Brief admissions by self-referral can help adolescents with self-harming or suicidal behavior

Gaining access to brief admission by self-referral reduced the need for emergency care in adolescents with severe self-harm. The method has previously been introduced for adults, and a study led by researchers from Lund University has now explored whether the method could also be used for children and young people. The results are published in The Lancet Psychiatry.

Most children and young people who are treated for psychiatric issues are not admitted to hospital. For some however, when their situation does not stabilize or where the risk for self-harm or suicide is elevated, there may be a need for more comprehensive care. Research shows that early interventions are important in hold back the development of disease, at a time when demand for child psychiatry is high.

Researchers at Lund University and the Department for Child and Adolescent Psychiatry in Region Skåne, Sweden, have investigated whether the method of patient-initiated admissions, which has previously been introduced and evaluated in adult psychiatry, could be used for children and young people.

A total of 63 people were included in the study. All were aged between 13 and 17 years old and met at least three of nine criteria for borderline personality disorder. The participants had previously been admitted for psychiatric emergency care or had made at least one emergency visit during the past six months. The researchers followed the group for just over a year (a median average of 13.5 months) and investigated how many emergency visits, admissions and the number of days of care that the patients had during the period.

"We saw that brief admissions by self-referral can successfully be introduced as a complement within child and adolescent psychiatry and that it seems to be an effective method for adolescents. For participants in the study, the need for acute visits, admissions and longer treatment periods was reduced," says Olof Rask, researcher at Lund University, consultant within child and adolescent psychiatry in Region Skåne and one of the researchers behind the study.

The method means that the adolescents themselves can determine when they need treatment. First, a contract is drawn up between the adolescent, guardians, psychiatric outpatient and inpatient units, in which it is agreed what will lead to admission. The agreement also contains information about how the patient wants staff to respond during the self-referral admission, which lasts between one and three days.

"This concerns a very vulnerable group of adolescents who have often previously experienced an authoritarian psychiatric care when they have wanted to be admitted but not been, or admitted against their will—something that sometimes, through the various kinds of restrictions applied, risks escalating the self-harming behavior and worsening well-being further.

"With self-referral admission, the patients' autonomy and sense of control are strengthened. When they call the psychiatric emergency unit, they are welcomed and there is a trust and predictability in the way they are received. That creates a feeling of safety," says Björn Axel Johansson, researcher at Lund University, consultant physician at Region Skåne and the first author of the study.

Among the 46 adolescents in the study who used self-referral admission, a questionnaire survey was conducted in which they graded the experience of their self-referral admission on a scale from one to nine. The average score was eight.

A large proportion of the group—95%—were girls.

"This kind of problem affects girls more often than boys, but that means that it is not as easy to generalize the results for boys. To do so will require a multi-center study with the opportunity to include more participants in the study. We hope that more clinics will be able to start using this method, since the results indicate that it may be a help for this group of adolescents," says Olof Rask.

The researchers also saw that the method could reduce costs by around SEK 10,000 per patient per month.

With the results of this study, it will now be possible to proceed and undertake forward-thinking randomized controlled trials.

"Self-referral admissions could mean reduced suffering for these vulnerable children and adolescents, who thanks to this method feel that they have more control over their situation. The method may make things easier, also for key people around the patient, firstly parents and siblings, who can experience hope when the situation calms," says Björn Axel Johansson.