Brief Admission Skane: Replacing General Admission for Individuals With Self-harm and Acute Risk of Suicide (BAS)

Brief Admission Skane: Can Brief Admission Replace General Admission for Individuals With Self-harm and Acute Risk of Suicide

The purpose of the study is to test a standardized version of brief admission (BA) through randomized controlled trial (RCT). The main objective is to evaluate if BA can serve as a crisis management model for individuals with recurrent self-harm, including suicide attempts and at least three symptoms of Borderline Personality disorder. Participants will be allocated to BA + Treatment as Usual (TAU) or TAU.

Study Overview

• Status: Completed
• Conditions: Suicidal Ideation; Suicide, Attempted; Self-Injurious Behavior; Borderline Personality Disorder; Emergency Services, Psychiatric
• Intervention / Treatment: Other: Brief Admission

Detailed Description

When individuals with recurrent self-harm and suicidal behaviour seek acute admission to hospital due to a crisis and associated increased suicidal ideation, recommendations for clinical care are still conflicting. The risk for iatrogenic effects of inpatient care are considerable, and long hospital admissions without a clear treatment structure may predict decompensation in functioning. This has resulted in a clinical practice of avoiding admission for individuals diagnosed with Borderline Personality Disorder (BPD).

Brief admission (BA) as an intervention has a longstanding history in the delivery of mental health services in the Netherlands. The core elements of brief admission were determined through consultation with Dutch researchers, interviews with individuals with experience, Dutch clinicians familiar with Brief Admission, and local guidelines from hospitals familiar with implementing this crisis management intervention. Core elements of the intervention were standardized into a protocol, and an educational manual was developed to train clinicians involved in the trial. An objectively rated fidelity measure was developed in order to ensure adherence.

• Study Type: Interventional
• Enrollment (Actual): 125
• Phase: Not Applicable

Contacts and Locations

Study Locations

• Sweden
  • Skåne
    • Lund, Skåne, Sweden, 22185
      • Division of Psychiatry, Region Skåne

Participation Criteria

Eligibility Criteria

• Ages Eligible for Study: 18 years to 60 years (Adult)
• Accepts Healthy Volunteers: No
• Genders Eligible for Study: All

Description

Inclusion Criteria:

• Current episodes of self-harm and/or recurrent suicidality.
• Fulfilling at least three criteria for borderline personality disorder.
• Admitted to psychiatric hospital for acute care for at least 7 days or presenting to the psychiatric emergency department at least 3 times during the last six months.

Exclusion Criteria:

• No regular contact with outpatient psychiatric services.
• Homelessness. Housing crises are outside the scope of this RCT.
• Medical disorder from other organs that significantly contributes to inclusion criteria (e.g. if self-harm only occurs during episodes of hypoglycemia in a diabetic patient).

Study Plan

How is the study designed?

Design Details

• Primary Purpose: Treatment
• Allocation: Randomized
• Interventional Model: Parallel Assignment
• Masking: Single

Number of Arms

2

Arms and Interventions

Participant Group / Arm	Intervention / Treatment
Experimental: Brief Admission; Participants randomised to Brief admission (BA) will have the possibility of admitting themselves to hospital for a maximum duration of three consecutive days at a maximum frequency of three times per month. Apart from BA they have access to all psychiatric care that they would have if they had not participated in the study (including general admission to hospital).	Other: Brief Admission; Participants randomised to Brief admission (BA) will participate in a negotiation together with their out-patient clinician and a representative from the ward. The aim of the negotiation is to form an individualised contract defining how BA will work for them. After signing the contract, will have the possibility to admit themselves to hospital according to the procedure stated in the contract.; Other Names: Brukarstyrd Inläggning (Swedish)
No Intervention: Control; Participants randomized to Treatment as Usual will receive no intervention from the study protocol, except the baseline assessments and repeated assessments administered on the same schedule as described above for the treatment group. They will not be given the evaluation measures that are specific to the intervention. Participants have access to all psychiatric care that they would have if they had not participated in the study (including general admission to hospital).

What is the study measuring?

Primary Outcome Measures

Outcome Measure	Measure Description	Time Frame
Number of days with hospital admission	Number of days with Brief admission, general admission, forced (involuntary) admission	Change between the period from 12 month retrospectively to Baseline and the period from baseline to 12 months prospectively

Secondary Outcome Measures

Outcome Measure	Measure Description	Time Frame
Frequency of forced acts (e.g. restraints and forced medication)		Change between the period from 12 month retrospectively to Baseline and the period from baseline to 12 months prospectively
Individuals' Experiences of the intervention	Outcome from the questionnaires developed for the method: Individual's Experience Scale (IES)	Data collected at each Brief Admission during a period of 140 weeks. A Brief Admission is defined as a hospital admission according to the procedure defined in the Brief Admission Skane Standardised Protocol.
Clinicians' Experiences of the intervention	Outcome from the questionnaires developed for the method: Clinician's Experience Scale (CES)	Data collected at each Brief Admission during a period of 140 weeks. A Brief Admission is defined as a hospital admission according to the procedure defined in the Brief Admission Skane Standardised Protocol.
Frequency of all self-harming behaviours including suicide attempts	Outcome from Five Self-Harm Behaviour Groupings Measure (5S-HM)	Change in frequency between baseline, 6 months and 12 months prospectively.
Severity of self-harming behaviours	Outcome from Five Self-Harm Behaviour Groupings Measure (5S-HM)	Change in severity between baseline, 6 months and 12 months prospectively.
Level of functioning in activities of daily life	The World Health Organization Disability Assessment Schedule II (WHODAS 2.0)	Change in ratings between baseline, 6 months and 12 months prospectively.
Ability to cope effectively with life stress	The Brief COPE	Change in ratings between baseline, 6 months and 12 months prospectively.
Ability to regulate emotions	The Difficulties in Emotion Regulation Scale	Change in ratings between baseline, 6 months and 12 months prospectively.
Global psychiatric symptoms	Outcome from Clinical Global Impression Severity Scale	Change in ratings between baseline, 6 months and 12 months prospectively.
Satisfaction with health care	Client Satisfaction Questionnaire (CSQ)	Change in ratings between baseline, 6 months and 12 months prospectively.

Collaborators and Investigators

• Sponsor: Region Skane
• Collaborators: Radboud University Medical Center; Lund University
• Investigators: Principal Investigator: Sofie Westling, MD PhD, Region Skåne

Publications and helpful links

General Publications

• Storebo OJ, Stoffers-Winterling JM, Vollm BA, Kongerslev MT, Mattivi JT, Jorgensen MS, Faltinsen E, Todorovac A, Sales CP, Callesen HE, Lieb K, Simonsen E. Psychological therapies for people with borderline personality disorder. Cochrane Database Syst Rev. 2020 May 4;5(5):CD012955. doi: 10.1002/14651858.CD012955.pub2.
• Witt KG, Hetrick SE, Rajaram G, Hazell P, Taylor Salisbury TL, Townsend E, Hawton K. Psychosocial interventions for self-harm in adults. Cochrane Database Syst Rev. 2021 Apr 22;4(4):CD013668. doi: 10.1002/14651858.CD013668.pub2.
• Westling S, Daukantaite D, Liljedahl SI, Oh Y, Westrin A, Flyckt L, Helleman M. Effect of Brief Admission to Hospital by Self-referral for Individuals Who Self-harm and Are at Risk of Suicide: A Randomized Clinical Trial. JAMA Netw Open. 2019 Jun 5;2(6):e195463. doi: 10.1001/jamanetworkopen.2019.5463. Erratum In: JAMA Netw Open. 2019 Oct 2;2(10):e1913724.
• Helleman M, Lundh LG, Liljedahl SI, Daukantaite D, Westling S. Individuals' experiences with brief admission during the implementation of the brief admission skane RCT, a qualitative study. Nord J Psychiatry. 2018 Jul;72(5):380-386. doi: 10.1080/08039488.2018.1467966. Epub 2018 Apr 27.
• Liljedahl SI, Helleman M, Daukantaite D, Westrin A, Westling S. A standardized crisis management model for self-harming and suicidal individuals with three or more diagnostic criteria of borderline personality disorder: The Brief Admission Skane randomized controlled trial protocol (BASRCT). BMC Psychiatry. 2017 Jun 15;17(1):220. doi: 10.1186/s12888-017-1371-6.

Study record dates

Study Major Dates

• Study Start (Actual): September 1, 2015
• Primary Completion (Actual): June 30, 2018
• Study Completion (Actual): August 10, 2018

Study Registration Dates

• First Submitted: November 25, 2016
• First Submitted That Met QC Criteria: December 6, 2016
• First Posted (Estimate): December 7, 2016

Study Record Updates

• Last Update Posted (Actual): August 28, 2018
• Last Update Submitted That Met QC Criteria: August 24, 2018
• Last Verified: August 1, 2018

More Information

Terms related to this study

• Keywords: self-harm; deliberate self-harm; Brief admission; admission
• Additional Relevant MeSH Terms: Behavioral Symptoms; Mental Disorders; Pathologic Processes; Disease Attributes; Personality Disorders; Emergencies; Suicide; Suicidal Ideation; Suicide, Attempted; Borderline Personality Disorder; Self-Injurious Behavior
• Other Study ID Numbers: 2014/570

Plan for Individual participant data (IPD)

• Plan to Share Individual Participant Data (IPD)?: NO