Is it time for a more nuanced view on self‐admission to in‐patient treatment in psychiatry?

Dear Editor, Self-admission to in-patient treatment has become an increasingly popular model in Scandinavian psychiatry in recent years. In self-admission, patients with severe mental illness and a history of frequent hospital admissions are invited to decide for themselves when brief admissions are warranted. The purposes are manifold, including promotion of early help-seeking, increased patient autonomy, and reduction in the overall time spent in in-patient treatment. Based on promising results from Norwegian programs (1), self-admission has become somewhat of a “hot topic” in psychiatry— new programs are being introduced at a fast pace and in the Stockholm county council providers of psychiatric healthcare are nowadays required to offer self-admission. The attractiveness of this model is easily understood: Its emphasis on recovery in mental illness, as opposed to recovery frommental illness, fits well within a framework of increased focus on qualityof-life pragmatism and patient empowerment. Participants in self-admission programs are generally satisfied with the model, which may not be all that surprising given that they are offered increased access to a scarce resource—hospital beds—in psychiatry. However, the study by Thomsen et al. (2) that was recently published in Acta Psychiatrica Scandinavica may bring about a sobering effect on the self-admission trend. Thomsen and colleagues compared an intervention group of 422 patients, most of whom had a diagnosis of schizophrenia, participating in Danish self-admission programs with a control group of 2 110 propensity scorematched patients receiving treatment as usual (TAU). They found that whereas the intervention group reduced their total number of days spent hospitalized and exposure to coercive measures over 12 months, so did the TAU group; in fact, the TAU group fared even better in terms of reducing their utilization of in-patient care. Thus, these results do not merely represent a regression to the mean; they show that patients who were offered self-admission actually fared slightly worse than those who were not. A previous Norwegian study (3) displayed similar results. Here, 54 patients with psychotic or bipolar disorders were randomized to either selfadmission or TAU. At 12-month follow-up, both groups had reduced their service use in equally large proportions. The relatively favorable outcomes in the TAU group in both of these studies are puzzling. In the Norwegian randomized controlled trial, the patients in the TAU group were assured that they would also gain access to the self-admission program after the 12-month study period was over and they met frequently with the researchers, which may have contributed to their positive results. Furthermore, patients in both groups were included in the study after an episode of in-patient treatment and were therefore probably less likely to need renewed hospital admission for some time. In the prospective cohort study by Thomsen et al., however, the reasons for the positive outcomes in the TAU group are not as easily understood. The groups were well-matched in terms of age (means of 43.4 years in the self-admission group and 43.5 years in the TAU group), diagnoses (62.5% schizophrenia and 28.4% affective disorder in both groups), and duration of illness (means of 12.5 years in the self-admission group and 10.7 years in the TAU group). At baseline, the self-admission group displayed a history of more frequent (means of 3.68 vs. 1.92 admissions) and slightly longer hospital admissions (means of 75.2 vs. 65.4 in-patient days), but the TAU group had a larger previous exposure to all types of coercion. Arguably, the favorable outcomes are substantially better than what can usually be expected in a group of patients suffering from severe and longstanding mental illness—a highly interesting DOI: 10.1111/acps.12903