Prospective outcome of referral psychotherapies for patients with deliberate self-harm in routine care

Deliberate self-harm is a frequent cause for contacts with somatic emergency clinics and denotes a strong predictor for self-harm repetition, suicide and premature mortality. Follow-up care is of great importance and could have a profound influence on the patients' health both in short and long term. However, the evidence-base to guide such clinical management is sparse. In this project, we aimed to carry out a thorough investigation on psychiatric health care following deliberate self-harm treatment and prospective health outcome of the patients using real-world data from Norwegian registers. We have followed a national cohort of patients with treated deliberate self-harm since 2008, and investigated how often these patients received a referral to psychiatric healthcare services; which patients attended psychiatric treatment to which they were referred; and how psychiatric referral and attendance affected the risk of subsequent suicide in these patients. We have also obtained important insights into follow-up psychiatric treatment for young people with deliberate self-harm, and assessed the influence of various specific psychiatric disorders on deliberate self-harm across adulthood. These findings could have significant implications for facilitation of high-quality follow-up care for self-harming patients, and ultimately contribute to preventing repetition of deliberate self-harm and death by suicide in this high-risk population.

The project has resulted in publication of 7 original research articles and 1 article in a Norwegian journal insofar, with at least 1 more article in the phase of finalisation, and will produce 2 PhD dissertations to be submitted within the next a few months as being expected. The project has produced a number of significant outcomes and findings that have strong implications for future research, clinical management and prevention strategies about patients with deliberate self-harm in Norway and internationally. 1) It produced a data-driven diagnostic coding system that can be used to identify incidents of deliberate self-harm from Norwegian Patient Register and to estimate the incidence rate in the population – challenging and fundamentally important issues (P. Qin, Burrell, Bøe, & Mehlum, 2020; Ping Qin & Mehlum, 2020). 2) It provided a systematic overview flowchart on how many patients with deliberate self-harm received a referral to psychiatric services after somatic treatment, how many of the patients subsequently attended to psychiatric services, and how many of these died by suicide and other causes during the follow-up; and moreover, what were important factors associated with each of these stage outcomes (P. Qin, Stanley, Melle, & Mehlum, 2022). 3) It identified education and sick leave being the most important risk factors for deliberate self-harm in young adults, investigated the direct transferal to psychiatric inpatient services and important factors associated with such a decision, and moreover, assessed how immediate psychiatric inpatient treatment could affect the risk for self-harm repetition among these young patient group prospectively (Lunde, Mehlum, Melle, & Qin, 2021, 2022, 2023). 4) It identified specific psychiatric disorders often co-existing when deliberate self-harm occurred, and evaluated the influence of these disorders on self-harm repetition and risk for eventual mortality by suicide, other external cause and the cause of mental illness and behavior disorders (Bøe, Mehlum, Melle, & Qin, 2022a, 2022b, 2023).

Deliberate self-harm is a frequent reason for emergency contacts and denotes a strong predictor for self-harm repetition, suicide and premature mortality in the population. Follow-up care for self-harming patients is of great importance in clinical management; however, the evidence-base to guide this management is sparse. We propose to use rich data from Norwegian registers for a thorough investigation on referrals to psychotherapies and their prospective outcome for patients with deliberate self-harm. We will study types of referral psychotherapies, factors determining specific referrals, therapy engagement and prospective influence on patients' health and social performance. We hypothesize that referral psychotherapy treatment and treatment engagement have a positive effect on prospective health and non-health outcomes of the patients. We will identify a national cohort of patients who have been treated for deliberate self-harm since 2008 and retrieve personal data on clinical features, psychotherapy referrals, treatments engagement, cause of death, socioeconomic status, etc., from relevant registers. We will follow the patients for outcomes of self-harm repetition, suicide and premature mortality as well as education and labor market performance. To assess the effect of specific referral psychotherapies, we will use patients who did not receive any treatment referral as the generic reference and use a propensity score matching design to draw 3 controls per case upon the closest match of the scores. Linkage across national registers will make the present study insofar the most comprehensive assessment of follow-up intervention for self-harm patients in routine care. The study will generate insightful knowledge about referral psychotherapies in a 'real' world. The findings will have significant implication for service provision and clinical management of self-harm patients, and may ultimately result in fewer suicide deaths and self-harm episodes.