumental variable analysis comparing i) self-harm and ii) specialist healthcare use within 30 days following presentation for patients referred to the acute hospital (versus primary care management). We also compared outcomes for those admitted by type of admission: 1) somatic, 2) voluntary psychiatric, or 3) involuntary psychiatric. Results Acute hospital referral occurred in 27% of out-of-hours primary care contacts, but such referrals were not clearly associated with a reduced risk of subsequent self-harm. Referral to any hospital contact was associated with a slightly increased risk of confirmed self-harm (Relative risk (RR) 1.05, 95% confidence interval (CI) 1.00–1.11). Patients referred to general medical services had a slight increased risk of confirmed self-harm (relative risk (RR) 1.06, 95% CI: 0.92–1.23), while psychiatric referrals showed no substantial protective effect, whether voluntary (RR 1.03, 95% CI: 0.97–1.10) or involuntary (RR 1.07, 95% CI: 1.01–1.15). Hospital care did not appear to change planned follow-up from outpatient treatment or general practitioners. Instrumental variable analyses supported the primary findings. Conclusions This study, which reduced the influence of confounding by indication, and focussed on patients who experience recurrent mental health crises, did not provide evidence to support referral of these patients for hospital admission when in acute mental health crisis. Further work is needed to be better understand more appropriate care plans. Barriers and facilitators for improving suicide prevention at emergency departments in the Netherlands using a network approach. A mixed methods study 1: 113 Suicide Prevention, the Netherlands; 2: Haaglanden Medisch Centrum, the Hague, the Netherlands; 3: Ikazia hospital, Rotterdam, the Netherlands Background: High quality care at an ED after a suicide attempt, e.g. kindly engaging with patients, involving next of kin, ensuring patient safety and arranging adequate follow-up care, can help prevent new attempts. A multi-component intervention to improve patient care at EDs after a suicide attempt was rolled out in a network of 25 hospitals with support from the national suicide prevention organization (113). This study aimed to identify barriers and facilitators to implement suicide prevention activities at emergency departments (ED) in the Netherlands. Methods: This mixed-methods study combined interview data from 16 hospital contact persons on barriers and facilitators for implementing suicide prevention activities with questionnaire data (n=741) of hospital staff about their needs, perspectives and experiences with implementing these activities. Interviews were transcribed and analyzed with thematic analysis. Results: The interviews showed that successful implementation was supported by structured implementation plans, sufficient resources, active project champions, cross-departmental collaboration, integration of activities within existing structures, and strong management support. In addition, providing hospitals flexibility to design their own implementation plans, increased their sense of ownership and ensured plans were aligned with the local context. Key barriers included high work pressure, staff turnover, and difficulties in establishing effective care collaborations. According to staff the main needs to implement suicide prevention activities were sufficient time, training and clear protocols. Discussion: The multi-component intervention enabled hospitals to implement suicide prevention activities. Although raising awareness and training staff was feasible, structurally embedding suicide prevention activities and arranging preconditions such as sufficient time and referral options remained challenging. LONGITUDINAL INVESTIGATION OF SUICIDAL DEATHS IN PATIENTS PREVIOUSLY PRESENTING WITH SUICIDALITY IN THE EMERGENCY ROOM, 2002-2023 1: UPC KU Leuven, Belgium; 2: UZ Leuven, Belgium Background Methods Results Conclusions | ||