Effects of Psychiatric Admissions on Self-harm and Suicide in People With Borderline Personality Disorder
Conditions: Borderline Personality Disorder, Self-harm, Non-suicidal Self-injury, Suicide
Sponsor: Lund University

EFFECTS OF PSYCHIATRIC ADMISSIONS ON SELF-HARM 
AND SUICIDE IN PEOPLE WITH BORDERLINE 
PERSONALITY DISORDER 
 
 
 
 
 
 
 
1 
Official title: Effects of psychiatric admissions on self-harm and suicide in people with borderline 
personality disorder 
NCT number: not yet assigned 
Date: 2024-05-03 
 
 
 
 

EFFECTS OF PSYCHIATRIC ADMISSIONS ON SELF-HARM 
AND SUICIDE IN PEOPLE WITH BORDERLINE 
PERSONALITY DISORDER 
 
 
 
 
 
 
 
2 
STUDY PROTOCOL 
PURPOSE AND AIMS 
Our purpose is to investigate whether long and/or compulsory psychiatric admissions have 
an effect on healthcare visits due to self-harm or completed suicide in people diagnosed with 
Borderline personality disorder (BPD). 
The specific aim is to compare psychiatric clinics that have provided long and/or compulsory 
psychiatric admissions more frequently to clinics that have provided these admissions less 
frequently, with respect to subsequent healthcare visits due to self-harm and completed 
suicide, also in relation to recent discharge. Furthermore, we aim to investigate the effects of 
long and/or compulsory psychiatric admission on time to readmission to inpatient care. 
HYPOTHESES 
When comparing the psychiatric clinics that for individuals diagnosed with BPD have 
provided the most long and/or compulsory admissions, to the clinics that have provided the 
least: 
1. healthcare visits due to self-harm are more frequent  
2. completed suicide is more frequent  
3. completed suicide within 30 days from discharge is more frequent 
4. time to readmission to inpatient care is shorter  
5. the number of days in somatic inpatient care due to self-harm is increased 
6. the ratio of men to women is approximately the same across healthcare visits due to 
self-harm, time to readmission to inpatient care, and number of days in somatic 
inpatient care due to self-harm 
7. the ratio of men to women is larger for completed suicide and completed suicide 
within 30 days from discharge 
INTRODUCTION 
First, do no harm, is a fundamental principle for all healthcare. When it comes to people 
diagnosed with BPD, there is a debate whether acute admission to inpatient care does harm 
or saves lives (Goodman et al., 2012; Warrender, 2018). BPD is a disorder affecting 
approximately 0,7-2,7% of the population, though diagnosed about three times more 
commonly in women as compared to men (American Psychiatric Association, 2013). 
Frequent acts of self-harm with or without suicidal intent are among the core symptoms and 
the risk for completed suicide is high (Bohus et al.,2021; Leichsenring et al, 2023). As 
compared to other psychiatric disorders, BPD is among those associated with the highest 
risk for suicide, especially among young people (Chesney et al., 2014; Fazel & Runeson, 
2020; Runeson & Beskow, 1991).  
Due to recurrent suicidality and self-harm, people diagnosed with BPD are frequent users of 
emergency services (Pasqual et al., 2007). Despite this, there is a striking lack of evidence 

EFFECTS OF PSYCHIATRIC ADMISSIONS ON SELF-HARM 
AND SUICIDE IN PEOPLE WITH BORDERLINE 
PERSONALITY DISORDER 
 
 
 
 
 
 
 
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based guidelines on how to manage suicidality in the emergency department in people 
diagnosed with BPD (Prosser et al., 2023). The discordance in opinions on the benefits of 
acute admissions can be demonstrated by the fact that although inpatient crisis intervention 
is recommended to be kept as short as possible for people diagnosed with BPD, and only 
based on life threatening behavior (NICE, 2009), BPD has a prevalence of 22,4% in adult 
psychiatric inpatient units (Bender et al., 2011; Bohus et al.,2021).  
Thus, despite little to no evidence that admission to inpatient care, especially with 
restrictions or force, actually prevents suicide in people diagnosed with BPD (NICE, 2009; 
Borshmann et al., 2012; James et al., 2012; Huber et al., 2016; Monk-Cunliffe et al., 2022; 
Paris et al., 2019), acts of self-harm and suicidality are often managed through acute 
admission (Dasgupta, 2004; Ellison et al., 2018). This conflict is further elucidated in the 
clinical experiences that on the one hand, too rapid admission to hospital might hamper the 
development of autonomy by preventing the person with self-harming behavior from 
developing the skills necessary to manage crises for themselves, possibly escalating the 
self-harming behavior and subsequently increasing the long-term risk for suicide (Bohus et 
al., 2021; Coyle et al. 2018, Warrender, 2018). On the other hand, refusal to admit the 
person to hospital might be experienced as rejection, triggering aggravated self-harm, and 
thus increasing the risk for suicide in the short-term (NICE, 2009).  
There are relatively few studies investigating the possible gains of inpatient care and some 
of these show beneficial outcomes. However, the interventions in these studies are not crisis 
responses to imminent suicidality but rather long-term inpatient psychotherapy (e.g. Bartak 
et al., 2011, Bateman et al., 1999, Fowler et al.,2018). The structure of these admissions for 
psychotherapy, tailored to treat specific symptoms, is not representative for acute 
admissions, where individuals with imminent suicidality seek help at a psychiatric emergency 
department and get admitted to hospital with the purpose of having a safe place to stay.  
To fully evaluate the benefits and iatrogenic effects of acute admissions to hospital as a 
response to a suicidal crisis through an RCT will be ethically complicated, since hospital 
admission traditionally has been considered life-saving (Black et al., 2004) and may be 
beneficial for people with comorbid disorders (Miller & Black, 2020). Randomization to non-
admission would therefore not only be complicated to motivate ethically, but also difficult to 
pursue if the suicidal crisis escalates and is likely to make plausible participants decline 
consent to participate. An innovative approach is a register-based study. The Swedish 
national registers, such as the National Patient Register, provide a unique opportunity to 
study near complete populations, removing the risk of selection bias. Hence, this type of 
study design should constitute the next-best thing to an RCT in terms of study quality. In 
addition, studies comparing outcomes for individuals diagnosed with BPD depending on 
exposure to long-term inpatient care and/or compulsory care will always be faced with 
criticism. Critics will argue that those who are subjected to compulsory care and/or remain in 
hospital for long periods of time are those patients that are the most severely ill, making it 
impossible to draw conclusions regarding causality. A study comparing clinics rather than 
individuals should reduce this problem. 
The basis for such a study would be the large differences in clinical practice between clinics, 
as well as over time (see table 1), in regards to acute admissions of individuals diagnosed 

EFFECTS OF PSYCHIATRIC ADMISSIONS ON SELF-HARM 
AND SUICIDE IN PEOPLE WITH BORDERLINE 
PERSONALITY DISORDER 
 
 
 
 
 
 
 
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with BPD, including differences in the amount of compulsory care provided (National Board 
of Health and Welfare, 2023a). Dividing clinics based on their yearly likelihood to admit a 
person diagnosed with BPD to hospital for longer periods of time or with compulsory care, 
assuming that people diagnosed with BPD have similar symptoms and prognosis when 
corrected for sociodemographic factors and access to treatment, would enable us to study 
the effects of acute hospital admission on time to subsequent admission, visits to healthcare 
due to self-harm and completed suicide.   
PRELIMINARY DATA 
Preliminary data show large variations between and within regions over time concerning 
care for people with personality disorders (F60), as well as compulsory psychiatric care for 
all diagnoses and admission due to self-harm (see table 1). Since averages are presented 
for every region, the variation between clinics is expected to be even larger. 
 
TABLE 1. PRELIMINARY DATA. OUTCOMES CALCUALTED PER CALENDAR YEAR AND REGION 
OUTCOME  
MEAN 
MEDIAN 
TERTILES 
RANGE 
SD 
SOURCE 
 
No. diagnosed with ICD-10 F60/ 
100 000 inhabitants 
99 
96 
90, 107 
28-175 
25 
a 
Average* no. days in inpatient 
care/ individual, for individuals 
with ICD-10 F60  
15 
12 
9, 16 
1-63 
10 
a 
Average* no. of people admitted 
to compulsory psychiatric 
inpatient care (any diagnosis) 
/100 000 inhabitants 
110 
107 
98, 119 
30-180 
29 
b 
Average* no. admissions due to 
self-harm /100 000 inhabitants 
109 
102 
91, 115 
47-232 
37 
c 
Average* no. people admitted to 
inpatient or specialized 
outpatient care due to self-harm 
/100 000 inhabitants 
77 
74 
67, 83 
38-142 
21 
c 
Average* number of suicides 
/100 000 inhabitants   
13 
13 
12, 14 
6-26 
2,8 
c 
F60 – Personality disorders 
a. National Board of Health and Welfare, 2023a, measured 2010-2022 
b. National Board of Health and Welfare, 2023b, measured 2011-2021 
c. 
National Board of Health and Welfare, 2023c, measured 2010-2022 

EFFECTS OF PSYCHIATRIC ADMISSIONS ON SELF-HARM 
AND SUICIDE IN PEOPLE WITH BORDERLINE 
PERSONALITY DISORDER 
 
 
 
 
 
 
 
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*Average per region 
 
 
 

EFFECTS OF PSYCHIATRIC ADMISSIONS ON SELF-HARM 
AND SUICIDE IN PEOPLE WITH BORDERLINE 
PERSONALITY DISORDER 
 
 
 
 
 
 
 
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PROJECT DESCRIPTION 
METHODS:  
PARTICIPANTS:  
Data for all psychiatric clinics in Sweden that have permission to provide compulsory 
care for adults will be collected (n=78, e-mail contact with The Health and Social Care 
Inspectorate 2023-11-13). A specific calendar year for a clinic will be used as one 
participant, and named after the clinic and the year e.g. Umeå2010, Linköping2013, 
Malmö2022. These participants will then be ranked based on a composite variable 
consisting of the mean number days with admissions for compulsory care and other 
psychiatric inpatient care >5 days for individuals diagnosed with BPD, highest through 
lowest, during the years 2010, 2013, 2016, 2019 and 2022 (n=78 clinics x 5 calendar 
years = 390 participants). The participants in the highest quartile (n=98) will be 
compared to those in the lowest (n=98).  
 
The use of >5 days has previously been suggested as cutoff for long admissions 
(Lundahl et al., 2018) and is also supported by the fact that the intervention Brief 
Admission (BA), which allows individuals with suicidal ideation and self-harming 
behavior to admit themselves into hospital, is generally restricted to 3-5 days (Helleman 
et al., 2014, Strand et al., 2015, Westling et al., 2019). 
 
The specific calendar years were selected given that data from the compulsory care 
register is available from 2010 at the earliest. We expect that some clinics will have 
reduced their long and/or compulsory care admissions for individuals diagnosed with 
BPD, in line with recent guidelines, over the past decade. We selected to use calendar 
years at a 3 year interval with two purposes; to better show changes in the use of 
compulsory care and/or long admissions of the various clinics over the years and to try 
to avoid dependence with respect to individual clinics and time. 
DATA COLLECTION 
- 
Data will be compiled on a calendar year basis (XX 01 01 – XX -12 31) for 2010, 2013, 
2016, 2019 and 2022. 
- 
Data will be collected from the National Patient Register (NPR), which has been 
validated for the personality disorder diagnoses and BPD in women (Kouppis & 
Ekselius, 2019), the Swedish cause of death register (which is considered to be a 
reliable source of data; Brooke et al., 2017), The total population register and the 
Swedish Longitudinal Integrated Database for Health Insurance and Labour Market 
Studies (LISA).  
RETRIEVED VARIABLES 
- 
Number of people, age ≥18 years, diagnosed with BPD (ICD-10: F60.3) 
- 
Number of days with compulsory admission, including dates and diagnoses, for people 
diagnosed with BPD, age ≥18 years 

EFFECTS OF PSYCHIATRIC ADMISSIONS ON SELF-HARM 
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- 
Number of days with voluntary psychiatric admissionso >5 days, including dates and 
diagnoses, for people diagnosed with BPD, age ≥18 years 
- 
Number of compulsory admissions for people diagnosed with BPD, age≥18 years 
- 
Number of voluntary psychiatric admissions >5 days for people diagnosed with BPD, 
age≥18 years 
- 
Number days with admission due to self-harm (X60-X84; Intentional self-harm), 
including dates and diagnoses, for people diagnosed with BPD 
- 
Number of healthcare visits due to self-harm (X60-X84; Intentional self-harm) for people 
diagnosed with BPD 
- 
Number of deaths by suicide (X60-X84; Intentional self-harm or Y10-34; Events of 
undetermined intent) in individuals diagnosed with BPD 
- 
Number of deaths by suicide (X60-X84; Intentional self-harm or Y10-34; Events of 
undetermined intent) within 30 days from discharge, in individuals diagnosed with BPD  
- 
Information on legal gender is collected for all of the variables above  
COMPOSITE VARIABLES  
- 
Total number of days with compulsory admission + total number of days with voluntary 
psychiatric admissions >5 days for people diagnosed with BPD/ total number of people 
diagnosed with BPD at the specific clinic and calendar year (Mean compulsory/long-
term admission duration; MCLTAD) 
- 
Total number of compulsory admissions for people diagnosed with BPD/ total number of 
people diagnosed with BPD at the specific clinic and calendar year (Compulsory 
admission frequency; CAF) 
- 
Total number of psychiatric admissions >5 days for people diagnosed with BPD/total 
number of people diagnosed with BPD at the specific clinic and calendar year (Long-
term admission frequency; LTAF) 
PRIMARY OUTCOME MEASURES: 
- 
Number of healthcare visits due to self-harm in specialized inpatient or outpatient 
care, as defined in the NPR (X60-X84; Intentional self-harm) divided by the number 
of individuals diagnosed with BPD per clinic and calendar year. 
- 
Number of deaths by suicide (X60-X84; Intentional self-harm or Y10-34; Events of 
undetermined intent) in individuals diagnosed with BPD divided by the number of 
individuals diagnosed with BPD per clinic and calendar year. 
 
- 
Number of deaths by suicide (X60-X84; Intentional self-harm or Y10-34; Events of 
undetermined intent) within 30 days after discharge, in individuals diagnosed with 
BPD divided by the number of individuals diagnosed with BPD, per clinic and 
calendar year. 
SECONDARY OUTCOME MEASURES 
- 
Number of days between admissions to psychiatric inpatient care for people 
diagnosed with BPD divided by the number of individuals diagnosed with BPD per 
clinic and calendar year.  

EFFECTS OF PSYCHIATRIC ADMISSIONS ON SELF-HARM 
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PERSONALITY DISORDER 
 
 
 
 
 
 
 
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- 
Number of days between death by suicide (X60-X84; Intentional self-harm or Y10-34; 
Events of undetermined intent) and discharge in individuals diagnosed with BPD. For 
this variable, death by suicide during inpatient admission will be labelled 0. 
- 
Number of days in somatic (non-psychiatric) inpatient care after self-harm (X60-X84; 
Intentional self-harm) divided by the number of individuals diagnosed with BPD per clinic 
and calendar year. 
MOTIVATION FOR OUTCOME MEASURES 
Self-harm is relatively common in people diagnosed with BPD and associated with an 
increased risk of suicide (Bohus et al.2021; Zahl et al., 2004; Carroll et al., 2014). It is often 
regarded as a key outcome (NICE, 2011; Kapur, 2013). 
Completed suicide is probably the most relevant outcome since the purpose of admission to 
inpatient care for individuals diagnosed with BPD is to prevent suicide. Meanwhile, there is 
little to no evidence to support that inpatient admission has these effects (Borshmann et al., 
2012; NICE, 2009; Monk-Cunliffe et al., 2022; Paris et al., 2019) and it is even thought to 
increase the risk of suicide in the long term. Moreover, completing suicide is more than twice 
as common for men as compared to women, in Sweden and globally (World Health 
Organization, 2022).  
Recent discharge from psychiatric admission is a known risk factor for completed suicide 
and 30 days is a reasonable time frame to consider it recent (Haglund et al., 2019). 
As a measure of the severity of self-harm we used number of days in somatic (non-
psychiatric) inpatient care after self-harm (X60-X84; Intentional self-harm). 
Time to readmission is a relevant outcome since individuals diagnosed with BPD are 
prevalent in inpatient care even though there is little evidence in regard to the positive effects 
of inpatient care on the risk of suicide.  
For all outcome measures, whole-sample results will be complemented by results 
disaggregated by gender, as per the Sex and Gender Equity in Research guidelines (Heidari 
et al., 2019).  
COMPARISIONS 
- 
The basis for comparisions will be a composite score based on the total number of days 
with compulsory admissions and the total number of days with psychiatric admissions 
>5 days. 
- 
Participants will be divided into quartiles based on this composite score, ranked from 
high to low.  
- 
Participants in the highest quartile will be compared to those in the lowest. 
- 
If statistically feasible, gender-based analyses will be performed comparing means of 
women and men between the highest and lowest quartiles.  
CONFOUNDERS 
- 
Number of people diagnosed with BPD, age ≥ 18years per clinic 

EFFECTS OF PSYCHIATRIC ADMISSIONS ON SELF-HARM 
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- 
Number of people diagnosed with BPD/100 000 inhabitants, age ≥ 18years 
- 
Number of psychiatric out-patient visits/100 000 inhabitants for people diagnosed 
with BPD, age ≥ 18years  
- 
Average yearly income people diagnosed with BPD, age ≥ 18years per clinic 
- 
Number of Dialectic behavioural therapy (DBT, DU021), mentalization based 
treatment (MBT, DU013) and ERGT(Emotion regulation group therapy, DU015) 
sessions/100 000 inhabitants, age ≥ 18years 
- 
Concomitant diagnoses in people diagnosed with BPD 
- 
Marital status and education of people diagnosed with BPD 
- 
Number of individuals residing in the uptake area 
- 
Mean age of the population in the uptake area  
- 
Distribution of gender in the uptake area 
 
STATISTICAL ANALYSES AND POWER 
Depending on the distribution, participants will be grouped to enable comparisons between 
participants with high and low admission rates and duration for compulsory and/or ≥5 days 
inpatient care. If the distribution is even grouping will be made in quartiles. If an uneven 
distribution cannot justify this procedure, grouping will be made to create reasonably large 
groups with the goal to detect significant between group differences. Data will also be 
analyzed as continuous variables. 
Since 2015, visits to the emergency department leading to inpatient admission must be 
reported both as visits to specialized outpatient care and inpatient admission. This will be 
corrected for when analyzing data. 
During data analyses, we will use different regression models (linear, logistic and Cox 
regressions) depending on the characteristics of the outcome. When we use the Cox 
regression models, we will be able to take the follow-up time into account. In all analyses, we 
will be able to adjust for potential confounders (e.g., age, number of diagnoses, income, 
marital status, educatin, as well as the size of the uptake area and the intensity of outpatient 
care for the different clinical calendar years as well as if there is for example geographical 
dependence between participants with the same clinic). 
A total of 78 clinics x 5 years = 390 participants (clinical calendar years) will be included. 
According to the experience of participating researchers (Lars Rylander, professor in 
epidemiology) this is a large number of participants, deemed to be fully sufficient to answer 
the research questions. This can be illustrated by the following example. We assume that 
the 390 participants are treated as independent observations and an outcome is prevalent in 
30% in the lowest quartile. We will then with 80% statistical power be able to detect a 

EFFECTS OF PSYCHIATRIC ADMISSIONS ON SELF-HARM 
AND SUICIDE IN PEOPLE WITH BORDERLINE 
PERSONALITY DISORDER 
 
 
 
 
 
 
 
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significant (p<0.05) odds ratio of 1.68 or higher when comparing the highest quartile with the 
lowest quartile.  
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