Sinclair & Green (2005) BMJ

1. Sinclair & Green (2005) BMJ I used to just get stressed out and think ‘”right hit the bottle”. I’d hit the bottle, get all depressed, at first I’d feel more relaxed…..then I’d end up like a volcano. I’d explode and either go and hit out at somebody or hit back on myself because I can’t cope with this and that’s when I’d hit myself hard’

2. Imperial College London: Mike Crawford, Emese Csipke CNWL NHS Foundation Trust: Adrian Brown, Steve Reid Imperial College Healthcare Trust: Julian Redhead, Robin Touquet SHARPAn exploratory randomised trial of brief intervention for alcohol misuse following deliberate self harm

3. Alcohol and completed suicide • Alcoholism is one of the best predictors of suicide following DSH (Beck 1989) • Suicide rate in those who misuse alcohol is 8 times that of general population (Foster et al. 1997) • Strong population level associations between alcohol consumption and suicide rates (Wasserman 2001)

4. Alcohol and self-harm • BAR study (Touquet et al, 2008) • Blood Alcohol Concentration measured among 1908 people treated in resus. at St Mary’s hospital • Alcohol in samples of 22 (49%) of 45 people

5. Alcohol and self-harm • BAR study (Touquet et al, 2008) • Blood Alcohol Concentration measured among 1908 people treated in resus. at St Mary’s hospital • Alcohol in samples of 22 (49%) of 45 people

6. SBI and behavioural change • Research conducted across a wide range of contexts has demonstrated that SBI leads to medium term reductions in alcohol consumption (Moyer et al. 2001; Kaner et al. 2007) • This outcome may not be valued by clinicians • REDUCE project: Decrease in 7 units of alcohol per drinking session AND reattendance at Emergency Departments (Crawford et al 2004) • Evidence from clinical trials and systematic reviews has shown that SBI leads to reductions in accidents and injuries of between 30 and 70% (Gentilello et al. 1999, Dinh-Zarr et al. 2004)

7. SHARP Self Harm Alcohol Reduction Programme • Does brief intervention for alcohol misuse among people who present to emergency medical services following deliberate self harm reduce the likelihood of repetition? • To compare levels of reattendance to ED following self harm over six months among those who receive a self help leaflet with those who receive a leaflet plus an appointment for brief intervention from an Alcohol Nurse Specialist. • Feasibility – recruitment rate and explore effect size

8. Study sample • ED at St Mary’s Paddington • Inclusion criteria: Misusing alcohol according to Paddington Alcohol Test (PAT) Aged over 18 Address in greater London Able to provide verbal consent to follow up (language and level of consciousness) • Excluding: those already in contact with alcohol services, those who make a specific request to do so

9. Paddington alcohol test

10. Study methods • Pre-prepared sealed opaque envelopes containing either: Experimental treatment (ET) - A card with details of appointment with Alcohol Nurse Specialist (ANS) together with a leaflet with information on drinking and health Control treatment (CT) - A blank piece of card and a leaflet • Baseline demographic and PAT details. Follow-up at 3 and 6 months • Primary: reattendance at ED with DSH from records Secondary: episodes of DSH. Alcohol consumption using AUDIT. General mental health – using the 12-item GHQ. Satisfaction with care CSQ-3 Covariate: extent of personality disturbance using SAP-AS (Moran et al, 2003)

11. Intervention • Referral for brief advice • ‘We believe that you are drinking alcohol at a level which may be harmful for your health, and would like to offer you an appointment with our Alcohol Nurse Specialist’ • ‘FRAMES’ approach and referral e.g. alcohol counselling, detoxification services etc.

12. Sample size and data analysis • A sample of over 1,400 participants would be required to have 80% power to detect a 30% reduction in the repetition of self harm using a 5% level of statistical significance. • Aimed to recruit at least 100 (over a two year period) • ANALYSIS: Primary analysis conducted using an intention to treat principle. Differences in our primary outcome measure compared using chi-squared tests. Logistic regression analysis was then used to take account of any differences in potential confounding factors.

13. Results Recruitment: 27 month period - November 2005 to January 2008.

14. Baseline characteristics

15. Outcome data

16. Baseline alcohol consumption Odds ratio for each unit increase in number of units drunk at baseline= 1.03 (95% CI = 1.00 to 1.06)

17. Adjusted Odds Ratios • Offer of brief intervention, adjusted for baseline alcohol consumption 1.00 (95% CI = 0.32 to 3.15) • Offer of brief intervention, adjusted all baseline variables 1.15 (95% CI = 0.34 to 3.97) • Twenty-four (47.1%) of the 51 randomised to experimental treatment received it. Odds of repetition of DSH among those attending an appointment 0.93 (95% CI = 0.27 to 3.14) • Trend towards reduced alcohol consumption among those referred for brief intervention persisted (B = -0.24, p = 0.06)

18. Discussion • High level of alcohol misuse (56%) • Intervention acceptable: 47% attended appointment • Intervention probably associated with decreased alcohol use (7 units per drinking session) • BUT no difference in repetition of DSH or likelihood that alcohol was used in an episode of self harm (wide confidence limits)

19. Strengths and limitations • Randomised • Masked assessment of outcomes • Feasible intervention BUT • Small size and low power • Little baseline data • Short follow-up period

20. Alcohol misuse and PD • Data on SAP-AS from 75 (73%). 67 (89%) had ‘probable PD’. • Concurrent alcohol misuse an indicator of PD among people who self harm (45% Haw et al 2001 75% of those with comorbid alcohol misuse) • Lower levels of attendance at appointment with ANS • NICE guidelines (2009): brief interventions for people with borderline PD are not recommended • Complex interventions such as DBT associated with reduced levels of use of alcohol (Linehan et al. 1999)

21. Achieving behavioural change • Leadership • Teachable moment: when a link between alcohol consumption and health can be clearly seen • Timing: after dealing with the patient’s agenda.

22. Achieving behavioural change • Leadership • Teachable moment: when a link between alcohol consumption and health can be clearly seen • Timing: after dealing with the patient’s agenda. • When the relationship between alcohol use and health consequence is ‘accidental’ rather than ‘instrumental’

23. Achieving behavioural change • Leadership • Teachable moment: when a link between alcohol consumption and health can be clearly seen • Timing: after dealing with the patient’s agenda. • When the relationship between alcohol use and health consequence is ‘accidental’ rather than ‘instrumental’ ‘when I feel I need to harm myself the first thing I do is pick up a drink’