Effect of Brief Admission to Hospital by Self-referral for Individuals Who Self-harm and Are at Risk of Suicide: A Randomized Clinical Trial

Sofie Westling, Daiva Daukantaite, Sophie I Liljedahl, Youngha Oh, Åsa Westrin, Lena Flyckt, Marjolein Helleman, Sofie Westling, Daiva Daukantaite, Sophie I Liljedahl, Youngha Oh, Åsa Westrin, Lena Flyckt, Marjolein Helleman

Abstract

Importance: To our knowledge, there is no consensus regarding when individuals who repeatedly self-harm and are at risk of suicide should be hospitalized. To evaluate a new alternative, we examined the effects of brief admission (BA) to hospital by self-referral.

Objectives: To determine the effects of BA on inpatient service use and on secondary outcomes of daily life functioning, nonsuicidal self-injuries, and attempted suicide among individuals who self-harm and are at risk of suicide.

Design, setting, and participants: The single-masked Brief Admission Skåne Randomized Clinical Trial was conducted from September 2015 to June 2018 at 4 psychiatric health care facilities in southern Sweden. Data were collected 6 months retrospectively at baseline and at 6-month and 12-month follow-ups. Participants were randomized to either BA and treatment as usual (BA group) or treatment as usual (control group). The sample was a referral population, with the most important inclusion criteria being current episodes of self-harm and/or recurrent suicidality, at least 3 diagnostic criteria for borderline personality disorder, and hospitalization in the last 6 months.

Interventions: Self-referred BA was offered for 12 months, with standard limits for duration and frequency, after the negotiation of a contract outlining the intervention.

Main outcomes and measures: Prespecified main outcome measures were days admitted to the hospital, including voluntary admission, BA, and compulsory admission.

Results: The 125 participants had a mean (SD) age of 32.0 (9.4) years, 106 (84.8%) were women, and 63 were randomized to the BA group and 62 to the control group. No significant advantage was observed in the number of days in the hospital for the BA group compared with the control group. Within-group analyses demonstrated significant decreases in both groups regarding days admitted to the hospital (BA group: χ2 = 22.71; P < .001; control group: χ2 = 23.01; P < .001) and visits to the emergency department (BA group: χ2 = 13.95; P < .001; control group: χ2 = 21.61; P < .001), but only the BA group showed a reduction in days with compulsory admission (χ2 = 7.67; P = .02) and nonsuicidal self-injuries (χ2 = 6.13; P = .047). The BA group showed significantly greater improvements in the mobility domain of daily life functioning (z = -2.39; P = .02) and significant within-group improvements in 3 other domains (cognition: F = 9.02; P < .001; domestic responsibilities: F = 3.23; P = .049; and participation: F = 3.79; P = .03).

Conclusions and relevance: Brief admission appears no more efficacious in reducing use of inpatient services than usual care for individuals who self-harm and are at risk of suicide. Future studies should explore other possible beneficial effects.

Trial registration: ClinicalTrials.gov identifier: NCT02985047.

Conflict of interest statement

Conflict of Interest Disclosures: None reported.

Figures

Figure.. CONSORT Diagram of Participant Flow During…
Figure.. CONSORT Diagram of Participant Flow During the Study

References

    1. Koekkoek B, van der Snoek R, Oosterwijk K, van Meijel B. Preventive psychiatric admission for patients with borderline personality disorder: a pilot study. Perspect Psychiatr Care. 2010;46(2):-. doi:10.1111/j.1744-6163.2010.00248.x
    1. Strand M, von Hausswolff-Juhlin Y. Patient-controlled hospital admission in psychiatry: a systematic review. Nord J Psychiatry. 2015;69(8):574-586. doi:10.3109/08039488.2015.1025835
    1. Sigrunarson V, Moljord IEO, 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;71(2):120-125. doi:10.1080/08039488.2016.1240231
    1. Thomsen CT, Benros ME, Maltesen T, et al. . Patient-controlled hospital admission for patients with severe mental disorders: a nationwide prospective multicentre study. Acta Psychiatr Scand. 2018;137(4):355-363. doi:10.1111/acps.12868
    1. Holth F, Walby F, Røstbakken T, et al. . Extreme challenges: psychiatric inpatients with severe self-harming behavior in Norway: a national screening investigation. Nord J Psychiatry. 2018;72(8):605-612. doi:10.1080/08039488.2018.1511751
    1. 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;86(2):116-124. doi:10.1037/ccp0000275
    1. Paris J. Is hospitalization useful for suicidal patients with borderline personality disorder? J Pers Disord. 2004;18(3):240-247. doi:10.1521/pedi.18.3.240.35443
    1. Lieb K, Zanarini MC, Schmahl C, Linehan MM, Bohus M. Borderline personality disorder. Lancet. 2004;364(9432):453-461. doi:10.1016/S0140-6736(04)16770-6
    1. Schulz KF, Altman DG, Moher D; CONSORT Group . CONSORT 2010 statement: updated guidelines for reporting parallel group randomised trials. BMJ. 2010;340:c332. doi:10.1136/bmj.c332
    1. Liljedahl SI, Helleman M, Daukantaité D, Westrin Å, 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 Skåne Randomized Controlled Trial protocol (BASRCT). BMC Psychiatry. 2017;17(1):220. doi:10.1186/s12888-017-1371-6
    1. American Psychiatric Association Diagnostic and Statistical Manual of Mental Disorders. 5th ed Washington, DC: American Psychiatric Association; 2013.
    1. Faul F, Erdfelder E, Lang AG, Buchner A. G*Power 3: a flexible statistical power analysis program for the social, behavioral, and biomedical sciences. Behav Res Methods. 2007;39(2):175-191. doi:10.3758/BF03193146
    1. Cohen J. Statistical Power Analysis for the Behavioral Sciences. 2nd ed Hillsdale, NJ: Lawrence Erlbaum Associates; 1988.
    1. Helleman M, Goossens PJ, Kaasenbrood A, van Achterberg T. Experiences of patients with borderline personality disorder with the brief admission intervention: a phenomenological study. Int J Ment Health Nurs. 2014;23(5):442-450. doi:10.1111/inm.12074
    1. Helleman M, Goossens PJ, Kaasenbrood A, van Achterberg T. Evidence base and components of brief admission as an intervention for patients with borderline personality disorder: a review of the literature. Perspect Psychiatr Care. 2014;50(1):65-75. doi:10.1111/ppc.12023
    1. Liljedahl S, Helleman M, Daukantaite D, Westling S. Brief Admission: Manual for Training and Implementation Developed from the Brief Admission Skåne Randomized Controlled Trial. Lund, Sweden: BASRCT; 2017.
    1. Bellg AJ, Borrelli B, Resnick B, et al. ; Treatment Fidelity Workgroup of the NIH Behavior Change Consortium . Enhancing treatment fidelity in health behavior change studies: best practices and recommendations from the NIH Behavior Change Consortium. Health Psychol. 2004;23(5):443-451. doi:10.1037/0278-6133.23.5.443
    1. Borrelli B, Sepinwall D, Ernst D, et al. . A new tool to assess treatment fidelity and evaluation of treatment fidelity across 10 years of health behavior research. J Consult Clin Psychol. 2005;73(5):852-860. doi:10.1037/0022-006X.73.5.852
    1. Borrelli B. The assessment, monitoring, and enhancement of treatment fidelity in public health clinical trials. J Public Health Dent. 2011;71(s1):S52-S63. doi:10.1111/j.1752-7325.2011.00233.x
    1. Sheehan DV, Lecrubier Y, Sheehan KH, et al. . The Mini-International Neuropsychiatric Interview (MINI): the development and validation of a structured diagnostic psychiatric interview for DSM-IV and ICD-10. J Clin Psychiatry. 1998;59(suppl 20):22-33.
    1. First MB, Gibbon M, Spitzer RL, Williams JBW, Benjamin LS. SCID II, Structured Clinical Interview for DSM-IV-Axis II Disorders. Uppsala, Sweden: Pilgrim Press; 1998.
    1. World Health Organization WHO Disability Assessment Schedule 2.0 (WHODAS 2.0). . Accessed October 22, 2016.
    1. Liljedahl S, Westling S A unified theoretical framework for understanding suicidal and self-harming behavior: synthesis of diverging definitions and perspectives. Poster presented at: 3rd International Conference on Borderline Personality Disorder and Allied Disorders; October 16-18, 2014; Rome, Italy.
    1. Bollen KA, Curran PJ. Latent Curve Models: A Structural Equation Perspective. Hoboken, NJ: Wiley-InterScience; 2006.
    1. Duncan TE, Duncan SC, Strycker LA. An Introduction to Latent Variable Growth Curve Modeling: Concepts, Issues, and Applications. 2nd ed Hillsdale, NJ: Lawrence Erlbaum Associates; 2006.
    1. Meredith W, Tisak J. Latent curve analysis. Psychometrika. 1990;55(1):107-122. doi:10.1007/BF02294746
    1. Enders CK. Applied Missing Data Analysis. New York, NY: Guilford Press; 2010.
    1. Bodner TE. What improves with increased missing data imputations? Struct Equ Modeling. 2008;15(4):651-675. doi:10.1080/10705510802339072
    1. White IR, Royston P, Wood AM. Multiple imputation using chained equations: issues and guidance for practice. Stat Med. 2011;30(4):377-399. doi:10.1002/sim.4067
    1. Asparouhov T, Muthén B. Multilevel mixture models In: Hancock GR, Samuelsen KM, eds. Advances in Latent Variable Mixture Models. Charlotte, NC: Information Age Publishing; 2008:27.
    1. Muthén LK, Muthén BO Mplus user’s guide: eighth edition. . Accessed May 2, 2019.
    1. Morris SB, DeShon RP. Combining effect size estimates in meta-analysis with repeated measures and independent-groups designs. Psychol Methods. 2002;7(1):105-125. doi:10.1037/1082-989X.7.1.105
    1. IBM Corp IBM SPSS Statistics for Windows, Version 25.0. Armonk, NY: IBM Corp; 2017.
    1. Bland JM, Altman DG. Some examples of regression towards the mean. BMJ. 1994;309(6957):780. doi:10.1136/bmj.309.6957.780

Source: PubMed

Patrocinadores e Colaboradores

Condições médicas

Intervenções de drogas

3
Se inscrever