Suicide in first episode psychosis: a nationwide cohort study

Systematic Review and Meta-analysis: Rates of Violence During First-Episode Psychosis (FEP)

BACKGROUND

Most people with psychotic disorders will never commit an act of violence. However, the risk of violence committed by people with schizophrenia is higher than the general population. Violence risk is also known to be highest during the first episode of psychosis compared to later stages of illness. Despite this, there have been no comprehensive reviews conducted in the past 10 years examining rates of violence during FEP. We aimed to provide an updated review of the rate of violence in people with FEP.

STUDY DESIGN

Meta-analytical techniques were used to identify pooled proportions of violence according to severity (less serious, serious, severe) and timing of violence (before presentation, at first presentation, after presentation to services).

STUDY RESULTS

Twenty-two studies were included. The pooled prevalence was 13.4% (95% CI [9.0%-19.5%]) for any violence, 16.3% (95% CI [9.1%-27.4%]) for less serious violence, 9.7% (95% CI [5.4%-17.0%]) for serious violence and 2.7% for severe violence, regardless of time point. The pooled prevalence of any violence was 11.6% (95% CI [6.8%-18.9%]) before presentation, 20.8% (95% CI [9.8%-38.7%]) at first presentation and 13.3% (95% CI [7.3%-23.0%]) after presentation to services.

CONCLUSION

Overall, rates of violence appear to be lower in more recent years. However, due to the high between-study heterogeneity related to study design, the findings must be interpreted with consideration of sample characteristics and other contextual factors. The prevalence of violence remained high at all-time points, suggesting that more targeted, holistic, and early interventions are needed for clinical FEP groups.

Using Electronic Health Records to Facilitate Precision Psychiatry

The use of clinical prediction models to produce individualized risk estimates can facilitate the implementation of precision psychiatry. As a source of data from large, clinically representative patient samples, electronic health records (EHRs) provide a platform to develop and validate clinical prediction models, as well as potentially implement them in routine clinical care. The current review describes promising use cases for the application of precision psychiatry to EHR data and considers their performance in terms of discrimination (ability to separate individuals with and without the outcome) and calibration (extent to which predicted risk estimates correspond to observed outcomes), as well as their potential clinical utility (weighing benefits and costs associated with the model compared to different approaches across different assumptions of the number needed to test). We review 4 externally validated clinical prediction models designed to predict psychosis onset, psychotic relapse, cardiometabolic morbidity, and suicide risk. We then discuss the prospects for clinically implementing these models and the potential added value of integrating data from evidence syntheses, standardized psychometric assessments, and biological data into EHRs. Clinical prediction models can utilize routinely collected EHR data in an innovative way, representing a unique opportunity to inform real-world clinical decision making. Combining data from other sources (e.g., meta-analyses) or enhancing EHR data with information from research studies (clinical and biomarker data) may enhance our abilities to improve the performance of clinical prediction models.

Mortality and suicidality in veterans health administration patients with newly-identified early episode psychosis

Within the Veterans Affairs (VA), management of self-harm is a major clinical priority. However, there is limited information on risks for self-harm among VA patients with emerging psychotic disorders relative to VA patients with other emerging mental health conditions. Using information from fiscal years 2010 through 2018, a national cohort of VA patients 30 or younger was classified based on mental health diagnoses into three groups: 1) early episode psychosis (EEP), 2) non-early episode psychosis mental health (non-EEP MH), or 3) no mental health (no MH). Analyses focused on cohort members' risk for all-cause mortality, suicide mortality, and non-fatal suicide attempts (NFSA) during the year following initial diagnosis of mental health conditions (or first year of VA care, for the no MH group). In unadjusted analyses, the EEP group had elevated rates of all-cause mortality, suicide mortality, and NFSA relative to the non-EEP MH and no MH groups and the non-EEP MH had elevated rates of all-cause mortality, suicide mortality, and NFSA relative to the no MH group. After adjusting for demographics and care receipt, EEP status was unrelated to all-cause mortality but associated with increased suicide mortality risk and NFSA. Non-EEP MH status was associated with reduced risk of all-cause mortality but increased risk for NFSA. In the year following first diagnosis, VA patients with EEP are at increased risk for suicide mortality and self-harm even after accounting for other risk factors. Clinical services targeting this crucial time can help promote safety for this vulnerable group.

Survival of patients with severe mental disorders: Influence of social functioning

BACKGROUND

Patients with severe mental disorders have a high risk of premature death due to the interaction of various factors. Social functioning is a strategic functional factor in understanding the course of psychotic disorders.

AIM

Analyze the relationship between social functioning and its various dimensions and survival during a 10-year follow-up.

METHOD

The Social Functioning Scale (SFS) was administered to 163 close relatives of patients under treatment at a Community Mental Health Unit. Survival was described by Kaplan-Meier analysis and any differences in survival by level of social functioning were found by long-rank analysis. Finally, Cox regression was used to predict premature mortality.

RESULTS

Significant differences in mortality were identified in the interpersonal behavior dimension of social functioning, while there were no significant gender or diagnostic differences in the rest of the dimensions. The interpersonal behavior dimension and age were found to be factors predicting premature death.

CONCLUSION

These findings show the protective effect of social functioning retained by patients with psychotic disorders on their survival, and the need to apply evidence-based psychotherapy focused on recovery of social functioning in the early stages of the disorder.

Examining Risk Factors for Suicidality in Adolescents and Adults Experiencing Their First Episode of Psychosis

This narrative review aimed to identify the risk factors associated with suicidality in adolescents and adults with first-episode psychosis. The review included studies that examined various factors such as psychiatric, familial, and social factors, as well as previous self-harm, suicidal ideation, and comorbid mental health disorders. A comprehensive literature search was conducted across three publicly available databases (Embase, American Psychological Association PsycINFO, and PubMed) using specific search terms related to first-episode psychosis, suicide, self-harm, and children/adolescents and adults. The inclusion criteria included original articles focusing on prospective and retrospective cohort trials, with substantial data on first-episode psychosis and self-harm, measuring both suicidal intent and outcome. Non-original studies, case reports, case series, non-English-language publications, and studies examining violence and self-harm related to substance-induced psychosis were excluded. After manual screening and removing duplicate articles, 13 articles met the established criteria for inclusion in this review. Included studies adhered to similar inclusion and exclusion criteria, had long-term follow-up, and assessed outcomes at least twice. The findings suggest that depressive symptoms, substance use disorders, previous self-harm or suicidal ideation, and longer duration of untreated psychosis are associated with an increased risk of suicidality. However, insights into psychosis and premorbid intellectual functioning did not show a direct association with suicidality.

Risk factors for mortality due to natural causes and suicide among people with severe mental illness in western China

Excess mortality in people with severe mental illness (SMI) has been extensively reported. However, little is known about mortality due to natural causes and suicide and their risk factors among people with SMI in western China. The study was conducted to determine the risk factors of natural death and suicide among people with SMI in western China. A totoal of 20,195 SMI patients in western China derived from severe mental illness information system in Sichuan province (January 1, 2006, through July 31, 2018) were included in the cohort study. Mortality rates per 10,000 person-years of natural causes and suicide for patients were calculated with different characteristics. Fine-Gray competing risk model was used to identify risk factors of natural death and suicide. The mortality was 132.8 per 10,000 person-years for natural death and 13.6 per 10,000 person-years for suicide. Males, older age, divorced/widowed, poverty and no anti-psychotic treatment were significantly associated with natural death. Higher education and suicide attempt were strong risk factors of suicide. Risk factors were not shared across natural death and suicide among people with SMI in western China. Risk management and interventions for people with SMI should be tailored for specific causes of death.

Suicide rates among people with serious mental illness: a systematic review and meta-analysis

BACKGROUND

People with serious mental illness are at great risk of suicide, but little is known about the suicide rates among this population. We aimed to quantify the suicide rates among people with serious mental illness (bipolar disorder, major depression, or schizophrenia).

METHODS

PubMed and Web of Science were searched to identify studies published from 1 January 1975 to 10 December 2020. We assessed English-language studies for the suicide rates among people with serious mental illness. Random-effects meta-analysis was used. Changes in follow-up time and the suicide rates were presented by a locally weighted scatter-plot smoothing (LOESS) curve. Suicide rate ratio was estimated for assessments of difference in suicide rate by sex.

RESULTS

Of 5014 identified studies, 41 were included in this analysis. The pooled suicide rate was 312.8 per 100 000 person-years (95% CI 230.3-406.8). Europe was reported to have the highest pooled suicide rate of 335.2 per 100 000 person-years (95% CI 261.5-417.6). Major depression had the highest suicide rate of 534.3 per 100 000 person-years (95% CI 30.4-1448.7). There is a downward trend in suicide rate estimates over follow-up time. Excess risk of suicide in males was found [1.90 (95% CI 1.60-2.25)]. The most common suicide method was poisoning [21.9 per 100 000 person-years (95% CI 3.7-50.4)].

CONCLUSIONS

The suicide rates among people with serious mental illness were high, highlighting the requirements for increasing psychological assessment and monitoring. Further study should focus on region and age differences in suicide among this population.

Depression, suicide intent, and plan among adults presenting in an emergency department after making a suicide attempt: Exploratory differences by psychosis symptom experience

Rates of suicide are significantly higher for individuals with schizophrenia spectrum disorders (SSDs) than those in the general population. With limited understandings of factors contributing to engaging in a suicide attempt among the psychosis population in the literature, the current study sought to preliminarily explore depression, suicide intent, and suicide plan among adults with and without psychosis symptom experiences who presented to an emergency department (ED) after making a suicide attempt. Electronic health record data were collected from the ED of an academic healthcare system in the Midwestern United States between 2011 and 2022. Patients included 1178 adults who arrived after making a suicide attempt. Trained research assistants conducted chart reviews and data were explored in SPSS28. A significantly smaller proportion of patients with psychosis had depressive symptoms and endorsed having suicide intent prior to their attempt in comparison to patients without psychosis. A smaller trending (p < .10) proportion of patients with psychosis endorsed having a suicide plan prior to their attempt than those with psychosis. Exploratory findings highlight the importance of EDs assessing for suicide risk beyond traditional approaches among patients with psychosis symptom experiences, including considerations for the potential of individuals not experiencing depression, suicide intent, or a suicide plan. Future research is particularly needed to examine psychosis symptomatology and the experience of distress as potential contributing factors to suicide behavior and death among patients with psychosis symptoms to better inform suicide risk assessment and intervention efforts.

Clinical insight and cognitive functioning as mediators in the relationships between symptoms of psychosis, depression, and suicide ideation in first-episode psychosis

First-episode psychosis (FEP) is a particularly high-risk period for suicide. Literature suggests poor cognitive functioning may serve as a protective factor, while investigations of clinical insight reveal a complex relationship with suicide outcomes. This study examined the mediating role of cognition and clinical insight in the relationships between positive and negative symptoms, depression, and subsequent suicide ideation among individuals in FEP. Data were obtained from the Recovery After an Initial Schizophrenia Episode project. Participants (n = 404) included adolescents and adults in FEP between the ages of 15 and 40. Measurement utilized the Calgary Depression Rating Scale, Positive and Negative Syndrome Scale, and Brief Assessment of Cognition in Schizophrenia. Structural equation modeling was used to examine the mediation model. The likelihood of experiencing suicide ideation was significantly decreased when working memory was stronger (b = -0.034, SE = 0.02, OR = 0.967, p < .05), and significantly increased when clinical insight was stronger (b = 0.191, SE = 0.08, OR = 1.21, p < .01), positive symptoms were greater (b = 0.422, SE = 0.20, OR = 1.52, p < .05) and depressive symptoms were greater (b = 0.545, SE = 0.15, OR = 1.70, p < .001). Clinical insight and working memory functioned as mediators in the relationships between depression, positive symptoms, negative symptoms, and suicide ideation. Findings suggest it is essential that clinicians have awareness of insight being a risk factor for suicide ideation and balance therapeutic efforts to strengthen clinical insight and cognition in psychosocial treatments with suicide risk assessment and prevention methods.

Neurocognitive functioning and impulsivity in first-episode psychosis with suicidal ideation and behavior: A systematic review

BACKGROUND

The prevalence of suicidal ideation (SI) and behavior (SB) among people suffering from psychotic disorders is a public health issue. Most suicide attempts (SAs) occur before or during the early phases of first-episode psychosis (FEP). Improving knowledge about the suicide risk in the early stages is essential to develop therapeutic and prevention strategies. We conducted a systematic review to investigate an association between neurocognitive impairments or a history of impulsive behavior and SI or SB among patients with FEP.

METHOD

PRISMA guidelines were followed. Ten databases were searched using MeSH terms or key-words related to FEP, impulsivity or cognitive functioning measures and SI or SB, without restrictions for study design or length of follow-up. Included studies evaluated at least one cognitive function with neuropsychological tests or validated questionnaires, or provided records of impulsive behavior.

RESULTS

Twenty one research papers were included from databases, bibliographic references or expert opinions. Among patients with FEP, seven studies showed more pronounced neuropsychological impairments, especially regarding attention, processing speed, executive functioning and theory of mind in patients that had attempted suicide. No association was found between cognitive impairments on neuropsychological tests and SI. Previous non-suicidal impulsive behaviors were associated with SAs and suicide.

CONCLUSION

Our review suggests an association between neurocognitive impairments and SAs among patients with FEP. Records of impulsive behavior are also associated with SB in that population. Further research on the neuropsychology of FEP is necessary to identify how these impairments facilitate SB and evaluate their potential utility as therapeutic targets.

A Population-Based Analysis of Interpersonal Trauma, Psychosis, and Suicide: Evidence, Pathways, and Implications

Subthreshold psychotic experiences (PEs) are known to confer a risk for suicidality. Yet, despite evidence of a strong etiological trauma-psychosis pathway, the coalesced effect of such concurrences on suicide risk is largely discounted. Our aims were to examine the impact of different manifestations of life span trauma and PEs on the risk of suicidal thoughts and attempts, using an exploratory person-centered approach. Data from the Adult Psychiatric Morbidity Survey (N = 7,403) were analyzed. PEs were assessed using the Psychosis Screening Questionnaire (PSQ) alongside items probing childhood and adult trauma, in addition to 12-month suicide thoughts and attempt. A manual three-step latent class analysis elicited four distinct profiles, namely, a socially disconnected/high PE, a sexual victimization/moderate PE, a life span trauma/low PE, and a baseline class. The socially disconnected class, characterized by a moderate likelihood of social disconnection, a high probability of various PE endorsements, yet a low likelihood of other significant trauma, showed the greatest risk of 12-month suicide ideation (odds ratio [OR] = 13.0, 95% confidence interval [CI] = [8.539, 19.021) and attempt (OR = 24.2, 95% CI = [10.349, 56.860). Neither multiple nor recurrent traumatic experiences invariably result in the emergence of PEs. Instead, a sense of social disconnection may be either resultant of PEs or alone sufficient to cultivate such symptom presentations, even in the absence of prior traumas. Moreover, just as traumatic encounters increase the risk of suicidality, so too might seemingly more innocuous adversities, such as poor-quality social relationships, further elevate the risk, particularly when proximal and coupled with the simultaneity of PEs.

Morbidity and mortality in schizophrenia with comorbid substance use disorders

OBJECTIVE

Schizophrenia is highly comorbid with substance use disorders (SUD) but large epidemiological cohorts exploring the prevalence and prognostic significance of SUD are lacking. Here, we investigated the prevalence of SUD in patients with schizophrenia in Finland and Sweden, and the effect of these co-occurring disorders on risks of psychiatric hospitalization and mortality.

METHODS

45,476 individuals with schizophrenia from two independent national cohort studies, aged <46 years at cohort entry, were followed during 22 (1996-2017, Finland) and 11 years (2006-2016, Sweden). We first assessed SUD prevalence (excluding smoking). Then, we performed Cox regression on risk of psychiatric hospitalization and all-cause and cause-specific mortality in SUD compared with those without SUD.

RESULTS

The prevalence of SUD ranged from 26% (Finland) to 31% (Sweden). Multiple drug use (n = 4164, 48%, Finland; n = 3268, 67%, Sweden) and alcohol use disorders (n = 3846, 45%, Finland; n = 1002, 21%, Sweden) were the most prevalent SUD, followed by cannabis. Any SUD comorbidity, and particularly multiple drug use and alcohol use, were associated with 50% to 100% increase in hospitalization (aHR any SUD: 1.53, 95% CI = 1.46-1.61, Finland; 1.83, 1.72-1.96, Sweden) and mortality (aHR all-cause mortality: 1.65, 95% CI = 1.50-1.81, Finland; 2.17, 1.74-2.70, Sweden) compared to individuals without SUD. Elevated mortality risks were observed especially for suicides and other external causes. All results were similar across countries.

CONCLUSION

Co-occurring SUD, and particularly alcohol and multiple drug use, are associated with high rates of hospitalization and mortality in schizophrenia. Preventive interventions should prioritize detection and tailored treatments for these comorbidities, which often remain underdiagnosed and untreated.

Self-harm, suicidal ideation, and the positive symptoms of psychosis: Cross-sectional and prospective data from a national household survey

BACKGROUND

Schizophrenia is associated with premature mortality, partly through increased suicide rates.

AIMS

To examine (1) if persecutory ideas, auditory hallucinations, and probable cases of psychosis are associated with suicidal thoughts or attempts cross-sectionally and prospectively, and (2) if such links are mediated by specific affective factors (depression, impulsivity, mood instability).

METHOD

We analysed the 2000, 2007, and 2014 British Adult Psychiatric Morbidity Surveys (APMS) separately. Measures of psychosis provided independent variables for multi-stage logistic regressions, with suicidal thoughts and attempts as dependent variables. We also conducted analyses to assess mediation by affective variables, and longitudinal analyses on a subset of the 2000 dataset.

RESULTS

In every dataset, persecutory ideas, auditory hallucinations and probable psychosis were associated cross-sectionally with lifetime suicidal attempts and thoughts, even after controlling for confounders, with a single exception (persecutory ideation and suicide attempts were unconnected in APMS 2014). Cross-sectional associations between auditory hallucinations and suicidal phenomena were moderated by persecutory ideation. In the 2000 follow-up, initial persecutory ideas were associated with later suicidal thoughts (O.R. 1.77, p < 0.05); there were no other longitudinal associations. In the 2007 and 2014 datasets, mood instability mediated the effects of psychotic phenomena on suicidality more strongly than impulsivity; depression was also an important mediator. There were appreciable direct effects of positive symptoms on suicidal thoughts and behaviour.

CONCLUSIONS

Improving psychotic symptoms and ameliorating co-morbid distress may in itself be effective in reducing suicidal risk in schizophrenia. Given their potential mediating role, mood instability and depression may also be targets for intervention.

Association of depressive symptoms with cognitive impairment in patients with never-treated first-episode schizophrenia: Analysis of the Depression in Schizophrenia in China (DISC) study

OBJECTIVE

Depressive symptoms and cognitive dysfunction are common in patients with schizophrenia and depressive disorder. This study aimed at exploring whether and how depressive symptoms were correlated with neuro-cognitive impairment in patients with never-treated first-episode (NTFE) schizophrenia.

METHODS

The Repeatable Battery for the Assessment of Neuropsychological Status (RBANS) was administered to 79 patients and 80 healthy controls to assess neuropsychological function. For all patients, the 17-item Hamilton Depression Rating Scale (HAMD-17) was adopted to evaluate depressive symptoms, and the Positive and Negative Syndrome Scale (PANSS) was utilized to assess psychopathological symptoms.

RESULTS

Thirty-nine patients (49.37%) met the criteria for comorbid depressive symptoms. The RBANS total and the four index scores in the patients were significantly lower than those in the healthy controls. Further, compared with patients without depressive symptoms, patients with depressive symptoms scored lower in attention index, but higher in PANSS general psychopathology and total scores. The HAMD-17 total score was significantly correlated with attention, PANSS total, and PANSS general psychopathology scores. Moreover, multiple regression analysis identified education and HAMD-17 score as the contributors to attention.

CONCLUSION

Our results suggest that the rate of depressive symptoms in NTFE schizophrenia is high, which is correlated with neuro-cognitive impairment, especially attention and psychopathology.

Suicidal thinking and behaviours in First Episode Psychosis: Findings from a 3-year longitudinal study

AIM

Suicide risk is greater at the beginning of the course of psychosis. Purpose of this research was: (a) to investigate prevalence and incidence rates of suicide attempts, suicidal thinking and completed suicide in First Episode Psychosis (FEP) help-seekers as compared with non-FEP help-seeking peers, and (b) to examine any correlation of suicidal ideation with other baseline psychopathological predictors.

METHODS

Two hundred and forty-one young people (13-35 years) were assessed with the World Health Organization Quality Of Life scale - Brief version (WHOQOL-BREF), the Beck Depression Inventory - II Edition (BDI-II) and the Comprehensive Assessment of At-Risk Mental States (CAARMS) at the enrollment and over a 36-month follow-up period. A Kaplan-Meier survival analysis to calculate cumulative incidence rates of attempted and completed suicide was used.

RESULTS

FEP patients showed more severe levels of CAARMS "Suicidality/Self-Harm" item than non-FEP peers. They also had higher 3-year incidence rates of attempted suicide (11%) and completed suicide (13%). Within the FEP total group, suicidal ideation was positively correlated with BDI-II and CAARMS "Perceptual Abnormalities" item scores, and showed negative associations with younger age and WHOQOL-BREF "Social Relationships" factor sub-score.

CONCLUSIONS

Suicidal ideation is relevant in FEP patents, supporting the routine monitoring of suicide risk in baseline assessment of adolescents and young adults with early psychosis. Suicidal thinking seems to be correlated to younger age, perceptual aberrations and depression severity, as well as to poorer quality of social relationships.

Mortality After the First Diagnosis of Schizophrenia-Spectrum Disorders: A Population-based Retrospective Cohort Study

There is emerging evidence of high mortality rates after the first diagnosis of psychotic disorder. The objective of this study was to estimate the standardized mortality ratio (SMR) in a population-based cohort of individuals with a first diagnosis of schizophrenia-spectrum psychotic disorder (SSD). The cohort included a population-based sample of individuals with a first diagnosis of SSD based on the first diagnosis occurring during hospitalization or in an outpatient setting between 2007 and 2010 in Ontario, Canada. All patients were followed for 5 years after the first diagnosis. The primary outcome was SMR, including all-cause, suicide-related, accidental, and other causes. Between 2007 and 2010, there were 2382 patients in the hospitalization cohort and 11 003 patients in the outpatient cohort. Over the 5-year observation period, 97 (4.1%) of the hospitalization cohort and 292 (2.7%) of the outpatient cohort died, resulting in an SMR of 13.6 and 9.1, respectively. In both cohorts, suicide was the most common cause of death. Approximately 1 in 25 patients with a first diagnosis of SSD during hospitalization, and 1 in 40 patients with a first diagnosis of SSD in an outpatient setting, died within 5 years of first diagnosis in Ontario, Canada. This mortality rate is between 9 and 13 times higher than would be expected in the age-matched general population. Based on these data, timely access to services should be a public health priority to reduce mortality following a first diagnosis of an SSD.

Review of Early Intervention Programmes in Psychosis: Implementation Proposal for Peru

A delay in receiving an antipsychotic treatment is associated with unfavourable clinical and functional outcomes in patients with a first episode of psychosis. In recent years, early psychosis intervention programmes have been implemented that seek the early detection and treatment of patients who begin to describe psychotic symptoms. These programmes have shown to be more effective than standard care in improving the symptoms of the disorder and recovering the patient's functionality, in turn proving to be more cost-effective. The benefits of these programmes have led to their implementation in high-income countries. However, implementation in medium- and low-income countries has been slower. Peru, a Latin American country with an upper middle income, is undergoing a mental health reform that prioritises health care based on the prevention, treatment and psychosocial recovery of patients from a comprehensive and community approach. The present manuscript describes the characteristics and structure of the pioneering and more developed programmes for early psychosis intervention, and discusses the benefits and challenges of implementing an early psychosis intervention programme in Peru in the current context of mental health reform.

Predictors of suicide at time of diagnosis in schizophrenia spectrum disorder: A 20-year total population study in Ontario, Canada

BACKGROUND

Suicide is a major cause of mortality for individuals with schizophrenia spectrum disorders (SSD). Understanding the risk factors for suicide at time of diagnosis can aid clinicians in identifying people at risk.

METHODS

Records from linked administrative health databases in Ontario, Canada were used to identify individuals aged 16 through 45 years who received a first lifetime diagnosis of SSD (schizophrenia, schizoaffective disorder, psychotic disorder not otherwise specified (NOS)) using a validated algorithm between 01/01/1993 and 12/31/2010. The main outcome was death by suicide following cohort entry until 12/31/2012.

OUTCOMES

75,989 individuals with a first SSD diagnosis (60.1% male, 39.9% female) were followed for an average of 9.56 years. During this period, 1.71% of the total sample (72.1% male, 27.9% female) died by suicide, after an average of 4.32 years. Predictors of suicide death included male sex (HR 2.00, 95% CI 1.76-2.27), age at diagnosis between 26 and 35 (HR 1.27, 95% CI 1.10-1.45) or 36-45 (HR 1.34, 95% CI 1.16-1.54), relative to 16-25, and suicide attempt (HR 2.23, 95% CI 1.86-2.66), drug use disorder (HR 1.21, 95% CI 1.04-1.41), mood disorder diagnosis (HR 1.32, 95% CI 1.17-1.50), or mental health hospitalization (HR 1.30 95% CI 1.13-1.49) in the 2 years prior to SSD diagnosis.

INTERPRETATION

Death by suicide occurs in 1 out of every 58 individuals and occurred early following first diagnosis of SSD. Psychiatric hospitalizations, mood disorder diagnoses, suicide attempts prior to SSD diagnosis, as well as a later age at first diagnosis, are all predictors of suicide and should be integrated into clinical assessment of suicide risk in this population.

The neurobiology of suicide in psychosis: A systematic review

The lifetime risk of dying by suicide in schizophrenia and related psychoses has been estimated to be approximately between 5% and 7%, though some have estimated that the number is closer to 10%. The highest risk for suicide occurs within the first year after presentation, when patients have a 12 times greater risk of dying by suicide than the general population, or a 60% higher risk compared with patients in other phases of psychosis, although the risk continues for many years. Some 31% of all deaths in first and early episode samples are due to suicide. Studies in individuals at clinical high-risk for psychosis (CHR) or with attenuated positive symptoms also demonstrate that suicidality is common and problematic in these individuals. Therefore, suicide in psychosis is a particularly severe problem. In order to develop interventions aimed at reducing the risk of suicide in psychotic individuals, it will be critical to understand the neurobiology of suicide in psychosis. In this paper, I report on the results of a systematic review of the work done to date on the neurobiology of suicide in psychosis and on suicidality in the CHR period. I will also identify gaps in knowledge and discuss future strategies for studying the neurobiology of suicidality in psychosis that may help to disentangle the links between suicide and psychosis and, by doing so, allow us to gain a greater understanding of the relationship between suicide and psychosis, which is critical for developing interventions aimed at reducing the risk of suicide in psychotic individuals.

Suicidal Ideation in Patients Experiencing a First-episode Psychosis: Findings From the 2-Year Follow-up of the "Parma Early Psychosis" Program

OBJECTIVE

Although suicide behavior is relevant in first-episode psychosis (FEP), little is known about suicidal ideation and its longitudinal stability. The aim of this study was (1) to assess incidence rates of suicide attempts, completed suicide, and suicidal thinking in FEP individuals at baseline and over a 24-month follow-up period; (2) to explore any significant association of suicidal ideation with psychopathology at baseline; and (3) to monitor longitudinally suicidal thinking along the 2-year follow-up.

METHODS

Participants (134 FEP patients, aged 13-54 years) were assessed with the Brief Psychiatric Rating Scale (BPRS) and the Positive and Negative Syndrome Scale (PANSS). A Kaplan-Meier survival analysis to calculate cumulative incidence rates of attempted and completed suicide was also performed.

RESULTS

FEP patients showed a 31.3% percentage of suicidal ideation (i.e., BPRS item 4 cutoff score of ≥ 3) and a 2-year cumulative incidence rate of attempted suicide of 11%. No completed suicide was found. In the FEP total sample, suicidal thinking was positively correlated with general psychopathology (especially depression) and negative symptoms.

CONCLUSIONS

Suicidal ideation is relevant in FEP patients, supporting a routine monitoring of suicide risk during the baseline assessment of adolescents and adults with early psychosis.

Suicidal ideation, behavior, and mortality in male and female US veterans with severe mental illness

BACKGROUND

We compared male and female American veterans with schizophrenia or bipolar disorder regarding clinical characteristics associated with lifetime suicidal ideation and behavior. Subsequent mortality, including death by suicide, was also assessed.

METHODS

Data from questionnaires and face-to-face evaluations were collected during 2011-2014 from 8,049 male and 1,290 female veterans with schizophrenia or bipolar disorder. In addition to comparing male-female characteristics, Cox regression models-adjusted for demographic information, medical-psychiatric comorbidities, and self-reported suicidal ideation and behavior-were used to examine gender differences in associations of putative risk factors with suicide-specific and all-cause mortality during up to six years of follow-up.

RESULTS

Women overall were younger, more likely to report a history of suicidal behavior, less likely to be substance abusers, and had lower overall mortality during follow-up. Among women only, psychiatric comorbidity was paradoxically associated with lower all-cause mortality (hazard ratio [HR]=0.53, 95% CI, 0.29-0.96, p = 0.037 for 1 disorder vs. none; HR=0.44, 95% CI, 0.25-0.77, p = 0.004 for ≥2 disorders vs. none). Suicide-specific mortality involved relatively few events, but crude rates were an order of magnitude higher than in the U.S. general and overall veteran populations.

LIMITATIONS

Incomplete cause-of-death information and low statistical power for male-female comparisons regarding mortality.

CONCLUSIONS

Female veterans with SMI differed from females in the general population by having a higher risk of suicide attempts. They also had more lifetime suicide attempts than male veterans with same diagnoses. These differences should inform public policy and clinical planning.

Suicides and Suicide Attempts Among Psychiatric Hospital Inpatients in Iran

Background:

Suicidal behavior is seen in the context of a variety of mental disorders. While many believe that, in general, first-episode psychosis is a particularly high-risk period for suicide, no general agreement regarding higher prevalence of suicide in first-episode psychosis is achievable.

Objective:

In the present study, suicides and suicide attempts among psychiatric in-patients have been evaluated to assess the general profile of suicidal behavior among native psychiatric inpatients and any relationship between serum cholesterol level and suicidal behavior.

Methods:

Five acute academic wards, which have been specified for admission of first episode adult psychiatric patients, and five acute non-academic wards, which have been specified for admission of recurrent episode adult psychiatric patients, were selected for the current study. All inpatients with suicidal behavior (successful suicide and attempted suicide, in total), during the last five years (2013-2018), were included in the present investigation. Also, the assessment of serum lipids, including triglyceride, cholesterol, low-density lipoprotein and high-density lipoprotein, was done , for comparing the suicidal subjects with non-suicidal ones.

Results:

Among 19160 psychiatric patients hospitalized in Razi psychiatric hospital during a sixtymonths period, 63 suicidal behaviors, including one successful suicide and sixty-two suicide attempts, were recorded by the safety board of hospital. The most frequent mental illness was bipolar I disorder, which was significantly more prevalent in comparison with other mental disorders (p<0.04, p<0.02, p<0.007, and p<0.003 in comparison with schizophrenia, depression, personality disorders and substance abuse, respectively). Self-mutilation, self-poisoning and hanging were the preferred methods of suicide among 61.11%, 19.44% and 19.44% of cases, respectively. In addition, no significant difference was evident between the first admission and recurrent admission inpatients, totally and separately, particularly with respect to psychotic disorders. Besides, with respect to different components of serum lipids, no specific or significant pattern was evident.

Conclusion:

While in the present study, the suicidal behavior was significantly more evident in bipolar disorder in comparison with other psychotic or no-psychotic disorders, no significant difference was evident between the first admission and recurrent admission of psychiatric inpatients. Moreover, no significant relationship between suicidal behavior and serum lipids was found .

Suicide ideation, suicide attempts, their sociodemographic and clinical associates among the elderly Chinese patients with schizophrenia spectrum disorders

BACKGROUND

It is still unknown whether many well-identified risk factors of suicide could be applied to the elderly Chinese patients with schizophrenia.

METHODS

1-month suicidal ideation and lifetime suicide attempts together with their sociodemographic and clinical associates were analyzed by retrospective data on 263 elderly patients with schizophrenia spectrum disorders at the Kangning Hospital, Shenzhen, China. T-tests and Chi-square tests were used to examine the differences between patients with and without suicidality. Backward stepwise logistic regression was performed to identify the associated factors.

RESULTS

Among the selected patients, 17.87% had 1-month suicide ideation and 7.60% had lifetime suicide attempts. It was further observed that the elderly patients with schizophrenia who had 1-month suicide ideation were more likely to report lifetime suicide attempts, suffer from severe hopelessness and negative symptoms, and have no pension. However, the backward stepwise logistic regression analyses revealed that lifetime suicide attempts and negative symptoms were most significantly associated with 1-month suicide ideation. In contrast, lifetime suicide attempters were more likely to be men, receive a pension, display symptoms of hopelessness, have longer duration of illness and poor family relationships. The regression analyses also indicated that only hopelessness, relatively long duration of schizophrenia, and poor family relationships were the most significantly associated with lifetime suicide attempts.

LIMITATIONS

The retrospective design do not allow for causal inferences.

CONCLUSIONS

Early interventions designed to decrease hopelessness, control negative symptoms, and improve family relationships may result in reduced risks of suicide among elderly Chinese patients with schizophrenia.

Personality traits, theory of mind and their relationship with multiple suicide attempts in a sample of first episode psychosis patients: One-year follow-up study

BACKGROUND

High rates of suicidal behaviour (SB) have been found in first episode psychosis (FEP) patients. It has been suggested that the presence of multiple suicide attempts (mSA) increases the risk of later SA and the risk of eventual death by suicide.

OBJECTIVE

Our main objective was to study the baseline factors associated with the presence of mSA during the first year after FEP. In addition, a second aim was to find out whether there were any differences between single and multiple suicide attempters in the timing of the first SA after FEP.

METHOD

A total of 65 FEP patients were evaluated. The presence of SAs were recorded at two different times after FEP. Bivariate and multivariate analyses were performed to explore the relationship between SA with sociodemographic and clinical variables.

RESULTS

Multiple linear regression showed that mSA was associated with the presence of increased symptom severity (B = 0.35; t = 3.67; p < 0.01) and errors in first-order false-belief task (B = 0.48; t = 2.11; p = 0.04). There were significant differences in the timing of first SA after FEP between multiple and single suicide attempters.

CONCLUSIONS

Theory of mind impairments along with more severe symptoms during the first contact with mental health services for psychotic symptoms appeared to be important predictors of mSA. On the other hand, multiple suicide attempters tend to make a first SA after FEP earlier than single suicide attempters. These results could contribute to the implementation of preventive suicidal programs, however they must be confirmed by additional research.

Medication, hospitalizations and mortality in 5 years after first-episode psychosis in a Swedish nation-wide cohort

AIM

To investigate medication, rehospitalizations and mortality after first-episode hospital-treated psychosis.

METHODS

A population-based nation-wide cohort (n = 2488) with a first hospitalization for psychosis at ages between 16 and 25 was identified. Cases were followed for up to 5 years after the first psychosis hospitalization with regard to mortality, hospitalizations and dispensations of antipsychotics and benzodiazepines.

RESULTS

The proportion of patients dispensing antipsychotics decreased from 80% year 1 after first discharge to 55% year 5. The proportion of patients having episodes of inpatient care also decreased year by year from 46% year 1 to 27% year 5. Of 863 cases with 5 years of observation time 41% had dispensations of antipsychotics every year; 21% had no dispensation of antipsychotics or hospitalization after the first year. The cumulative 5-year mortality was 3.9%. Cumulative suicide mortality was 2.4%. Incidence of suicide was highest in the first year. Male gender, benzodiazepines, recent hospital-discharge and self-harm were identified as risk factors for suicide.

CONCLUSIONS

The proportion of cases dispensing antipsychotics decreases year by year after first discharge. Mortality and rates of rehospitalization also decrease year by year from high levels the first year.

Service utilization and suicide among people with schizophrenia spectrum disorders

OBJECTIVE

To compare individuals with and without schizophrenia spectrum disorders (SSD) (schizophrenia, schizoaffective disorder, or psychotic disorder not otherwise specified) who die by suicide.

METHOD

This is a retrospective case control study which compared all individuals who died by suicide in Ontario, Canada with (cases) and without (controls) SSD between January 1, 2008 and December 31, 2012. Cases (individuals with SSD) were compared to controls on demographics, clinical characteristics, and health service utilization proximal to suicide. A secondary analysis compared the characteristics of those with SSD and those with severe mental illness (defined as those without SSD who have had a psychiatric hospitalization within the five-years before suicide (excluding the 30 days prior to death)).

RESULTS

Among 5650 suicides, 663 (11.7%) were by individuals with SSD. Compared to other suicides, SSD suicides were significantly more likely to be between the ages of 25-34. SSD suicide victims were significantly more likely to reside in the lowest income neighbourhoods and to reside in urban areas. SSD victims were also significantly more likely to have comorbid mood and personality disorders and all types of health service utilization, including outpatient mental health service contact in the 30 days prior to death, even when compared only with those who had a history of mental health hospitalization.

CONCLUSIONS

Individuals with schizophrenia spectrum disorder account for over 1 in 10 suicide deaths, tend to be younger, poorer, urban, more clinically complex, and have higher rates of mental health service contact prior to death. The demographic and service utilization differences persist even when the SSD group is compared with a population with severe mental illness that is not SSD. Suicide prevention strategies for people with schizophrenia spectrum disorder should emphasize the importance of clinical suicide risk assessment during clinical encounters, particularly early in the course of illness.

The impact of psychological problems and adverse life events on suicidal ideation among adolescents using nationwide data of a school-based mental health screening test in Korea

The aim of this study was to investigate the risk factors for suicidal ideation in adolescents by gender and age. This study used 2013 nationwide school-based mental health screening test data from 591,303 seventh grade students and 618,271 tenth grade students in Korea. Suicidal ideation, four psychological problems, and three adverse life events were evaluated using the Adolescents Mental Health and Problem Behavior Screening Questionnaire-II. Of all students, 12.9-14.7% of the boys and 17.1-23.2% of the girls had suicidal ideation. Mood had the greatest impact on the risk for suicidal ideation and other factors also significantly increased the risk of suicidal ideation. Distractibility was positively related to suicidal ideation only in seventh grade students and behavioral problems increased suicidal ideation more in girls than in boys. Violence constituted the most powerful factor for suicidal ideation among the events; however, bullying constituted the most important event that increased suicidal ideation in seventh grade girls. All factors except 'Distractibility' increased the risk of severe suicidal ideation. The risk factors for suicidal ideation in adolescents differed by gender and age. Interventions should be made according to these characteristics to reduce suicidal ideation in adolescents.

Total and cause-specific standardized mortality ratios in patients with schizophrenia and/or substance use disorder

Individuals with schizophrenia or substance use disorder have a substantially increased mortality compared to the general population. Despite a high and probably increasing prevalence of comorbid substance use disorder in people with schizophrenia, the mortality in the comorbid group has been less studied and with contrasting results. We performed a nationwide open cohort study from 2009 to 2015, including all Norwegians aged 20-79 with schizophrenia and/or substance use disorder registered in any specialized health care setting in Norway, a total of 125,744 individuals. There were 12,318 deaths in the cohort, and total, sex-, age- and cause-specific standardized mortality ratios (SMRs) were calculated, comparing the number of deaths in patients with schizophrenia, schizophrenia only, substance use disorder only or a co-occurring diagnosis of schizophrenia and substance use disorder to the number expected if the patients had the age-, sex- and calendar-year specific death rates of the general population. The SMRs were 4.9 (95% CI 4.7-5.1) for all schizophrenia patients, 4.4 (95% CI 4.2-4.6) in patients with schizophrenia without substance use disorder, 6.6 (95% CI 6.5-6.8) in patients with substance use disorder only, and 7.4 (95% CI 7.0-8.2) in patients with both schizophrenia and substance use disorder. The SMRs were elevated in both genders, in all age groups and for all considered causes of death, and most so in the youngest. Approximately 27% of the excess mortality in all patients with schizophrenia was due to the raised mortality in the subgroup with comorbid SUD. The increased mortality in patients with schizophrenia and/or substance use disorder corresponded to more than 10,000 premature deaths, which constituted 84% of all deaths in the cohort. The persistent mortality gap highlights the importance of securing systematic screening and proper access to somatic health care, and a more effective prevention of premature death from external causes in this group.

Association of an Early Intervention Service for Psychosis With Suicide Rate Among Patients With First-Episode Schizophrenia-Spectrum Disorders

IMPORTANCE

Patients with schizophrenia have a substantially higher suicide rate than the general public. Early intervention (EI) services improve short-term outcomes. However, little is known about the association of EI with suicide reduction in the long term.

OBJECTIVE

To examine the association of a 2-year EI service with suicide reduction in patients with first-episode schizophrenia-spectrum (FES) disorders during 12 years and the risk factors for early and late suicide.

DESIGN, SETTING, AND PARTICIPANTS

This historical control study compared 617 consecutive patients with FES who received the 2-year EI service in Hong Kong between July 1, 2001, and June 30, 2003, with 617 patients with FES who received standard care (SC) between July 1, 1998, and June 30, 2001, matched individually. Clinical information was systematically retrieved for the first 3 years of clinical care for both groups. The details of death were collected up to 12 years from presentation to the services. Data analysis was performed from October 30, 2016, to August 18, 2017.

MAIN OUTCOMES AND MEASURES

Suicide rate during 12 years was the primary measure. The association of the EI service with the suicide rates during years 1 through 3 and years 4 through 12 were explored separately.

RESULTS

The main analysis included 1234 patients, with 617 in each group (mean [SD] age at baseline, 21.2 [3.4] years in the EI group and 21.3 [3.4] years in the SC group; 318 male [51.5%] in the EI group and 322 [52.2%] in the SC group). The suicide rates were 7.5% in the SC group and 4.4% in the EI group (McNemar χ2 = 5.55, P = .02). Patients in the EI group had significantly better survival (propensity score-adjusted hazard ratio, 0.57; 95% CI, 0.36-0.91; P = .02), with the maximum association observed in the first 3 years. The number of suicide attempts was an indicator of early suicide (1-3 years). Premorbid occupational impairment, number of relapses, and poor adherence during the initial 3 years were indicators of late suicide (4-12 years).

CONCLUSIONS AND RELEVANCE

This study suggests that the EI service may be associated with reductions in the long-term suicide rate. Suicide at different stages of schizophrenia was associated with unique risk factors, highlighting the importance of a phase-specific service.

The role of premorbid personality and social cognition in suicidal behaviour in first-episode psychosis: A one-year follow-up study

BACKGROUND

High suicide attempt (SA) rates have been reported in first-episode psychosis (FEP) patients, particularly during the first year after the illness onset. Despite previous studies establishing several risk factors for suicidal behaviour in FEP, premorbid personality and social cognition have not been sufficiently investigated to date.

OBJECTIVE

To test whether personality traits and social cognition are associated with SAs in FEP over a 12-month follow-up.

METHOD

Sixty-five FEP patients were evaluated at first contact with mental health services. The presence of SAs was recorded at six and twelve months after first presentation. Bivariate and multivariate analyses explored the influence of a range of sociodemographic and clinical variables, including premorbid personality and social cognition-related Theory of Mind (ToM) measures, on SAs.

RESULTS

SAs were associated with greater severity of symptoms at first hospitalization with psychotic symptoms (OR = 2.18, 95% CI = 1.25-3.82), schizoid personality traits (OR = 1.62, 95% CI = 1.02-2.57) and impairment in a first-order false belief task (OR = 4.26, 95% CI = 1.05-17.31) in the multivariate models.

CONCLUSIONS

Symptom severity at illness onset, premorbid schizoid personality traits and ToM impairment emerged as predictors of SA in this FEP sample, which, if replicated, may be useful in identifying high-risk groups and implementing more targeted suicide prevention programs in FEP.

Recovery and serious mental illness: a review of current clinical and research paradigms and future directions

INTRODUCTION

Recovery from serious mental illness has historically not been considered a likely or even possible outcome. However, a range of evidence suggests the courses of SMI are heterogeneous with recovery being the most likely outcome. One barrier to studying recovery in SMI is that recovery has been operationalized in divergent and seemingly incompatible ways: as an objective outcome versus a subjective process. Areas covered: This paper offers a review of recovery as a subjective process and recovery as an objective outcome; contrasts methodologies utilized by each approach to assess recovery; reports rates and correlates of recovery; and explores the relationship between objective and subjective forms of recovery. Expert commentary: There are two commonalities of approaching recovery as a subjective process and an objective outcome: (i) the need to make meaning out of one's experiences to engage in either type of recovery and (ii) there exist many threats to engaging in meaning making that may impact the likelihood of moving toward recovery. We offer four clinical implications that stem from these two commonalities within a divided approach to the concept of recovery from SMI.

Suicide Rates After Discharge From Psychiatric Facilities: A Systematic Review and Meta-analysis

Importance

High rates of suicide after psychiatric hospitalization are reported in many studies, yet the magnitude of the increases and the factors underlying them remain unclear.

Objectives

To quantify the rates of suicide after discharge from psychiatric facilities and examine what moderates those rates.

Data Sources

English-language, peer-reviewed publications published from January 1, 1946, to May 1, 2016, were located using MEDLINE, PsychINFO, and EMBASE with the search terms ((suicid*).ti AND (hospital or discharg* OR inpatient or in-patient OR admit*).ab and ((mortality OR outcome* OR death*) AND (psych* OR mental*)).ti AND (admit* OR admis* or hospital* OR inpatient* OR in-patient* OR discharg*).ab. Hand searching was also done.

Study Selection

Studies reporting the number of suicides among patients discharged from psychiatric facilities and the number of exposed person-years and studies from which these data could be calculated.

Data Extraction and Synthesis

The meta-analysis adhered to Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) and Meta-analysis of Observational Studies in Epidemiology (MOOSE) guidelines. A random-effects model was used to calculate a pooled estimate of postdischarge suicides per 100 000 person-years.

Main Outcomes and Measures

The suicide rate after discharge from psychiatric facilities was the main outcome, and the association between the duration of follow-up and the year of the sampling were the main a priori moderators.

Results

A total of 100 studies reported 183 patient samples (50 samples of females, 49 of males, and 84 of mixed sex; 129 of adults or unspecified patients, 20 of adolescents, 19 of older patients, and 15 from long-term or forensic discharge facilities), including a total of 17 857 suicides during 4 725 445 person-years. The pooled estimate postdischarge suicide rate was 484 suicides per 100 000 person-years (95% CI, 422-555 suicides per 100 000 person-years; prediction interval, 89-2641), with high between-sample heterogeneity (I2 = 98%). The suicide rate was highest within 3 months after discharge (1132; 95% CI, 874-1467) and among patients admitted with suicidal ideas or behaviors (2078; 95% CI, 1512-2856). Pooled suicide rates per 100 000 patients-years were 654 for studies with follow-up periods of 3 months to 1 year, 494 for studies with follow-up periods of 1 to 5 years, 366 for studies with follow-up periods of 5 to 10 years, and 277 for studies with follow-up periods longer than 10 years. Suicide rates were higher among samples collected in the periods 1995-2004 (656; 95% CI, 518-831) and 2005-2016 (672; 95% CI, 428-1055) than in earlier samples.

Conclusions and Relevance

The immediate postdischarge period is a time of marked risk, but rates of suicide remain high for many years after discharge. Patients admitted because of suicidal ideas or behaviors and those in the first months after discharge should be a particular focus of concern. Previously admitted patients should be able to access long-term care and assistance.

Classification of suicide attempters in schizophrenia using sociocultural and clinical features: A machine learning approach

OBJECTIVE

Suicide is a major concern for those afflicted by schizophrenia. Identifying patients at the highest risk for future suicide attempts remains a complex problem for psychiatric interventions. Machine learning models allow for the integration of many risk factors in order to build an algorithm that predicts which patients are likely to attempt suicide. Currently it is unclear how to integrate previously identified risk factors into a clinically relevant predictive tool to estimate the probability of a patient with schizophrenia for attempting suicide.

METHODS

We conducted a cross-sectional assessment on a sample of 345 participants diagnosed with schizophrenia spectrum disorders. Suicide attempters and non-attempters were clearly identified using the Columbia Suicide Severity Rating Scale (C-SSRS) and the Beck Suicide Ideation Scale (BSS). We developed four classification algorithms using a regularized regression, random forest, elastic net and support vector machine models with sociocultural and clinical variables as features to train the models.

RESULTS

All classification models performed similarly in identifying suicide attempters and non-attempters. Our regularized logistic regression model demonstrated an accuracy of 67% and an area under the curve (AUC) of 0.71, while the random forest model demonstrated 66% accuracy and an AUC of 0.67. Support vector classifier (SVC) model demonstrated an accuracy of 67% and an AUC of 0.70, and the elastic net model demonstrated and accuracy of 65% and an AUC of 0.71.

CONCLUSION

Machine learning algorithms offer a relatively successful method for incorporating many clinical features to predict individuals at risk for future suicide attempts. Increased performance of these models using clinically relevant variables offers the potential to facilitate early treatment and intervention to prevent future suicide attempts.

Depressive symptoms and suicidal behavior after first-episode psychosis: A comprehensive systematic review

Depressive symptoms and suicidal behavior are common among patients that suffered a first-episode psychosis. We searched Web of Knowledge^SM and Pubmed® for English and Portuguese original articles investigating prevalence of depressive symptoms and/or suicidal behavior and associated factors after first-episode psychosis. We included 19 studies from 12 countries, 7 studied depressive symptoms and 12 suicidal behavior. The findings confirm that depressive symptoms and suicidal behavior have high rates in the years after first-episode psychosis. Factors identified as being associated with depressive symptoms after first-episode psychosis were anomalies of psychosocial development, poor premorbid childhood adjustment, greater insight, loss, shame, low level of continuing positive symptoms and longer duration of untreated psychosis. Suicidal behavior was associated with previous suicide attempt, sexual abuse, comorbid polysubstance use, lower baseline functioning, longer time in treatment, recent negative events, older patients, longer duration of untreated psychosis, higher positive and negative psychotic symptoms, family history of severe mental disorder, substance use, depressive symptoms and cannabis use. Data also indicate that treatment and early intervention programs reduce depressive symptoms and suicidal behavior after first-episode psychosis. Future research should overcome some methodological discrepancies that exist between studies and limit generalization of current findings.

Suicide in the Early Stage of Schizophrenia

Suicide is a relevant leading cause of death among patients affected by schizophrenia. Even if suicidal ideation may be present in different stages of disease, some differences have been described between the risk of suicide in patients experiencing first episode of psychosis and those with long-term schizophrenia. It is particularly higher during the first year of illness and reaches a steady decline over the following years. Suicidal ideation and attempts may also be common among subjects with subthreshold psychotic experiences. Factors associated with the risk of suicide in the early phase of schizophrenia are previous suicidal attempts and social aspects: the lack of social support and stable relationships, social drift after the first episode, and social impairment. Also, several psychotic symptoms (suspiciousness, paranoid delusions, mental disintegration and agitation, negative symptoms, depression and hopelessness, and command hallucinations) and substance abuse are associated with higher risk of suicide. It has been described that perfectionism and good levels of insight among individuals who have recently developed psychotic symptoms are significantly associated with higher numbers of suicidal attempts. Moreover, recent evidences show that prefrontal cortex-based circuit dysfunction may be related to suicide in the early stage of schizophrenia. This narrative review summarizes available evidences on suicide in the early stage of schizophrenia and deals with issues to be further studied and discussed.

A population-based longitudinal study of suicide risk in male schizophrenia patients: Proximity to hospital discharge and the moderating effect of premorbid IQ

Suicide is a major cause of death in schizophrenia. Identifying factors which increase the risk of suicide among schizophrenia patients might help focus prevention efforts. This study examined risk of suicide in male schizophrenia patients using population-based data, examining the timing of suicide in relation to the last hospital discharge, and the effect of premorbid IQ on risk of suicide. Data on 930,000 male adolescents from the Israeli military draft board were linked with data from the Israeli Psychiatric Hospitalization Case Registry and vital statistics from the Israeli Ministry of Health. The relationship between premorbid IQ and risk for suicide was examined among 2881 males hospitalized with schizophrenia and compared to a control group of 566,726 males from the same cohort, who were not hospitalized for a psychiatric disorder, using survival analysis methods. Over a mean follow-up period of 9.9 years (SD=5.8, range: 0-22 years), 77/3806 males with schizophrenia died by suicide (a suicide rate of 204.4 per 100,000 person-years). Approximately 48% of the suicides occurred within a year of discharge from the last hospital admission for schizophrenia. Risk of suicide was higher in male schizophrenia patients with high premorbid IQ (HR=4.45, 95% CI=1.37-14.43) compared to those with normal premorbid IQ. These data indicate that male schizophrenia patients with high premorbid IQ are at particularly high risk of suicide, and the time of peak risk is during the first year after the last hospitalization discharge.

The Impact of Suicide on Co-patients

While there is a large literature on the impact of patient suicide on care providers and on family members, and a small literature on the impact of hospital suicide on inpatients and on surviving members of a therapy group, nothing has been written about the effect of a suicide on patients in a community mental health facility. This paper discusses the potential for ripple effects and the need for extra care and surveillance when a patient commits suicide in an outpatient program for the seriously mentally ill. The paper draws on related literature (suicide in groups, hospitals, schools, and college campuses) and, using examples from a clinic for women with psychosis, makes recommendations for psychiatric intervention post suicide. After the trauma of suicide, staff needs protected time to inform and support survivors, taking special care with those seen as most vulnerable. Following a trauma such as suicide, patients tend to stay near a source of comfort, and may require extra staff time. Survivors need to make sense of what happened and to honor the dead. This brings privacy concerns to the fore, as well as staff ambivalence about the respect due to a person who should be remembered, but should not serve as a role model to fellow patients who are susceptible to contagion effects. The review that follows a suicide can lead to closure for staff and patients and to the development of a protocol to follow should similar incidents recur.

Clinical variables associated with suicide attempts in schizophrenia before and after the first episode

The aim of this study was to investigate variables associated with suicide attempts in schizophrenia before and after the first episode. We evaluated history of past sucide attempts, clinical symptoms, level of functioning and cognitive performances of 172 patients with first-episode schizophrenia at first admission. Information was collected regarding clinical symptom severity, treatment compliance, and suicide attempts during the follow-up. We found that 16.5% of the patients attempted suicide before admission, and 6.2% of them attempted suicide during the follow-up. The patients who had attempted suicide before admission were mostly women, and more likely to be hospitalized in first year of follow up. BPRS-depression subscale score at admission and alcohol/substance use appeared as independent variables that found associated with suicide attempts prior to admission in logistic regression analysis. The patients who attempted suicide during the follow-up had significantly higher BPRS-depression subcale scores at sixth months of follow-up. Treatment compliance during the first 6 months and duration of remission was lower in this group. Our findings suggest that longer duration of first hospital treatment, the presence of depressive symptoms, and nonadherence to treatment in early phases of follow up after FES are predictors of suicide attempts. On the other hand, keeping remission during the follow-up protects against suicide attempts.

Effects of depression on the cytokine profile in drug naïve first-episode psychosis

Schizophrenia is accompanied by alterations in immuno-inflammatory pathways, including abnormalities in cytokine profile. The immune assessment of patients in a first episode of psychosis (FEP) and particularly in drug naïve patients is very important to further elucidate this association. The objectives of this study are to delineate the cytokine profile (IL-2, IL-10, IL-4, IL-6, IFNγ, TNFα and IL-17) in FEP patients (n=55) versus healthy controls (n=57) and to examine whether the presence of depressive symptoms in FEP is accompanied by a specific cytokine profile. We found increased levels of IL-6, IL-10 and TNFα in FEP patients when compared to healthy controls. FEP patients with depression showed higher IL-4 and TNFα levels versus those without depression. Cytokine levels were not correlated to the total PANSS and the positive or negative subscale scores. Our results suggest that FEP is accompanied by a cytokine profile indicative of monocytic and T regulatory cell (Treg) activation. Depression in FEP is accompanied by monocytic and Th-2 activation, whereas FEP without depression is characterized by Treg activation only. In conclusion, depression emerged as a key component explaining the cytokines imbalance in FEP that is responsible for a large part of the immune-inflammatory abnormalities described.

[Youth-onset schizophrenia: psychopathology, clinical presentation and therapy]

The paper reviews the clinical presentations and pathogenetic features of youth-onset schizophrenia with onset at the age of 16-25 years old. The clinical presentation of the disease in young people is different in comparison to adult patients. Psychopathological and biological characteristics of the first episode, the course of «progressive» schizophrenia and «malignant youth schizophrenia» in the pubertal period are described. Early diagnosis and prevention of disease manifestation are discussed. Recommendations on therapeutic measures at different stages of the endogenous process in this age are presented. The most important future goals of research in this field are formulated.