PEER REVIEW HISTORY ARTICLE DETAILS TITLE (PROVISIONAL)

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1 PEER REVIEW HISTORY BMJ Open publishes all reviews undertaken for accepted manuscripts. Reviewers are asked to complete a checklist review form ( and are provided with free text boxes to elaborate on their assessment. These free text comments are reproduced below. ARTICLE DETAILS TITLE (PROVISIONAL) AUTHORS Investigating the feasibility of an enhanced contact intervention in self harm and suicidal behaviour: A protocol for a randomised controlled trial delivering a Social support and Wellbeing Intervention following Self Harm (SWISH) Ahmed, Nilufar; John, Ann; Islam, Saiful; Jones, Richard; Anderson, Pippa; Davies, Charlotte; Khanom, Ashrafunnesa; Harris, Shaun; Huxley, Peter VERSION 1 - REVIEW REVIEWER REVIEW RETURNED Sarah Hetrick Orygen, The National Centre of Excellence in Youth Mental Health Centre for Youth Mental Health, University of Melbourne I have undertaken a review that is under consideration on psychological interventions for self harm. 07-Apr-2016 GENERAL COMMENTS This is an excellent and well-conceived study (in the main part). The rationale for the study is compelling and certainly the field requires this sort of innovation. My main concern is with regard to the outcomes, which are not well justified in terms of how the protocol and this manuscript are written. The aim is to test an intervention for those who engage in self-harm and have suicidal ideation (the second of these inclusion criteria are not well justified by the background), and yet these behaviours are not measured as outcomes. I am aware that while this is the publication of the protocol, that in fact the study is almost if not already complete so that the outcome measurement cannot be modified; however, I think the authors could include some rationale for why depression is the main outcome. The other key issues that need to be addressed are as follows: There is a need for greater clarification of the inclusion criteria: it is not clear that those who present to emergency departments are to be included in this study (in my mind these are not mental health settings). I think the authors need to clearly articulate the service system organization in Wales (in the section of setting perhaps?) so that the reader is clear about what the services are that participants are presenting to (for inclusion) and where they are likely to be referred (including something about what type of presentations would gain them access to each of the levels of service) both for those who will be included and those who will be excluded. It should be noted that while those with suicidal ideation are to be

2 included, it is not clear what the rationale for this is based on the background. It isn t clear if the inclusion criteria are for those who won t get referral to agencies or for those who will but will have to wait; or both. Again, I think clarifying the service system and the types of services you are talking about in terms of where people present to and where they get referred to will help here. There was a good description of the intervention, which is important in terms of being able to implement findings into practice (see Hoffman 2014). However, I would recommend including some information about the theoretical framework for the intervention; there is an important statement made in the protocol paper that states the intervention is based on psychosocial assessment, assertive engagement, brief client-centered psychotherapy and community linkage. With regard to the section on intervention, I think there is some repetition that could be removed, and the only information I thought there was information missing about how it is that the intervention is assertive i.e. compared to TAU where information might be given about appropriate services, in the case of the intervention is assertive linking done by actually making the referrals, driving people to their appointments at these places i.e. what makes it assertive over and above providing information. I also thought there was information missing about how it might be that for some people the intervention might entail simple support i.e. this sounds like it might akin to client centered counseling? The qualitative side-study is not described in the manuscript, although it may not be necessary to do so. The background is compelling and there are some good arguments put forward that justify why this study is needed. However, I think it needs further work/restructuring. My suggestion for the flow of the argument is as follows (and means that some of what is included in the background currently could be removed): Provide, as you have done, the prevalence and impacts of selfharm. State evidence for, and recommendations for psychosocial assessment (i.e. while there is a close association with mental health disorders, an depression in particular, the most common reasons for hospital presentation are interpersonal and social problems; Haw 2008). You need to give a good rationale for there being social needs and what these are that are clearly addressed by your intervention; perhaps even provide examples. Psychosocial assessment is often not done and if it is and certainly when it is not done the focus is often on treating the mental health symptoms and addressing medical needs related to self harm (I think this is what authors mean by medical approaches?) It might be prudent to cite the seminal work of Keith Hawton summarizing interventions for self harm (I am aware that this Cochrane review is being updated; so far only the pharmacological interventions for self harm has been published and the original review was published well over 10 years ago). In any case you need to highlight that there are a range of interventions for self harm; some are promising but as yet the evidence base is certainly not robust in terms of clearly pointing to interventions that work. There are newer trials in the field that include both psychological and well as contact interventions; some conducted by case workers. Then

3 discuss brief interventions, which focus on contact. I think that it isn t entirely clear what need is being met by your intervention so this needs to be clarified. Is it about increasing social contact for those who are socially isolated; or is it more broad in terms of addressing social problems including finance difficulties, hardship, interpersonal difficulties, such that linkage to social services agencies address the issue. Or both? Make sure it is clear. There is no information about how fidelity to the intervention is controlled; is there training of your therapists? Is there a manual? Does supervision provide some of this role? In terms of analysis, multiple imputation methods seem to be preferred for dealing with missing data; have authors considered this. Also, consideration should be made of therapist effects, similar to how clusters are dealt with in cluster randomsied controlled trials, where there will be a correlation between outcomes for participants seen by a particular therapist. In terms of the abstract and the Strengths and Limitations sections, both of these need considerable work. The abstract leaves a lot of questions albeit ones that are answered when you read the entire manuscript but given people often only read the abstract this should tell a succinct and complete story of you work in and of itself. Similarly, the strengths and limitations section doesn t clearly articulate what the strengths and limitations are and should be reworked. References Haw C, Hawton K. Life problems and deliberate self-harm: associations with gender, age, suicidal intent and psychiatric and personality disorder. J Affect Disord 2008;109(1): Hawton, K. K. E., E. Townsend, E. Arensman, D. Gunnell, P. Hazell, A. House and K. Van Heeringen (1999). "Psychosocial and pharmacological treatments for deliberate self-harm." Cochrane Database of Systematic Reviews Issue 4(CD001764). Hoffmann, T. C., P. P. Glasziou, I. Boutron, R. Milne, R. Perera, D. Moher and S. Michie (2014). "Better reporting of interventions: template for intervention description and replication (TIDieR) checklist and guide." British Medical Jo REVIEWER REVIEW RETURNED Philip Hazell University of Sydney Australia 19-Apr-2016 GENERAL COMMENTS The paper describes the protocol for a study which, according to supplementary documentation, was completed in March The title indicates this is a feasibility study, however it appears to be an efficacy study. Perhaps the title could be revised simply to The protocol for a randomised control trial delivering a social support intervention following self harm. 2. The background could do with a clearer statement of how the

4 intervention may work. 3. People are excluded from the study if they receive any active care and treatment with an adult mental health mental service. What proportion of people presenting with self harm do not get offered a follow up from an adult mental health service? Will the study include people who were offered aftercare but declined or did not attend? 4. Why does the study not include as a primary outcome a measure of social integration or social connectedness? This seems to be the main focus of the intervention. 5. Why does the study not include further self harm or suicidality as a primary outcome measure? This was how the study population was defined. 6. The sample size calculation has not allowed for attrition the sample. Will there be any interim analyses and stopping guidelines? 7. What is the justification for permitting follow up assessments to be conducted by the practitioner rather than the researcher? What are the risks of this approach? REVIEWER REVIEW RETURNED Ying-Yeh Chen Taipei City Psychiatric Center, Taipei, Taiwan 07-May-2016 GENERAL COMMENTS This is a protocol assessing the feasibility of a social support intervention program. Specific comments are listed below: 1. My major comment is about the theory background of the intervention elements, and their effect measurement. This is not clearly introduced in the introduction section. It seems that the intervention is a contact programme, but how your program enhances social support/or connectedness, and how you measure the changes are not clearly illustrated in introduction. 2. The outcomes are depression and life quality, but how does your intervention lead to these two outcomes? Why not measuring social support? Social connection? Or suicide ideation/attempt? No justification for choice of outcomes in your manuscript. 3. Your sample contains both individuals with suicide ideation and suicide attempt. When you randomized, did you stratify by their suicidal behaviors? so each group has equal number of attempters/ideators? VERSION 1 AUTHOR RESPONSE We have reworked the background section in line with suggestions and inserted a clarification in the background explaining relevance of suicidal ideation, and the rationale for depression as the main outcome its link with suicidal behaviour. We have described where people are likely to be referred and we have explained why we are exploring depression and social wellbeing as outcome measures and included a paragraph on SAIL in the background section which describes follow up to collect information on self harm presentations. Reviewers were concerned that these were not primary outcomes. We have added information on SAIL follow up data collection which will collect information on the number and reasons for presentations at hospital and/or GP for the year preceding and the year following the trial. We have explained this data will be available for analysis in 2017 We have amended the design and setting section to clarify the inclusion criteria. We have stated in the background that over 200,000 people present to hospital with self harm and explain that they are seen by mental health practitioners in the Emergency Department. This justifies the setting of the

5 Emergency Department where people present as a mental health setting. There is no information available on number of people who were not offered aftercare, our inclusion criteria states that we will include all who meet our criteria and they will receive the intervention along with their Treatment As Usual. This necessarily includes those who did not attend or were not offered aftercare. We have added further detail to the intervention section and qualitative follow up section. We have added further information on psychosocial assessments in the emergency department in the background and added the literature suggested by Reviewer 1. We have explained that the clinical supervisor trained the practitioners and research assistants and provides regular supervision of contact with patients and the conduct of the trial. In terms of questions on analysis, these will be addressed at the analysis stage and reported separately. We have clarified that we did apply any stratification as this is a feasibility study and we will separate groups during analysis. Any significant stratification criteria will be adopted for the full trial. We have addressed queries on sample size and attrition and added more detail to why we resorted to allowing the practitioner to collect follow up assessments We have reworked the strengths and limitations, but have made minimum changes to abstract. We are confident that keywords and the abstract as it is will be informative. Reviewer 2 suggested altering the title as they were not sure this was a feasibility study. This is a feasibility study and so we will retain the title as it stands. We have addressed the reason for choosing depression as a primary outcome depression is significant indicator of self harm. Social connectedness is measured in the MANSA as a secondary outcome. We take on board the reviewers comments regarding the importance of measuring social integration and connectedness, and acknowledge that whilst MANSA measures this to some extent as a secondary outcome, for a full trial we may explore other ways of measuring social integration and connectedness. VERSION 2 REVIEW REVIEWER REVIEW RETURNED Sarah Hetrick Orygen, The National Centre of Excellence in Youth Mental Health Centre for Youth Mental Health, University of Melbourne I have undertaken a review that is under consideration on psychological interventions for self harm. 19-Jun-2016 GENERAL COMMENTS My main point and where there is need for further major revision is with regard to the background: I think the authors still need to do more work in terms of how the background is written. This section is particularly important in terms of leading the reader to understand the rationale of your study and the design that it will logically have based on your background. For example, the background states that depression is linked with

6 self-harm, but that not all people have a psychiatric diagnosis but rather social factors may be the precipitant and it is these people who are often discharged without any follow-up intervention, implying that it is this group who are the focus of this study. It does not make sense then to have depression as the main outcome. It is particularly important that the authors think through and explicate for the reader how and why depression is important and will be the main outcome. Stylistically, each paragraph usually contains one main idea, with the next giving another main idea that logically flows etc.authors should ensure this is how the background is written, an example of a stylistic error is that the third paragraph again comes back to the issue of social and interpersonal factors, which have been briefly mentioned in the second paragraph. Another example, is that the end of paragraph five states that more brief contact interventions are needed, then the first line of paragraph six states that more social interventions are needed without clearly defining brief contact interventions as social interventions. Is that what the authors are implying? It is unclear in what respect brief contact interventions are important and related to what you will be testing, and yet in the first paragraph of the methods your intervention is called a brief contact intervention. There is some repetition e.g. as mentioned above, but also the last line of the sixth paragraph is about aims, and then paragraph seven begins by talking about aims. There are also instances where it is not clear what is being referred to e.g. Fifth paragraph such interventions does this mean problem solving, emergency card access and/or brief contact? The first line of the second paragraph is not referenced. Here it would be appropriate to include a reference to Hawton s work: I provided the original Cochrane review but this has now been updated and the two new reviews should be cited: Hawton, K., Witt, K. G., Taylor Salisbury, T. L., Arensman, E., Gunnell, D., Hazell, P.,... van Heeringen, K. (2015). Pharmacological interventions for self-harm in adults. Cochrane Database of Systematic Reviews, Issue 7.Art. No.: CD DOI: / CD Hawton, K., Witt, K. G., Taylor Salisbury, T. L., Arensman, E., Gunnell, D., Hazell, P.,... van Heeringen, K. (2016). Psychosocial interventions for self-harm in adults. Cochrane Database of Systematic Reviews, Issue 5. Art. No.: CD DOI: / CD Note that problem solving therapy is no longer supported in this review; rather CBT is. In attempting to address reviewers comments, the authors have now included in the background what probably belongs best in the methods e.g. details of the measurement tools to be used. Methods: as mentioned above, the authors might want to think carefully about whether their intervention is a brief contact intervention or whether it contains more psychosocial elements than that and would more readily fit into e.g. the Hawton review of

7 psychological and psychosocial interventions for self-harm. In my view it is the later. I note that in the discussion it is then referred to as a social intervention. The discussion also refers to it as a crisis response intervention but there has been no mention of there being a crisis response aspect to the intervention e.g. open access to a clinician/practitioner if there was another crisis. The first mention of an emergency department and the local primary mental health support service is on page 7, and I believe will confuse the reader because it has not been clearly explained that these are the places where people will present to and be recruited from in the Design and Setting Section. There are minor typo s throughout e.g. double full-stops or no full stops. REVIEWER REVIEW RETURNED Philip Hazell University of Sydney Australia 17-Jun-2016 GENERAL COMMENTS I stand by my previous comment that this appears to be an efficacy study, not a feasibility study. There is more detail in the Background about how the intervention may work. The authors have introduced a measure of repeat self-harm, based on re-presentation to hospital via the Secure Anonymised Information linkage (SAIL) database, but this has not been integrated into the Method Section. The authors have not addressed other questions I raised in my initial review. Reviewer: 1 Reviewer Name: Sarah Hetrick VERSION 2 AUTHOR RESPONSE My main point and where there is need for further major revision is with regard to the background: I think the authors still need to do more work in terms of how the background is written. This section is particularly important in terms of leading the reader to understand the rationale of your study and the design that it will logically have based on your background. For example, the background states that depression is linked with self-harm, but that not all people have a psychiatric diagnosis but rather social factors may be the precipitant and it is these people who are often discharged without any follow-up intervention, implying that it is this group who are the focus of this study. It does not make sense then to have depression as the main outcome. It is particularly important that the authors think through and explicate for the reader how and why depression is important and will be the main outcome. We have reworked the background to flow more logically in line with the study and explained why we are collecting depression as our primary outcome in paragraph 5 of the Background section. We have explained that we were attempting to initially replicate an Australian study that had a similar context.

8 Stylistically, each paragraph usually contains one main idea, with the next giving another main idea that logically flows etc.authors should ensure this is how the background is written, an example of a stylistic error is that the third paragraph again comes back to the issue of social and interpersonal factors, which have been briefly mentioned in the second paragraph. Another example, is that the end of paragraph five states that more brief contact interventions are needed, then the first line of paragraph six states that more social interventions are needed without clearly defining brief contact interventions as social interventions. Is that what the authors are implying? It is unclear in what respect brief contact interventions are important and related to what you will be testing, and yet in the first paragraph of the methods your intervention is called a brief contact intervention. We have clarified this and we are calling our intervention an enhanced contact intervention (paragraph 6 in Background section). The enhanced reflects the fact that most of the contact interventions described in the literature refer to more remote types of contact such as telephone or postcards. We actively engage face to face with patients. There is some repetition e.g. as mentioned above, but also the last line of the sixth paragraph is about aims, and then paragraph seven begins by talking about aims. We have rewritten this so that the flow is more logical and readable. We apologise for the clumsiness in the previous versions There are also instances where it is not clear what is being referred to e.g. Fifth paragraph such interventions does this mean problem solving, emergency card access and/or brief contact? We have clarified this (now paragraph 4 in the Background section). We thank the reviewer for spotting the lack of clarity in the previous version The first line of the second paragraph is not referenced. Here it would be appropriate to include a reference to Hawton s work: I provided the original Cochrane review but this has now been updated and the two new reviews should be cited: Hawton, K., Witt, K. G., Taylor Salisbury, T. L., Arensman, E., Gunnell, D., Hazell, P.,... van Heeringen, K. (2015). Pharmacological interventions for self-harm in adults. Cochrane Database of Systematic Reviews, Issue 7.Art. No.: CD DOI: / CD Hawton, K., Witt, K. G., Taylor Salisbury, T. L., Arensman, E., Gunnell, D., Hazell, P.,... van Heeringen, K. (2016). Psychosocial interventions for self-harm in adults. Cochrane Database of Systematic Reviews, Issue 5. Art. No.: CD DOI: / CD RESPONSE We thank the reviewer for these references and have inserted and cited them appropriately in paragraph 4 of the Background section Note that problem solving therapy is no longer supported in this review; rather CBT is. RESPONSE In recognition of this we have removed the reference to problem solving therapy

9 In attempting to address reviewers comments, the authors have now included in the background what probably belongs best in the methods e.g. details of the measurement tools to be used. RESPONSE We thank the reviewer for highlighting this and we have re-written the details of measurement for the background sectionas we are describing the comparison with the Australian study, but we agree with the reviewer that this should be in the methods section and so have also created a section on Outcome measures in the methods section on p7. Methods: as mentioned above, the authors might want to think carefully about whether their intervention is a brief contact intervention or whether it contains more psychosocial elements than that and would more readily fit into e.g. the Hawton review of psychological and psychosocial interventions for self-harm. In my view it is the later. We have considered this point, and whilst the intervention is flexible enough to contain psychosocial elements (depending on who is delivering the intervention), we have opted to call it an enhanced contact intervention. This keeps the role of practitioner open to those who may not have psychosocial registration or qualifications. It is expected that staff would have some familiarity and experience with mental health services, but it retains the option for an excellent community worker who is well linked in the community services to be given mental health outreach training by a suitably trained professional for the role of practitioner. I note that in the discussion it is then referred to as a social intervention. The discussion also refers to it as a crisis response intervention but there has been no mention of there being a crisis response aspect to the intervention e.g. open access to a clinician/practitioner if there was another crisis. Under the section on Intervention we have included the sentence If at any time during the intervention the practitioner is concerned that these needs may be escalating and require specialised support, or there is a crisis situation this will be immediately discussed with the clinical supervisor who will refer the patient accordingly (p6, paragraph 1) The first mention of an emergency department and the local primary mental health support service is on page 7, and I believe will confuse the reader because it has not been clearly explained that these are the places where people will present to and be recruited from in the Design and Setting Section. We have addressed this omission and discuss the emergency department and local primary mental health services in the method section under Design and setting on p4 There are minor typo s throughout e.g. double full-stops or no full stops. We apologise for this, and have made every attempt to ensure that the paper is clearly and well written Reviewer: 2 Reviewer Name: Philip Hazell

10 I stand by my previous comment that this appears to be an efficacy study, not a feasibility study. RESPONSE We respect the view of the reviewer thinking it as an efficacy study and we admit that there are some reasons to suggest it could be an efficacy study. For example, we did a power calculation for sample size, randomised the patients, and tested some outcome measures based on the intervention. However, our main aim was to attempt to replicate the Australian study (as detailed in the protocol), At the outset we were unsure on: Whether the study framework will work for UK? Whether we would be able to recruit? What would be our response rates? Does the attrition rate? All these above uncertainties are the main aim of study. Hence for this reason we have described it as feasibility study. Pragmatically, we also wanted to take the opportunity to check whether the defined intervention actually works for such a setting and how effective it can be and whether the BDI-II and MANSA work as outcome measures. We admit that the results (from the efficacy part) may be under powered (because of not considering the attrition) but will nonetheless provide us better with conformity to proceed towards a definitive main trial. We admit that we were a tad opportunistic through running an RCT, but felt it would not impede our main aim. We hope that we have been able and justify our choice of the term feasibility. We sincerely apologise for the lack of clarity provided previously. There is more detail in the Background about how the intervention may work. Thank you for acknowledging this. We have further re-worked the background section to provide more information and clarity. The authors have introduced a measure of repeat self-harm, based on re-presentation to hospital via the Secure Anonymised Information linkage (SAIL) database, but this has not been integrated into the Method Section. We have now rewritten the section related to SAIL. It is now sitting under the Assessment section in the one year follow up subheading on p8. We have also added a paragraph (in the 'statistical analysis section on p9) saying how we are going to use the information collected from SAIL databank. Thanks. The authors have not addressed other questions I raised in my initial review. We apologise for any omission. We have copied the reviewers original questions below and provide answers for them. 1. The title indicates this is a feasibility study, however it appears to be an efficacy study. Perhaps the title could be revised simply to The protocol for a randomised control trial delivering a social support intervention following self harm. We have addressed this above, but have paid attention to the title following the reviewers comment and we have altered the title to better reflect the content of the intervention. The acronym of the

11 intervention remains the same. We thank the reviewer for drawing our attention to the title and giving us the opportunity to make the title more appropriate to the content. 2. The background could do with a clearer statement of how the intervention may work. We have reworked the background section as recognised by the reviewer. We hope that further revisions we have made add more clarity and thank the reviewer for pointing this out. 3. People are excluded from the study if they receive any active care and treatment with an adult mental health mental service. What proportion of people presenting with self harm do not get offered a follow up from an adult mental health service? Will the study include people who were offered aftercare but declined or did not attend? There is no readily available data on the proportion of people who present with self harm and do not get offered follow up from an adult mental health service. The study includes people who were offered (non- secondary mental health service) aftercare but declined or did not attend. This is an important group of people to reach. The intervention can help encourage patients to attend adult mental health support services. Oftentimes patients receive an appointment weeks after the event and do not feel the need to attend. The intervention helps to encourage patients to attend the service even if they feel that they do not need it at that present time. 4. Why does the study not include as a primary outcome a measure of social integration or social connectedness? This seems to be the main focus of the intervention. The study attempted to initially replicate and then resorted to adapting an Australian study which had the same premise of a social linkage intervention as described in the Background section on p3 and Outcome measures section on p7. We detail how the Australian study used BDI-II as a primary measure and MANSA as a secondary measure. We apologise for not making this clearer in the original version, but hope it is now clarified. For a further trial we will collect social connectedness as a primary outcome as we have recognised the importance of collecting this information. 5. Why does the study not include further self harm or suicidality as a primary outcome measure? This was how the study population was defined. Please see response to point 4. We are trying to keep the study as close to the Australian study based on the information available. However we will be collecting data on further self harm and/or suicidality as part of the questionnaires administered and will also be able to collect longer term data from SAIL which will provide information on presentations to primary and secondary healthcare services for self harm, suicidal ideation and depression. We have detailed this on p8 under one year follow up subheading in the Assessments section 6. The sample size calculation has not allowed for attrition the sample. Will there be any interim analyses and stopping guidelines? The main reason of not considering the attrition of the sample is because we are performing a feasibility study (we have explained above why this is a feasibility study). Although we are doing a power analysis by assuming the effect size from the Australian study and from the experience of the team, we do not know much about the possible attrition rate for such population. We are hoping to

12 have estimates of the attrition of sample from this study which will be useful for our future main trial. We thank the reviewer for raising this important issue. 7. What is the justification for permitting follow up assessments to be conducted by the practitioner rather than the researcher? What are the risks of this approach? We accept that this is does introduce potential bias in to the study. Our justification is explained under the Blinding section on p8 - we felt it important to prioritise data collection. This is a vulnerable group, and some people did not feel up to having repeated visitors and so in some cases it was at the patient s request. When the practitioner/ research assistant phoned to arrange a meeting, the patient would often respond with I am seeing XX on this day, can I do both at the same time?. VERSION 3 REVIEW REVIEWER REVIEW RETURNED Sarah Hetrick Orygen, The National Centre of Excellence in Youth Mental Health and The Centre for Youth Mental Health, University of Melbourne 04-Aug-2016 GENERAL COMMENTS This manuscript has always been excellent and the authors have meaningfully addressed editorial comments and substantially improved it so that it is ready for publication. I have only minor comments that the authors can choose to ignore: Authors have now articulated why depression is the primary outcome as being the fact that they want to replicate a previous study. The reader may still find it odd that depression is being measured when the background highlights that not everyone has a diagnosis, but now at least the reason for this is given. I do wonder if there is just minor adjustments to the way the background is written that could clear this up: i.e. stating it more along the lines of it isn t just mental disorders that result in presentations and in fact we know that the precipitants are usually interpersonal and social issues i.e. take out the statement that not everyone has depression. Both those with as well as those without depression require psychosocial assessment, support, and having their social needs addressed. There is now a mention in the background of how the health systems differ so full replication not possible can you briefly state how they differ and why full replication is not possible (I understand there are word limits to this may not be possible; perhaps consider using online supplement material). A statement about aim is now entirely missing (it had been replicated in both the background and methods but now does not feature in either) although the paper is clear anyway. The labeling of the intervention as an enhanced contact intervention is appropriate and it is now clear what this is and how it sits within the literature in this area. It is also clearly and consistently described this way throughout the manuscript.

13 VERSION 3 AUTHOR RESPONSE Reviewer: 1 1. Authors have now articulated why depression is the primary outcome as being the fact that they want to replicate a previous study. The reader may still find it odd that depression is being measured when the background highlights that not everyone has a diagnosis, but now at least the reason for this is given. I do wonder if there is just minor adjustments to the way the background is written that could clear this up: i.e. stating it more along the lines of it isn t just mental disorders that result in presentations and in fact we know that the precipitants are usually interpersonal and social issues i.e. take out the statement that not everyone has depression. Both those with as well as those without depression require psychosocial assessment, support, and having their social needs addressed. *****RESPONSE***** This has been addressed in paragraph 2 of the background section, sentence starting However it is not just mental health disorders. 2. There is now a mention in the background of how the health systems differ so full replication not possible can you briefly state how they differ and why full replication is not possible (I understand there are word limits to this may not be possible; perhaps consider using online supplement material). *****RESPONSE***** This has been addressed in paragraph 5 of the background section. We have taken the reviewer s suggestion of including a reference to the Australian health care system. We felt it would be cumbersome (and possibly distracting) to start discussing the complexity of medicare in Australia and the differing levels of access based on types of insurance that people hold; and wanted to concentrate the paper on detailing our intervention. 3. A statement about aim is now entirely missing (it had been replicated in both the background and methods but now does not feature in either) although the paper is clear anyway. ****RESPONSE***** A statement on aim was in the paper already in the abstract and in the final paragraph of the background which starts The aim of this study is As it was not missing we have made no amendments based on this comment.