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

Abstract 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.