Background

Self-harm represents a major public health concern. It has been estimated that there are more than 200,000 general hospital presentations for self-harm in England each year (Tsiachristas et al 2017). In addition, just over 20% will re-present to hospital within 12 months following further episodes of self-harm (Geulayov et al 2016). Patients who self-harm have a significantly increased risk of suicide in the future compared with the general population, especially during the first few months after leaving hospital (Geulayov et al 2019). Patients who self-harm are also at greater risk of premature death than the general population, often due to issues relating to their physical health and lifestyle choices (Bergen et al 2012). The National Institute for Health and Care Excellence (2004, 2011) recommends that all patients who attend a general hospital following an episode of self-harm should be offered a psychosocial assessment and that subsequent interventions should be tailored to their needs, including psychological and other issues that may have led to them self-harming.

There has been considerable research into the factors that can reduce self-harm and improve well-being in this patient group. For example, brief psychological interventions represent a pragmatic and effective approach for reducing self-harm, depression, hopelessness and suicidal ideation (Hawton et al 2016). There is also evidence from Denmark that providing psychological interventions, such as elements of cognitive behavioural therapy (CBT) and/or dialectical behaviour therapy, can be effective in routine clinical care (Erlangsen et al 2015).

With significant numbers of patients presenting with self-harm to hospitals in England and a shortage of clinicians to provide psychological therapies following discharge, the authors contend that treatment for some patients after discharge from hospital should be provided by members of the hospital self-harm service who undertook the initial psychosocial assessment. This would have the advantage of providing continuity of clinical care.

Self-harm services

Self-harm services in England are typically multidisciplinary and available seven days a week, often for 24 hours a day. Most services involve nurses undertaking a psychosocial patient assessment. In an early study, Catalan et al (1980) showed that with specific training nurses could undertake such assessments as efficiently as psychiatrists. Recently, Pitman et al (2020) found no difference in patients’ subsequent rates of repetition of self-harm following assessment by nurses or psychiatrists. In addition, qualitative research has suggested that psychiatric nurses may use a particularly collaborative approach in their assessments (Hunter et al 2013).

One such self-harm service is the Emergency Department Psychiatric Service (EDPS) in Oxford, England. The EDPS is based in a large general teaching hospital and is staffed by band 7 mental health nurses, junior doctors and consultant psychiatrists. The EDPS offers psychosocial assessment to anyone aged over 13 years who presents to a hospital emergency department (ED) following an episode of self-harm or any other mental health issue. The ED staff contact the EDPS when a patient who has self-harmed attends the department. Following assessment, a discharge plan is formulated in collaboration with the patient. Any patient who does not meet the criteria for referral to secondary mental health services but who requires more than non-statutory services or primary care may be offered follow-up with the Brief Interventions for people at Risk of further Self Harm (BIRSH) programme, which is provided by the EDPS team.

BIRSH is a nurse-led service that is delivered by nurses in the EDPS team. Wand et al (2011) supported the value of mental health nurses delivering follow-up interventions after patients had presented to the ED, particularly when the interventions were delivered using a solution-focused therapeutic approach, which seeks to identify solutions rather than focusing on the patient’s ‘problem’. The BIRSH programme consists of a maximum of six sessions of therapy with the assessing nurse, following the patient’s discharge from hospital. These sessions are undertaken in outpatient rooms at the general hospital or via an online application such as Skype.

The therapy content of the BIRSH sessions is patient-led and focuses on any issues they have, but specifically covers issues relating to repetitive self-harm, alcohol misuse, bereavement, anxiety and depression. The underpinning value of the BIRSH programme is of validation with an emphasis on problem-solving. Curran and Brooker (2007) noted the skills nurses have in delivering problem-solving interventions, together with the value of the mix of interventions that can be provided by experienced nurses. This might include self-mapping, CBT-based techniques and/or short-term interventions for alcohol misuse.

The BIRSH intervention has been shown to be a contributory factor in reducing self-harming behaviour (Brand and Lascelles 2017). For example, all patients who attended two or more follow-up BIRSH sessions after an initial self-harm presentation to the ED experienced a reduction in presentations to the ED in the six-month period after the BIRSH sessions, compared with the previous six-month period (Brand and Lascelles 2017). This indicated the potential value of the BIRSH sessions in reducing self-harm presentations.

Digital health technologies

Digital health technologies are another potentially valuable method of transforming mental healthcare by connecting patients to services and health data. Online digital and mobile applications can offer patients greater access to information and enhance clinical management and early intervention through access to real-time patient data, for example mobile applications that enable patients to track their symptoms (Hollis et al 2015). One example of how digital health technologies can support patients and clinicians is the online self-assessment system True Colours. This system allows patients to monitor their symptoms using text, email and the internet (Goodday et al 2020). Using True Colours, the patient develops an online record of their mood and mental state, which they can monitor over time to assess their progress and to flag any unusual trends.

The authors wanted to explore the possible benefits of adding this digital self-monitoring component to the BIRSH programme, since there is minimal evidence that digital self-monitoring has been used in this patient population. As a result, the authors worked alongside the True Colours team to devise a questionnaire that collected weekly digital data directly from patients. The aim of this was to monitor patients’ mood, mental state, episodes of self-harm and any suicidal thoughts and/or behaviours. The data, which were accessible online to both the individual patient and their nurse, were then available for exploration with patients during therapy sessions. The authors wanted to explore whether the True Colours self-monitoring system was acceptable to patients and clinicians, and if it was feasible to implement it alongside the established BIRSH programme of therapy sessions, for example by using the True Colours data to inform the BIRSH therapy sessions.

Service evaluation

Findings

During the evaluation, 15 patients were offered BIRSH therapy sessions alongside monitoring with the True Colours system. Two patients declined to take part because they did not have the technology required to access the True Colours system, and another declined as they did not want the pressure of the weekly email prompting them to complete a questionnaire. The remaining 12 patients accepted the BIRSH therapy sessions, with nine also accepting the True Colours self-monitoring.

Most of the participants were female (n=10; 83%) and aged between 18 and 35 years (n=10; 83%). All but one of the participants had engaged in self-harm previously (n=11; 92%). The characteristics of the 12 evaluation participants are shown in Table 1.

Overall, eight (67%) of the participants attended three or more BIRSH therapy sessions. Four attended no BIRSH therapy sessions, but one of these still used the True Colours system.

Patients’ use of the True Colours system

A total of nine patients used the True Colours system. Two examples of participants’ True Colours’ results are shown in Figures 1 and 2, and demonstrate the BIRSH therapy period and any repeat episodes of self-harm. In terms of the PHQ-9 and HADS scores, the higher the score the more the patient’s mood or anxiety had deteriorated. Significant life events such as loss of employment or relationship breakdown are also shown in Figures 1 and 2.

Figure 1.

Example of True Colours system monitoring – participant 1

Figure 2.

Example of True Colours system monitoring – participant 4

The period detailed in Figure 1 shows when this participant was actively engaged in BIRSH therapy sessions, which were associated with improvements in their mood and anxiety scores from baseline. The patient lost their job during week nine, which was followed by a deterioration in their mental state for a short period of time and a repeat episode of self-harm. After their series of BIRSH therapy sessions ended – at week 14 – their mood and anxiety fluctuated, with their ratings indicating generally suboptimal levels compared with the therapy period.

The patient shown in Figure 2 engaged in further self-harm before therapy began, and in the first few weeks after it started. Then in week 7 they experienced a relationship breakdown, which was followed by an increase in anxiety scores but a decrease in depression, reflected in the figure.

Both patients continued using the True Colours system for many months after their BIRSH therapy sessions had ended.

Discussion

The findings from this evaluation suggested that both patients and nurses found it useful to use a digital self-management tool to monitor patients’ mood, thoughts of self-harm and suicidality alongside psychological therapy sessions. From the feedback questionnaire, it was clear that the nurse participants were able to use the real-time True Colours data in the BIRSH therapy sessions. These data provided a structure to the BIRSH therapy sessions because the nurses were able to ask the patients why they had felt more or less suicidal that week, for example. It also gave the patient participants a sense of ownership and responsibility about recording their data. The True Colours data also enabled the nurses and patients to monitor changes in the patients’ mood and suicidality over time, and to recognise how these changes related to life events or treatment modifications, for example.

One of the nurses related how they found registering patients on the True Colours online system challenging. This shows the value of ensuring clinicians have access to appropriate training to ensure that they feel able to use innovative technology such as the True Colours system. Fetter (2009) stated that although evidence links information technology with improved patient safety, nurses should be competent in using the information technology, which further indicates the need for adequate training in the True Colours system.

Shan et al (2019) noted that patient engagement with technology influenced the outcomes of any digital health intervention. Also, while numerous types of digital health interventions are available to patients and members of the public, many factors affect their ability to engage with these interventions (O’Connor et al 2016). Some potential participants in this evaluation were excluded from engaging with the True Colours system because they could not reliably self-monitor their mood and mental state, for example because of their mental health issues, or the possible ‘triggering’ nature of some of the questions. In addition, some patients lacked the technology required to operate the True Colours system, such as a mobile phone.

Although the results of this evaluation could not be generalised to the overall population of people who self-harm, due to the relatively small size of the sample, they did provide preliminary findings concerning the usefulness of the True Colours system when used as an adjunct to outpatient follow-up.

The findings of this evaluation should be developed in future research by testing the True Colours system in a larger population group to ascertain if it should be offered to all patients who self-harm and who require follow-up.

In terms of the True Colours measures used in this evaluation, the authors considered that the PHQ-9, with added questions about self-harm, was instrumental in eliciting the required information.

While this evaluation used items concerning anxiety extracted from the HADS scale, on reflection it might have been preferable to use a complete scale for this purpose, such as the General Anxiety Disorder-7 (GAD-7) (Spitzer et al 2006). This is because the evaluation only used the ‘anxiety’ element of HADS. Using a full anxiety scale might have been an improvement. Also, the GAD-7 is shorter, which would have meant fewer questions for participants to complete.

In this evaluation, participants were emailed a reminder to undertake their True Colours ratings weekly. However, because participants’ situations can often change rapidly, on reflection the authors believe that twice-weekly ratings would have been preferable.

Conclusion

The use of a digital, real-time method of monitoring mood, thoughts of self-harm and suicidality alongside a psychological intervention was found to be acceptable and useful to both patients and nurses. While it requires evaluation on a larger scale, the authors suggest that innovations such as the True Colours system could enhance the aftercare of people who self-harm.