Using Electronic Health Records to Identify Medical Presentation for Self-harm as a Predictor of Psychotic or Bipolar Disorders: A Systems-level Alternative to the Clinical High-risk Approach.

Background and hypothesis: We examined associations between medical presentation for self-harm and subsequent diagnosis of a psychotic or bipolar disorder in a sample from the United States. Nordic registry studies have identified hospital (inpatient/emergency department) presentation of self-harm as a risk factor for developing psychotic or bipolar disorder, but it is unknown if this relationship exists within the United States and whether this relationship extends to outpatient settings.

Study design: We extracted electronic health records of individuals aged 8-29 years from Boston Children's Hospital (October 2015-August 2023), which included 155 590 individuals (mean age = 12.67 years, 52.6% female). We used Kaplan-Meier and Cox Proportional Hazard analyses to assess time-to-event associations between medical presentation for self-harm and a subsequent new diagnosis of a psychotic or bipolar disorder.

Study results: Self-harm presentation to any type of medical setting was associated with increased likelihood of developing a psychotic or bipolar disorder (Hazard Ratio [HR] = 4.99, 95% confidence interval (CI), 3.33-7.47, P = 5.65e-15). 5.8% of those who presented at an outpatient setting with self-harm were later diagnosed with psychotic or bipolar disorder (HR = 3.60, 95% CI, 2.12-6.09, P = 1.88e-06). Among individuals who presented to inpatient/emergency department settings with self-harm, 19.6% were later diagnosed with a psychotic or bipolar disorder (HR = 10.8, 95% CI, 5.98-19.6, P = 3.47e-15).

Conclusions: Presentations with self-harm to a medical setting is a robust predictor of psychotic and bipolar disorders in the United States. It is essential to consider a broad range of psychiatric outcomes when evaluating youth presenting to medical settings with self-harm and refrain from limiting clinical focus to diagnoses of depression or borderline personality disorder.