‘Wasn’t offered one, too poorly to ask for one’ – Reasons why some patients do not receive a psychosocial assessment following self-harm: Qualitative patient and carer survey

Global prevalence of psychosocial assessment following hospital-treated self-harm: systematic review and meta-analysis

BACKGROUND

Hospital-treated self-harm is common, costly and associated with repeated self-harm and suicide. Providing a comprehensive psychosocial assessment following self-harm is recommended by professional bodies and may improve outcomes.

AIMS

To review the provision of psychosocial assessments after hospital-presenting self-harm and the extent to which macro-level factors indicative of service provision explain variability in these estimates.

METHOD

We searched five electronic databases to 3 January 2023 for studies reporting data on the proportion of patients and/or events that were provided a psychosocial assessment. Pooled weighted prevalence estimates were calculated with the random-effects model. Random-effects meta-regression was used to investigate between-study variability.

RESULTS

119 publications (69 unique samples) were included. Across ages, two-thirds of patients had a psychosocial assessment (0.67, 95% CI 0.58-0.76). The proportion was higher for young people and older adults (0.75, 95% CI 0.36-0.99 and 0.83, 95% CI 0.48-1.00, respectively) compared with adults (0.64, 95% CI 0.54-0.73). For events, around half of all presentations had these assessments across the age range. No macro-level factor explained between-study heterogeneity.

CONCLUSIONS

There is room for improvement in the universal provision of psychosocial assessments for self-harm. This represents a missed opportunity to review and tailor aftercare supports for those at risk. Given the marked unexplained heterogeneity between studies, the person- and system-level factors that influence provision of psychosocial assessments after self-harm should be studied further.

Social services utilisation and referrals after seeking help from health services for self-harm: a systematic review and narrative synthesis

Objectives

Suicide prevention is a major public health challenge. Appropriate aftercare for self-harm is vital due to increased risks of suicide following self-harm. Many antecedents to self-harm involve social factors and there is strong rationale for social services-based self-harm aftercare. We aimed to review evidence for social service utilisation and referrals among people seeking help following self-harm.

Design

Systematic review with narrative synthesis.

Data sources

PubMed, PsycINFO, AMED, Social Policy and Practice, EMBASE, Medline, Web of Science, Social Care Online, citation lists of included articles and grey literature.

Eligibility criteria

Studies of people of any age in contact with health services following self-harm, with study outcomes including referrals to or utilisation of social workers and social services.

Data extraction and synthesis

Information was extracted from each included study using a proforma and quality was critically assessed by two reviewers. Narrative synthesis was used to review the evidence.

Results

From a total of 3414 studies retrieved, 10 reports of 7 studies were included. Study quality was generally high to moderate. All studies were based in emergency departments (EDs) and most were UK based. In studies based solely on ED data, low proportions were referred to social services (in most studies, 1%-4%, though it was up to 44% when social workers were involved in ED assessments). In one study using linked data, 15% (62/427) were referred to social services and 21% (466/2,205) attended social services over the subsequent 3-year period.

Conclusions

Overall, few patients were referred to social services after self-harm. Higher reported referral rates may reflect greater service availability, involvement of social workers in psychosocial assessments or better capture of referral activity. Social services-based and integrated approaches for self-harm aftercare are important future directions for suicide prevention. Improved links between social services and health services for people seeking support after self-harm are recommended.

Examining the Feasibility of Implementing Digital Mental Health Innovations Into Hospitals to Support Youth in Suicide Crisis: Interview Study With Young People and Health Professionals

BACKGROUND

Hospitals are insufficiently resourced to appropriately support young people who present with suicidal crises. Digital mental health innovations have the potential to provide cost-effective models of care to address this service gap and improve care experiences for young people. However, little is currently known about whether digital innovations are feasible to integrate into complex hospital settings or how they should be introduced for sustainability.

OBJECTIVE

This qualitative study explored the potential benefits, barriers, and collective action required for integrating digital therapeutics for the management of suicidal distress in youth into routine hospital practice. Addressing these knowledge gaps is a critical first step in designing digital innovations and implementation strategies that enable uptake and integration.

METHODS

We conducted a series of semistructured interviews with young people who had presented to an Australian hospital for a suicide crisis in the previous 12 months and hospital staff who interacted with these young people. Participants were recruited from the community nationally via social media advertisements on the web. Interviews were conducted individually, and participants were reimbursed for their time. Using the Normalization Process Theory framework, we developed an interview guide to clarify the processes and conditions that influence whether and how an innovation becomes part of routine practice in complex health systems.

RESULTS

Analysis of 29 interviews (n=17, 59% young people and n=12, 41% hospital staff) yielded 4 themes that were mapped onto 3 Normalization Process Theory constructs related to coherence building, cognitive participation, and collective action. Overall, digital innovations were seen as a beneficial complement to but not a substitute for in-person clinical services. The timing of delivery was important, with the agreement that digital therapeutics could be provided to patients while they were waiting to be assessed or shortly before discharge. Staff training to increase digital literacy was considered key to implementation, but there were mixed views on the level of staff assistance needed to support young people in engaging with digital innovations. Improving access to technological devices and internet connectivity, increasing staff motivation to facilitate the use of the digital therapeutic, and allowing patients autonomy over the use of the digital therapeutic were identified as other factors critical to integration.

CONCLUSIONS

Integrating digital innovations into current models of patient care for young people presenting to hospital in acute suicide crises is challenging because of several existing resource, logistical, and technical barriers. Scoping the appropriateness of new innovations with relevant key stakeholders as early as possible in the development process should be prioritized as the best opportunity to preemptively identify and address barriers to implementation.

New guidance for self-harm: an opportunity not to be missed

In this editorial we, as members of the 2022 NICE Guideline Committee, highlight and discuss what, in our view, are the key guideline recommendations (generated through evidence synthesis and consensus) for mental health professionals when caring for people after self-harm, and we consider some of the implementation challenges.

Liaison psychiatry practitioners' views on accessing aftercare and psychological therapies for patients who present to hospital following self-harm: multi-site interview study

BACKGROUND

Timely provision of aftercare following self-harm may reduce risks of repetition and premature death, but existing services are frequently reported as being inadequate.

AIMS

To explore barriers and facilitators to accessing aftercare and psychological therapies for patients presenting to hospital following self-harm, from the perspective of liaison psychiatry practitioners.

METHOD

Between March 2019 and December 2020, we interviewed 51 staff members across 32 liaison psychiatry services in England. We used thematic analyses to interpret the interview data.

RESULTS

Barriers to accessing services may heighten risk of further self-harm for patients and burnout for staff. Barriers included: perceived risk, exclusionary thresholds, long waiting times, siloed working and bureaucracy. Strategies to increase access to aftercare included: (a) improving assessments and care plans via input from skilled staff working in multidisciplinary teams (e.g. including social workers and clinical psychologists); (b) supporting staff to focus on assessments as therapeutic intervention; (c) probing boundaries and involving senior staff to negotiate risk and advocate for patients; and (d) building relationships and integration across services.

CONCLUSIONS

Our findings highlight practitioners' views on barriers to accessing aftercare and strategies to circumvent some of these impediments. Provision of aftercare and psychological therapies as part of the liaison psychiatry service were deemed as an essential mechanism for optimising patient safety and experience and staff well-being. To close treatment gaps and reduce inequalities, it is important to work closely with staff and patients, learn from experiences of good practice and implement change more widely across services.

Achieving Behavioural Advancement through the Dynamic Maturation Model and the Assessment of Parent–Child Interactions in a Music Therapy Context

Using concise and valid assessment tools before embarking on therapy with clients not only provides key information on areas of concern, but it can also focus the ongoing therapy, giving a greater chance of positive outcomes. This article discusses the use of the Dynamic Maturational Model (DMM) and the Assessment of Parent–Child Interactions (APCI) as a framework for assessment with adoptive families in a music therapy service. It is proposed that using a Screening Family Formulation (SFF) as detailed through the DMM alongside the APCI can provide this secure foundation for assessment. It is proposed that the DMM promotes the use of the professional–parent relationships as a useful outline for the parent–child relationship alongside a thorough understanding of the issues faced by the family. In addition, the APCI enhances the assessment process by providing clinical and therapeutic evidence of areas of development for the family.

Experiences of care for self-harm in the emergency department: the perspectives of patients, carers and practitioners

Emergency departments are often the point of entry to the healthcare system for people who self-harm, and these individuals are at high risk of further self-harm and suicide in the post-discharge period. These settings therefore provide a critical opportunity for intervention. However, many studies have identified that the experiences of patients, carers and the emergency department staff themselves is often suboptimal. In this editorial we summarise one such study, by O'Keeffe and colleagues, and consider strategies for improving the experiences of patients and their carers when presenting to the emergency department. We also reiterate the need for wider systemic change in attitudes and approaches towards people who self-harm that are pervasive across the healthcare system and beyond.