Alexandra Elissavet Bakou

Conducting mental health trials in busy EDs presents challenges, including record demand, bed shortages, 4-hour targets from arrival to discharge or admission, and staff shortages. This essay reflects on real-world challenges in a mental health trial involving people presenting to the ED with self-harm and/or suicidal thoughts and outlines lessons learned for future studies. No quantitative data will be reported. ASSURED is a randomised controlled clinical trial investigating the effectiveness of a brief psychological intervention for adults attending the ED with self-harm and/or suicidal thoughts. The original aims were to improve psychosocial assessments conducted by liaison psychiatry practitioners and to have the same practitioner deliver the intervention after discharge ensuring relational continuity. We worked with people with lived experience to address engagement challenges during mental health crises. 620 people across 14 EDs in England were recruited between 2022–2024. Although liaison psychiatry practitioners were trained to deliver the intervention, recruiting participants in crisis was difficult due to 4-hour targets and limited mental health research nurses. Delivering follow-up care post-discharge was challenging, as practitioners prioritised urgent assessments over delivering the follow-up intervention. However, it was feasible for researchers to recruit people within 1–2 weeks of ED attendance and for other mental health professionals to deliver the intervention. Flexibility in time and mode of delivery was paramount in participant engagement, which was mostly not achievable within liaison psychiatry roles. As many patients reattended the ED, experienced suicidal ideation or harmed themselves, supporting local clinical Principal Investigators to complete time-consuming paperwork in relation to these Serious/Adverse Events was helpful. ED liaison psychiatry teams face significant barriers to trial participation compared to other settings. Brief psychological interventions after ED attendance were more feasibly delivered by other practitioners such as assistant psychologists, and lived-experience advisors were central to ensuring sensitive engagement, approach and follow-up in research. Clinical Trial Number ISRCTN 13472559, Registered on 18 of November 2021.

Background: Patients with self-harm and suicidal ideation are increasingly presenting in emergency departments (ED) in the UK. Self-harm is the strongest risk factor for suicide. Currently, there are no evidence-based interventions for self-harm offered in the context of general hospitals in the UK. This trial, funded by the National Institute for Health and Care Excellence (NIHR), aims to assess the clinical and cost-effectiveness of the ASSURED intervention. The ASSURED intervention includes up to five rapid follow-up contacts, comprising a narrative interview and enhanced safety planning session and three solution-focused sessions. The trial is sponsored by Devon Partnership NHS Trust and City St George’s, University of London. Methods: ASSURED is a multicentre, two-arm, parallel-group, individually randomised, controlled trial comparing the ASSURED intervention with usual care. The primary outcome is whether study participants re-attend ED and are referred to liaison psychiatry within 18 months from the date of randomisation. Secondary outcomes include suicidality, self-reported self-harm, psychological wellbeing, social outcomes, experiences of attending the ED, and suicide. The study will also evaluate the cost-effectiveness of the intervention. The aim of this study was to recruit and randomise 620 patients across 14 acute hospital sites in London, Devon, Somerset, and the Midlands. Participants are invited to complete research assessments at baseline and 3, 9, and 18 months. The first participant was enrolled in the study in August 2022, and the recruitment target was met in December 2024. Discussion: This will be the first UK trial to test the effectiveness and cost-effectiveness of a rapid intervention for patients presenting to EDs with self-harm and suicidal ideation and has the potential to improve outcomes for these patients. Trial registration: ISRCTN 13472559. Registered on 18 of November 2021.

In this chapter, researchers and practitioners reflect on running two research studies, which are evaluating brief, Solution Focused (SF) interventions in NHS mental health crisis care for young people and adults presenting to Emergency Departments with self-harm and suicidality. Working in an SF way is a considerable paradigm shift for some of the practitioners, and we discuss how we have trained and supervised existing NHS staff across professional groups to have SF conversations while working within NHS systems of care and in the context of risk management. Three case studies illustrate how SF conversations can support people in crisis to identify their strengths and cope with setbacks. We are not necessarily implementing the purest version of Solution Focused Practice (SFP) as training is brief due to the demands on services. However, even this brief training in SFP is well-received by and rewarding for practitioners. Some practitioners have described it as a more playful way of working with young people. Given that practitioners are enjoying their work, it is perhaps not surprising that people presenting in mental health crises – who often have negative experiences of care – feel supported in a validating, empowering and hopeful way.

Objectives: Mindfulness therapy improves drinking outcomes arguably by attenuating negative mood–induced drinking, but this mechanism has not been demonstrated in hazardous community drinkers. To address this, three studies tested whether a key ingredient of mindfulness, breath counting, would attenuate the increase in motivation for alcohol produced by experimentally induced negative mood, in hazardous community drinkers. Method: In three studies, hazardous community drinkers were randomized to receive either a 6-min breath counting training or listen to a recited extract from a popular science book, before all participants received a negative mood induction. Motivation for alcohol was measured before and after listening to either the breath counting training or the control audio files, with a craving questionnaire in two online studies (n = 122 and n = 111), or an alcohol versus food picture choice task in a pub context in one in-person study (n = 62). Results: In Study 1, breath counting reduced alcohol craving. However, since the mood induction protocol did not increase craving, the effect of breath counting in reversing such increase could not be demonstrated. Online breath counting eliminated the increase in alcohol craving induced by negative mood (Study 2) and eliminated the stress-induced increase in alcohol picture choice in the pub environment (Study 3). Conclusions: Briefly trained breath counting attenuated negative mood–induced alcohol motivation in hazardous community drinkers. These results suggest that breath counting is a reliable and practical method for reducing the impact of negative emotional triggers on alcohol motivation. Preregistration: These studies are not preregistered.

Public Health Significance This study suggests that distraction appears to be equally effective at reducing stress-induced alcohol cravings as breath counting. Therefore, it may be that the effectiveness of breath counting at reducing alcohol cravings is a result of distraction, rather than increased mindfulness. Prior research suggests brief mindfulness (breath counting) interventions may be effective at attenuating stress-induced alcohol-related cravings. However, it remains unclear whether this reduction in craving is due to increased state mindfulness or mere distraction. To test this, the present study examined whether brief breath counting would attenuate a stress-induced increase in the relative value of alcohol in young adult alcohol users, and whether this therapeutic effect was superior to simple distraction (cross counting). University students from England and the United States (N = 278, M (age) = 20.2 years, 56.5% females) were randomly assigned to one of four conditions: breath counting, distraction, stress-only, no-stress. Participants first listened to a 6-min audio file training the breath counting technique or control audio, before exposure to 2-min noise stress induction or no-stress during which participants engaged in breath counting, cross counting (distraction), or nothing. The relative value of alcohol was then assessed by preferential choice of alcohol versus food pictures. Results indicated that stress-only augmented alcohol picture choice compared to no-stress, and that this stress induction effect was attenuated to a comparable extent by breath counting and distraction. Group differences in alcohol picture choice washed out in the second half of the choice test. The results suggest that the therapeutic effect of breath counting (interoceptive attention) on stress-induced alcohol-seeking may stem from distraction (cognitive load) rather than a unique state of mindful acceptance. The implications of this lab study for mindfulness therapy are considered.

Introduction. Imagery-based stress management therapies are effective at reducing alcohol use. To explore the therapeutic mechanism, the current study tested whether brief functional imagery training linked to personal negative affect drinking triggers would attenuate sensitivity to noise stress-induced alcohol seeking behaviour in a laboratory model. Methods. Participants were UK-based hazardous student drinkers (N = 61, 80.3% women, aged 18–25) who reported drinking to cope with negative affect. Participants in the active intervention group (n = 31) were briefly trained to respond to personal negative drinking triggers by retrieving an adaptive strategy to mitigate negative affect, whereas participants in the control group (n = 30) received risk information about binge drinking at university. The relative value of alcohol was then measured by preference to view alcohol versus food pictures in two-alternative choice trials, before (baseline) and during noise stress induction. Results. There was a significant two-way interaction where the control group increased their alcohol picture choice from baseline to the noise stress test , whereas the active intervention group did not , and the control group chose alcohol more frequently than the active group in the stress test , but not at baseline . Conclusions. These findings indicate that imagery-based mood management can protect against the increase in the relative value of alcohol motivated by acute stress in hazardous negative affect drinkers, suggesting this mechanism could underpin the therapeutic effect of mood management on drinking outcomes.