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

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: χ(2) = 22.71; P < .001; control group: χ(2) = 23.01; P < .001) and visits to the emergency department (BA group: χ(2) = 13.95; P < .001; control group: χ(2) = 21.61; P < .001), but only the BA group showed a reduction in days with compulsory admission (χ(2) = 7.67; P = .02) and nonsuicidal self-injuries (χ(2) = 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