University of Oulu

Koen Bolhuis, Ulla Lång, David Gyllenberg, Antti Kääriälä, Juha Veijola, Mika Gissler, Ian Kelleher, Hospital Presentation for Self-Harm in Youth as a Risk Marker for Later Psychotic and Bipolar Disorders: A Cohort Study of 59 476 Finns, Schizophrenia Bulletin, Volume 47, Issue 6, November 2021, Pages 1685–1694,

Hospital presentation for self-harm in youth as a risk marker for later psychotic and bipolar disorders : a cohort study of 59 476 Finns

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Author: Bolhuis, Koen1,2; Lång, Ulla1; Gyllenberg, David3,4,5;
Organizations: 1Department of Psychiatry, Royal College of Surgeons in Ireland, Dublin, Ireland
2Department of Child and Adolescent Psychiatry, Erasmus Medical Centre-Sophia Children’s Hospital, Rotterdam, The Netherlands
3Department of Child Psychiatry and INVEST Research Flagship Center, University of Turku and Turku University Hospital, Turku, Finland
4Department of Adolescent Psychiatry, University of Helsinki and Helsinki University Central Hospital, Helsinki, Finland
5Finnish Institute for Health and Welfare, Helsinki, Finland
6Research Unit of Clinical Neuroscience, Department of Psychiatry, University of Oulu; Department of Psychiatry, Oulu University Hospital, Oulu, Finland
7Medical Research Center Oulu, Oulu University Hospital and University of Oulu, Oulu, Finland
8Karolinska Institute, Department of Neurobiology, Care Sciences and Society, Division of Family Medicine and Primary Care, Stockholm, Sweden
9Lucena Clinic Child and Adolescent Mental Health Service, Rathgar, Dublin, Ireland
10School of Medicine, University College Dublin, Dublin, Ireland
Format: article
Version: published version
Access: open
Online Access: PDF Full Text (PDF, 3.3 MB)
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Language: English
Published: Oxford University Press, 2021
Publish Date: 2021-12-08


Expanding clinical strategies to identify high risk groups for psychotic and bipolar disorders is a research priority. Considering that individuals diagnosed with psychotic and bipolar disorder are at high risk of self-harm, we hypothesised the reverse order relationship would also be true (ie, self-harm would predict psychotic/bipolar disorder). Specifically, we hypothesised that hospital presentation for self-harm would be a marker of high risk for subsequent development of psychotic/bipolar disorder and sought to test this hypothesis in a large population sample. This prospective register-based study included everyone born in Finland in 1987, followed until age 28 years (N = 59 476). We identified all hospital records of self-harm presentations, as well as all ICD-10 healthcare registrations of first diagnoses of psychotic and bipolar disorders. Cox proportional hazards models were used to assess the relationship between self-harm and psychotic/bipolar disorders. Of all individuals who presented to hospital with self-harm (n = 481), 12.8% went on to receive a diagnosis of psychosis (hazard ratio [HR] = 6.03, 95% confidence interval [CI] 4.56–7.98) and 9.4% a diagnosis of bipolar disorder (HR = 7.85, 95% CI 5.73–10.76) by age 28 years. Younger age of first self-harm presentation was associated with higher risk—for individuals who presented before age 18 years, 29.1% developed a psychotic or bipolar disorder by age 28 years. Young people who present to hospital with self-harm are at high risk of future psychotic and bipolar disorders. They represent an important cohort for the prevention of serious mental illness.

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Series: Schizophrenia bulletin
ISSN: 0586-7614
ISSN-E: 1745-1707
ISSN-L: 0586-7614
Volume: 47
Issue: 6
Pages: 1685 - 1694
DOI: 10.1093/schbul/sbab061
Type of Publication: A1 Journal article – refereed
Field of Science: 3124 Neurology and psychiatry
Funding: This work was supported by the Sophia Research Fund (fellowship 921 to K.B.); the Health Research Board (Ireland; ECSA-2020-05 to I.K.); the St John of God Research Foundation (project grant to I.K.); the Academy of Finland (297598 to D.G.). This work was partially funded by Academy of Finland as a project (288960 to A.K.), Flagship Programme (320162 to A.K.), and Health from Cohorts and Biobanks Programme (308552 to A.K.). Ms Lång was supported by a Strategic Academic Recruitment (StAR) award to Dr Kelleher from the Royal College of Surgeons in Ireland. Data are held at the Finnish Institute for Health and Welfare (THL) and Permission to use data is applied via Health and Social Data Permit Authority Findata or THL depending on the case. Web link:
Copyright information: © The Author(s) 2021. Published by Oxford University Press on behalf of the Maryland Psychiatric Research Center. This is an Open Access article distributed under the terms of the Creative Commons Attribution-NonCommercial License (, which permits non-commercial re-use, distribution, and reproduction in any medium, provided the original work is properly cited. For commercial re-use, please contact