Brief Admission by Self-referral for Individuals With Self-harm: Effects on Compulsory Care

Brief Admission by self-referral (BA) is a standardized treatment model, providing patient-controlled and person-centered care. It was developed to reduce self-harm and compulsory care by promoting autonomy. Randomized clinical trials have not yielded significant between group differences with respect to inpatient care, including compulsory care. The major difficulty in evaluating BA is preventing the control group from cross-contamination, as in the implementation process of BA, all physicians, all inpatient and outpatient staff as well as managers need to be informed and undergo basic education regarding the intervention. As BA addresses a prevalent and frustrating issue in psychiatric health care, there is considerable risk that the approach leaks to the control group, reducing the possibility to detect between-group differences. In the current study this will be addressed through a register-based approach, comparing similar clinics, implementing BA at different timepoints over time. Individuals with traits of borderline personality disorder will be included and comparisons will be made with respect to compulsory care, voluntary inpatient care and mortality.

Study Overview

• Status: Recruiting
• Conditions: Suicide, Attempted; Suicide; Borderline Personality Disorder; Self-harm; Emergency Psychiatric; Self-injury; Hospitalizations Psychiatric
• Intervention / Treatment: Other: Brief Admission by self-referral (BA)

• Study Type: Observational
• Enrollment (Estimated): 7000

Contacts and Locations

• Study Contact: Name: Sofie Sofie, PhD; Phone Number: +46735626099; Email: sofie.westling@med.lu.se
• Study Contact Backup: Name: Josefin Vikström Eckevall, PhD; Phone Number: +46703320527; Email: josefin.vikstrom@liu.se

Study Locations

• Sweden
  • Linköping, Sweden, 581 91
    • Recruiting
    • Region Östergötland
    • Contact: Rolf Wiklund; Email: Rolf.Wiklund@regionostergotland.se
  • Solna, Sweden, 171 54
    • Recruiting
    • Statistiska centralbyrån
    • Contact: Åsa Holmström; Email: Asa.Holmstrom@scb.se
  • Stockholm, Sweden, SE-106 30
    • Recruiting
    • Socialstyrelsen
    • Contact: Jessica Magnusson; Email: Jessica.Magnusson@socialstyrelsen.se
  • Skåne
    • Lund, Skåne, Sweden, 22185
      • Recruiting
      • Division of Psychiatry, Region Skåne
      • Contact: Erika Svanström, MD, PhD; Email: erika.svanstrom@skane.se
      • Contact: Psychologist

Participation Criteria

Eligibility Criteria

• Ages Eligible for Study: Adult; Older Adult
• Accepts Healthy Volunteers: No

• Sampling Method: Probability Sample

Study Population

Individuals with repeated self-harm and traits of Borderline personality disorder

Description

Inclusion Criteria:

• Living in the uptake area of Lund, Linköping, Helsingborg or Norrköping
• Age 18-65 years at the time of inclusion
• Admitted to hospital either diagnosed with ICD-10 diagnosis BPD F60.3, or admitted at least twice with Intentional self-harm X60-83 in combination with one of more of the following diagnoses ADHD (F90.0-F90.X), Bipolar disorder type 2, (F31.8W, F318A-F, F31.0, F31.8-9, F31.8W) or Autism, Atypical autism, Aspergers syndrome (F84.0, F84.1, F84.5) or Mild intellectual disability (F70.0-F70.9).

Exclusion Criteria:

• not fulfilling inclusion criteria

Study Plan

How is the study designed?

Number of groups / cohorts

12

Cohorts and Interventions

Group / Cohort	Intervention / Treatment
Lund 2010-09-15-2015-09-14; Lund, before implementation of Brief Admission by self-referral
Lund 2015-09-15-2020-09-14; Lund, after implementation of Brief Admission by self-referral in Lund, before implementation of Brief Admission by self-referral in Linköping	Other: Brief Admission by self-referral (BA); Through means of an individualised contract access to self-referral to inpatient treatment limited to a maximum of three nights, three times per month.; Other Names: Patient initiated Brief admission; Self-referral to inpatient treatment; Patient controlled hospital admission
Lund 2020-09-15-2025-09-14; Lund, after implementation of Brief Admission by self-referral in Lund and in Linköping	Other: Brief Admission by self-referral (BA); Through means of an individualised contract access to self-referral to inpatient treatment limited to a maximum of three nights, three times per month.; Other Names: Patient initiated Brief admission; Self-referral to inpatient treatment; Patient controlled hospital admission
Linköping 2010-09-15-2015-09-14; Linköping before implementation of Brief Admission by self-referral
Linköping 2015-09-15-2020-09-14; Linköping after implementation of Brief Admission by self-referral in Lund, before implementation of Brief Admission by self-referral in Linköping
Linköping 2020-09-15-2025-09-14; Linköping after implementation of Brief Admission by self-referral in Lund and in Linköping	Other: Brief Admission by self-referral (BA); Through means of an individualised contract access to self-referral to inpatient treatment limited to a maximum of three nights, three times per month.; Other Names: Patient initiated Brief admission; Self-referral to inpatient treatment; Patient controlled hospital admission
Helsingborg 2014-02-15-2017-02-14; Helsingborg before implementation of Brief Admission by self-referral
Helsingborg 2017-02-15-2020-02-14; Helsingborg after implementation of Brief Admission by self-referral in Helsingborg, before implementation of Brief Admission by self-referral in Norrköping	Other: Brief Admission by self-referral (BA); Through means of an individualised contract access to self-referral to inpatient treatment limited to a maximum of three nights, three times per month.; Other Names: Patient initiated Brief admission; Self-referral to inpatient treatment; Patient controlled hospital admission
Helsingborg 2020-02-15-2023-02-14; Helsingborg after implementation of Brief Admission by self-referral in Helsingborg and in Norrköping	Other: Brief Admission by self-referral (BA); Through means of an individualised contract access to self-referral to inpatient treatment limited to a maximum of three nights, three times per month.; Other Names: Patient initiated Brief admission; Self-referral to inpatient treatment; Patient controlled hospital admission
Norrköping 2014-02-15-2017-02-14; Norrköping before implementation of Brief Admission by self-referral
Norrköping 2017-02-15-2020-02-14; Norrköping after implementation of Brief Admission by self-referral in Helsingborg, before implementation of Brief Admission by self-referral in Norrköping
Norrköping 2020-02-15-2023-02-14; Norrköping after implementation of Brief Admission by self-referral in Helsingborg and in Norrköping	Other: Brief Admission by self-referral (BA); Through means of an individualised contract access to self-referral to inpatient treatment limited to a maximum of three nights, three times per month.; Other Names: Patient initiated Brief admission; Self-referral to inpatient treatment; Patient controlled hospital admission

What is the study measuring?

Primary Outcome Measures

Outcome Measure	Measure Description	Time Frame
Days with compulsory admission	Days with compulsory admission (days/year)	2010-09-15 - 2025-09-14

Secondary Outcome Measures

Outcome Measure	Measure Description	Time Frame
Days with voluntary psychiatric admission	Days with voluntary psychiatric admission (days/year)	2010-09-15 - 2025-09-14
Duration of free intervals between admissions	Duration of free intervals between admissions (days)	2010-09-15 - 2025-09-14
Mortality	All cause mortality as well as death by suicide specifically (X60-X84 and Y10-Y34 in ICD10)	2010-09-15 - 2025-09-14
Number of compulsory admissions	Number of compulsory admissions (admissions/year)	2010-09-15 - 2025-09-14
Number of voluntary psychiatric admissions (admissions/year)	Number of voluntary psychiatric admissions	2010-09-15 - 2025-09-14
Number of compulsory acts/year	Number of compulsory acts/year	2010-09-15 - 2025-09-14

Other Outcome Measures

Outcome Measure	Measure Description	Time Frame
Gender distribution	Differences in distribution of diagnoses between men and women	2010-09-15 - 2025-09-14
Number of admissions with Brief admission by self-referral (BA)	Number of BA admissions (admissions/year)	2010-09-15 - 2025-09-14
Compulsory admission - median length	Compulsory admission - median length (days/admission)	2010-09-15 - 2025-09-14
Voluntary psychiatric admissions - median length	Voluntary psychiatric admissions - median length (days/admission)	2010-09-15 - 2025-09-14
Number of voluntary psychiatric admissions	Number of voluntary psychiatric admissions (admissions/year)	2010-09-15 - 2025-09-14

Collaborators and Investigators

• Sponsor: Region Skane
• Collaborators: Lund University; Linkoeping University
• Investigators: Principal Investigator: Sofie Sofie, PhD, Lund University

Publications and helpful links

General Publications

• Thomsen CT, Benros ME, Maltesen T, Hastrup LH, Andersen PK, Giacco D, Nordentoft M. Patient-controlled hospital admission for patients with severe mental disorders: a nationwide prospective multicentre study. Acta Psychiatr Scand. 2018 Apr;137(4):355-363. doi: 10.1111/acps.12868. Epub 2018 Mar 4.
• Strand M, von Hausswolff-Juhlin Y. Patient-controlled hospital admission in psychiatry: A systematic review. Nord J Psychiatry. 2015;69(8):574-86. doi: 10.3109/08039488.2015.1025835. Epub 2015 Apr 2.
• Lindkvist RM, Landgren K, Liljedahl SI, Daukantaite D, Helleman M, Westling S. Predictable, Collaborative and Safe: Healthcare Provider Experiences of Introducing Brief Admissions by Self-referral for Self-harming and Suicidal Persons with a History of Extensive Psychiatric Inpatient Care. Issues Ment Health Nurs. 2019 Jul;40(7):548-556. doi: 10.1080/01612840.2019.1585497. Epub 2019 May 17.
• Warrender D. Borderline personality disorder and the ethics of risk management: The action/consequence model. Nurs Ethics. 2018 Nov;25(7):918-927. doi: 10.1177/0969733016679467. Epub 2017 Jan 19.
• Coyle TN, Shaver JA, Linehan MM. On the potential for iatrogenic effects of psychiatric crisis services: The example of dialectical behavior therapy for adult women with borderline personality disorder. J Consult Clin Psychol. 2018 Feb;86(2):116-124. doi: 10.1037/ccp0000275.
• 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.
• Sigrunarson V, Moljord IE, Steinsbekk A, Eriksen L, Morken G. A randomized controlled trial comparing self-referral to inpatient treatment and treatment as usual in patients with severe mental disorders. Nord J Psychiatry. 2017 Feb;71(2):120-125. doi: 10.1080/08039488.2016.1240231. Epub 2016 Oct 14.
• 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.

Study record dates

Study Major Dates

• Study Start (Actual): September 15, 2010
• Primary Completion (Estimated): December 31, 2025
• Study Completion (Estimated): December 31, 2025

Study Registration Dates

• First Submitted: April 19, 2024
• First Submitted That Met QC Criteria: May 7, 2024
• First Posted (Actual): May 9, 2024

Study Record Updates

• Last Update Posted (Actual): August 14, 2025
• Last Update Submitted That Met QC Criteria: August 10, 2025
• Last Verified: August 1, 2025

More Information

Terms related to this study

• Keywords: self-harm; Brief Admission by self-referral; traits of borderline personality disorder; compulsory care
• Additional Relevant MeSH Terms: Mental Disorders; Pathologic Processes; Disease Attributes; Behavioral Symptoms; Emergencies; Suicide; Personality Disorders; Borderline Personality Disorder; Self-Injurious Behavior; Suicide, Attempted
• Other Study ID Numbers: 2022-02307-01

Drug and device information, study documents

• Studies a U.S. FDA-regulated drug product: No
• Studies a U.S. FDA-regulated device product: No