Self-harm presentations to emergency departments (EDs) are strongly associated with higher suicide risk. NLP models have shown robust performance in detecting self-harm from triage notes within single hospitals, yet performance often declines across institutions. To examine potential causes, we compare ED triage notes from two hospitals by analyzing lexical characteristics, highly associated predictive features, and salient topics. Our results reveal variation in lexical expression and feature importance related to self-harm across hospitals, despite consistent core themes such as self-poisoning and self-injury. These documentation differences are associated with reduced cross-site performance. Our findings provide insight into how institutional variation affects the identification of self-harm in clinical text and highlight potential methods to improve model generalisability.
Self-harm is a major public health concern, but current surveillance relying on hospital presentations is inadequate due to the low sensitivity of diagnostic codes. Emergency Department (ED) triage notes, recorded at the initial point of contact, provide a succinct summary of presentations and an opportunity to identify self-harm. We developed a three-stage approach, augmenting traditional machine learning with large language model-based screening and evidence extraction to detect self-harm in ED triage notes. We assessed model transferability across three Australian hospitals. Our approach showed AUPRCs of 0.887 +/- 0.016 and 0.884 +/- 0.012 during internal and external validation. Prospectively, it achieved AUPRC of 0.881 +/- 0.008 at the development site, and 0.879 +/- 0.012 and 0.816 +/- 0.015 at two external sites without site-specific retraining. A key advantage of the approach is that it enables identification of the primary self-harm method with an accuracy of 95%, supporting more granular surveillance beyond binary classification.
Self-harm content is particularly challenging to detect using NLP techniques, and is also a high-stakes task which requires the highest accuracy to enable timely intervention or flagging at-risk users. We therefore present an analysis of how LLMs represent such self-harm content, which has downstream applications in self-harm detection, LLM intervention and governance and policing. In this paper, we focus on two datasets and four models, and perform two main experiments: (1) We train and evaluate linear probes across all layers of each model on two self-harm datasets: X-Sensitive and SH-Detection. Across both corpora, self-harm information crystallizes in the final 3 - 7% of network layers (93 to 97% depth). (2) We extract contrastive self-harm directions and, after performing a normaliation step, we find that the most accurate probes are not necessarily the most linearly separable. In particular, we find Gemma-3-4B to represent this \textit{contrastive self-harm direction} in a slightly different, more intricate way than the other LLMs.
Clinical NLP increasingly relies on electronic health record (EHR) data to detect suicidal behaviors, treating clinical documentation as more reliable ground truth than social media. We argue that this framing obscures how EHR-based suicidality datasets encode a particular operationalization of suicidality, shaped by who authors the data, how episodes are bounded, and how ambiguity is resolved. We ground this argument in a case study of the ScAN dataset, built over MIMIC-III clinical notes. We show how governance constraints, ICD-based cohort selection, single-annotator labeling, and hospital-stay-level aggregation produce labels that reflect clinician-documented judgments, treat suicidality as a bounded episode, and assume that intent can be reliably inferred from documentation. A linguistic analysis demonstrates that identical labels subsume heterogeneous clinical framings differing in temporality, negation, and uncertainty. We argue that clinical NLP should examine the assumptions embedded in suicidality datasets before interpreting their labels as ground truth.