Self-harm in patients with schizophrenia spectrum disorders

Predictive factors and symptom severity spectrum in adult schizophrenia: Potential insights for improved management and adequate care

Schizophrenia is one of the most disabling psychiatric disorders characterized by positive (hallucinations, delusions, formal thinking disorder) and negative symptoms (anhedonia, lack of speech and motivation). The present study aimed to identify the predictive factors of schizophrenia in adults, and potential differences in the environment of origin, sex, levels of occupational stress, intellectual level, marital status and age of onset of the disease depending on the severity of symptoms using analysis of data collected from 120 patients with a diagnosis of schizophrenia. The study was conducted at the 'Prof. Dr. Alexandru Obregia' Clinical Psychiatric Hospital in Bucharest and included adult patients hospitalized between March 2018 and January 2021 diagnosed with schizophrenia and evaluated by general clinical examination, psychiatric, neurological and psychological evaluation. Results revealed that robust predictors of mild and moderate symptoms were affective symptoms, heredo-collateral history of schizophrenia, late onset, the presence of positive and negative symptoms, substance abuse, stress and marital status, unmarried, lower IQ and mental deficiency. For moderate-severe and severe symptoms, predictors were affective symptoms, heredo-collateral history of schizophrenia and affective disorders, substance abuse, stress, borderline IQ and mild mental deficiency. The present results can be used for further development of psychopharmacological management of schizophrenia.

Self-reported suicidal ideation among individuals with first episode psychosis and healthy controls: Findings from the international multicentre EU-GEI study

INTRODUCTION

Suicidal ideation is common among individuals with first episode psychosis (FEP), with prevalence estimates up to 56.5 %. Despite its high prevalence, relatively little is known about how sociodemographic, clinical and/or developmental characteristics contribute to the experience of suicidal ideation in individuals with FEP.

METHODS

In this cross-sectional study (FEP n = 551 and controls n = 857), univariate logistic regression analyses were performed to study the associations of sociodemographic, clinical, and developmental factors with suicidal ideation in individuals with FEP as well as controls. Suicidal ideation was assessed using the Community Assessment of Psychic Experiences (CAPE). In addition, multivariate logistic regression analyses were conducted based on a stepwise approach.

RESULTS

In FEP, only depressive symptoms remained significantly associated with suicidal ideation when all correlates were integrated into one model. In the multivariate model in controls, depressive symptoms, positive symptoms, and traumatic childhood experiences were significantly associated with suicidal ideation.

CONCLUSIONS

This study showed that depressive symptoms are an important factor relating to suicidal ideation in individuals with FEP, over and above other clinical, sociodemographic, and developmental factors. This underscores the relevance of screening for suicidal ideation in individuals with FEP, and highlights the need for a better understanding of the diagnostic uncertainty and course of mood symptoms in early psychosis.

LIMITATIONS

Cross-sectional study design, self-reported questionnaires.

Emotional distress and dysregulation as treatment targets to reduce suicide in psychosis: a scoping review

There is a pressing need for effective treatments that address the high rate of suicide observed among people with psychosis. In this scoping review we highlight two suicidogenic treatment targets that have been relatively neglected in people with psychotic disorders: emotional distress and emotion dysregulation. We review the research on these constructs in psychosis and their relationship to suicide in this population, and then make clinical recommendations based on research findings. Emotional distress and emotional dysregulation may be promising treatment targets for suicide among people with psychosis.

[Association Between Medication Compliance and Various Risky Behaviors in Patients With Schizophrenia]

Objective

To investigate the status of medication adherence and various types of risky behaviors of schizophrenia patients in a certain area of western China and to explore accordingly the correlation between the two.

Methods

A total of 292 667 patients with schizophrenia were enrolled in a follow-up survey between 2006 and 2018. In addition, based on the outcome-wide analysis strategy, a multivariate Cox proportional risk regression model was used to estimate and compare the impact of medication adherence on different types of risky behaviors in schizophrenia patients.

Results

In this 13-year prospective cohort, 65 175 patients (31.4%) showed good medication adherence, while 142 394 patients (68.6%) showed poor medication adherence. The incidence rates of various risky behaviors during the follow-up period were as follows, minor nuisances, 12.25%, violation of the Law of the People's Republic of China on Penalties for Administration of Public Security (APS law), 3.82%, violation of criminal law, 0.94%, suicide completed, 0.28%, self-harm, 1.42%, and attempted suicide, 0.82%. Schizophrenia patients who had poor medication adherence had higher risks of committing violence against others and self-inflicted injury compared to patients with good medication adherence did, with the associated effects being minor nuisances (hazard ratio [HR]=1.31, 95% confidence interval [CI]: 1.27-1.35), violation of APS law (HR=1.47, 95% CI: 1.38-1.56), violation of criminal law (HR=1.17, 95% CI: 1.05-1.31), and self-harm (HR=1.43, 95% CI: 1.32-1.56), respectively, while the risk of suicide completed is lower in schizophrenia patients with poor medication adherence than that in patients with good medication adherence (HR=0.56, 95% CI: 0.47-0.66). There was no statistically significant association between attempted suicide and medication adherence.

Conclusion

There are variations in the direction and strength of the association between medication adherence and different types of risky behaviors and further research is needed to elucidate the mechanisms of the association.

Mental health disorders, functioning and health-related quality of life among extensively hospitalized patients due to severe self-harm - results from the Extreme Challenges project

Background

Severe self-harm leading to extensive hospitalization generates extreme challenges for patients, families, and health services. Controversies regarding diagnoses and health care often follow. Most evidence-based treatments targeting self-harm are designed for borderline personality disorder (BPD). However, current knowledge about mental health status among individuals with severe self-harm is limited.

Objectives

To investigate psychopathology among patients extensively hospitalized due to severe or frequent self-harming behaviors.

Method

A cross sectional study (period 2019-2021) targeting psychiatric inpatients (>18 years) with frequent (>5) or long (>4 weeks) admissions last year due to self-harm. The target sample (N = 42, from 12 hospitals across all Norwegian health regions) was compared to individuals admitted to outpatient personality disorder (PD) treatment within specialist mental health services in the same period (N = 389). Clinicians performed interviews on self-harm and psychopathology, supplemented by self-report.

Results

The target sample were young adults, mainly female, with considerable hospitalization and self-harming behaviors, both significantly more extensive than the comparison group. The majority in both groups reported self-harm onset <18 years. The target sample reported increasing severity of self-harm acts and suicidal intention over time. Both samples had high levels of childhood trauma, impaired personality functioning, and a majority fulfilled criteria for PD. In the target sample, comorbid depression, PTSD, anxiety disorders, and substance use occurred more frequently and in 50%, psychosis/dissociative disorder/autism spectrum disorder/ADHD was reported (outpatient comparison sample: 9%). 35% in the target sample screened over cut-off for possible intellectual disability. The target sample reported poor psychosocial functioning and health-related quality of life - greater impairment than the outpatient comparison sample.

Conclusion

The study reveals that severe self-harm inpatients have complex psychopathology and highlights the importance of individualized and thorough assessment among patients with severe and/or repetitive self-harm.

Self-Harm Among Forensic Psychiatric Inpatients With Schizophrenia Spectrum Disorders: An Explorative Analysis

The burden of self-injury among offenders undergoing inpatient treatment in forensic psychiatry is substantial. This exploratory study aims to add to the previously sparse literature on the correlates of self-injury in inpatient forensic patients with schizophrenia spectrum disorders (SSD). Employing a sample of 356 inpatients with SSD treated in a Swiss forensic psychiatry hospital, patient data on 512 potential predictor variables were retrospectively collected via file analysis. The dataset was examined using supervised machine learning to distinguish between patients who had engaged in self-injurious behavior during forensic hospitalization and those who had not. Based on a combination of ten variables, including psychiatric history, criminal history, psychopathology, and pharmacotherapy, the final machine learning model was able to discriminate between self-injury and no self-injury with a balanced accuracy of 68% and a predictive power of AUC = 71%. Results suggest that forensic psychiatric patients with SSD who self-injured were younger both at the time of onset and at the time of first entry into the federal criminal record. They exhibited more severe psychopathological symptoms at the time of admission, including higher levels of depression and anxiety and greater difficulty with abstract reasoning. Of all the predictors identified, symptoms of depression and anxiety may be the most promising treatment targets for the prevention of self-injury in inpatient forensic patients with SSD due to their modifiability and should be further substantiated in future studies.

Self-mutilation in people with psychiatric diagnosis - literature review

Introduction: Self-mutilation is of an auto-aggressive nature. They take many forms. Usually they do not occur as an isolated phenomenon. Self-injuring persons often have a diagnosed mental disorder, and a psychiatric diagnosis is one of the risk factors for the occurrence of self-harm. Material and method: In this study, articles were analyzed that contained information on the occurrence of various mental disorders. These articles searched for information on the occurrence of self-mutilation, its type, origin and causes.  Discussion: Self-mutilation is common in patients with a psychiatric diagnosis. The frequency of such behaviors can range from 33% to 50% in people with autism, up to 22%, and even 49% in people diagnosed with psychotic disorders. Acts of selfharm may affect 50-78% of people diagnosed with border-line personality disorder. In adolescents with eating disorders, 41% of patients report self-harm. In the group of people diagnosed with bipolar disorder, it may be as high as 77.3%. People with depression are also a large self-injuring group. It is reported that it may be up to 71.2% of patients with unipolar disorder. Conclusions: Self-mutilation is a phenomenon that is more and more topical and common not only in the adolescent population. This is a multi-factorial issue. One of the risk factors are mental disorders. Self-mutineers choose various methods, and this choice depends, among others, on from recognition. The size of the phenomenon and its evolution make it necessary to study it in order to increase the level of knowledge, update information and, consequently, the ability to help people at risk of NSSI.  Keywords: self-mutilation, autism spectrum disorder, schizophrenia, bipolar disorder, personality disorders

[Non-suicidal self-injurious behavior in conduct disorders and schizotypal disorder]

OBJECTIVE

To compare the methods and motives of non-suicidal self-injurious behavior (NSIB) in conduct disorders and schizotypal disorder.

MATERIAL AND METHODS

The main group consisted of 91 patients (77.8%), aged 13-24 years, with behavioral disorders and NSIB, who completed questionnaires using the self-harm statements questionnaire. The younger subgroup consisted of 54 patients under the age of 18 with a diagnosis of «Behavior Disorders» (ICD-10 F91), the older subgroup included 37 patients aged 18 years or more with a diagnosis of Emotionally Unstable Personality Disorder (F60.3). The comparison group consisted of 100 patients, aged 13-41 years with a diagnosis of schizotypal disorder (F21) and NSIB. We used clinical-psychopathological, standardized and statistical methods.

RESULTS

Significant differences were revealed in the sexual preference for NSIB (p=0.0001), a number of leading types of NSIB, and the absence of differences in the motives of self-injurious behavior in patients of the compared groups. In the comparison group, cuts and cauterization prevailed as the leading type of NSIB, in patients with behavioral disorders prevailed obstacles to wound healing, which is hypothetically associated with the influence of obsessive psychopathological mechanisms, since pathological excoriation has the same nature as obsessive-compulsive disorder and is included with it in the same DSM-5 category. The impulsive subtype of NSIB observed in this situation usually arises due to an increasing sense of tension and is associated with the motive of intrapersonal self-regulation.

CONCLUSION

The study showed that the difference between the compared nosological groups according to the methods and motives of self-harming actions is determined not so much by intergroup differences as by sex and age patterns within each of the compared groups. This allows us to talk about the proximity of the mechanisms of self-harm in various mental disorders, and the phenomenon of NSIB itself should be considered rather as a nosologically nonspecific psychopathological phenomenon.

The role of psychological autopsy in investigating a case of atypical suicide in schizophrenia: a case report with a brief review of literature

Background

Self-harm typically is without lethal intent. Death can occur rarely, with suicide taking on an atypical form that raises the suspicion of hetero-aggression. Our study aimed to identify the link between self-harm and suicide intent and also to outline the positive diagnosis of an atypical suicide case which has raised the suspicion of hetero-aggression. For this purpose, the psychological autopsy method should be used regularly in suicide investigation because it not only allows a positive diagnosis of suicide but can also provide a detailed picture of mental degradation and associated suicide risk factors.

Case presentation

The case of a 26-year-old man from a rural area, found dead in the basement, at home, naked, barricaded inside, is described.

Methods

The on-site investigation and a complete forensic autopsy were performed. In addition, we apply the psychological autopsy method which gathered enough information to outline the positive diagnosis of suicide. We also made a brief literature review on the suicide risk factors and the behavioral changes that occurred during the COVID-19 pandemic in schizophrenic patients.

Results

The forensic autopsy revealed that he presented a complex craniofacial trauma as the cause of death (with scalp lacerations, frontal fracture, subarachnoid hemorrhage, and frontal cerebral contusions) associated with torso trauma (with self-inflicted stabbed wounds) with bruises and abrasions on the limbs. The injuries that caused death were self-inflicted and ensued repeatedly hitting his head against blunt objects. Using the psychological autopsy method, we found out that he presented multiple psychiatric hospitalizations for schizophrenia for almost 10 years, recently with reduced compliance to treatment. We also documented two previous suicide attempts and a gradual deterioration of his mental health.

Conclusions

We highlighted the role of the psychological autopsy (in addition to the judicial investigation and the forensic autopsy) for the diagnosis of committed suicide, for making a rigorous differential diagnosis between accident, hetero-aggression, and suicide, and also in pin-pointing the suicide risk factors.

Supplementary Information

The online version contains supplementary material available at 10.1186/s41935-022-00291-5.

Description of a Dialectical Behavior Therapy program in a Veterans Affairs Health Care System

A comprehensive Dialectical Behavior Therapy (DBT) program was created within a VA Health Care System for patients with recent psychiatric hospitalization, suicidality and/or significant emotion dysregulation. The program was notable for being one of a relatively small number of comprehensive DBT programs in the VA system, and for including patients with psychosis and psychotic disorder, with a majority of patients (58%) having a documented history of psychosis or endorsing psychotic symptoms in assessments. We describe the process of creating this program at a VA medical center and present preliminary program evaluation data. All patients completed assessments of suicidality (C-SSRS), emotion dysregulation (DERS), skills use and dysfunctional coping (DBT-WCCL), borderline symptomatology (BSL-23), and depression (PHQ-9) at program entry and subsequently every 6-8 weeks through program completion. Suicide attempts and hospitalizations were also tracked. Twelve patients completed multiple (up to six) assessment timepoints, allowing for evaluation of change during treatment. Patients demonstrated improvements on most measures and no hospitalizations or suicide attempts during active treatment, and the subsample with psychosis showed average improvements on every outcome measure. Eleven of 12 patients completed a full six-month rotation.

The Prevalence of Self-injurious Behavior in Patients With Schizophrenia Spectrum Disorders: A Systematic Review and Meta-analysis

Background and Hypothesis

In patients with schizophrenia spectrum disorder (SSD), the lifetime prevalence of self-harm (SH) and non-suicidal self-injury (NSSI) is currently uncertain. The primary aim of this review was to provide a synthesis of the existing literature concerning the prevalence of SH/NSSI in individuals with SSD, and individuals at clinical high risk of psychosis (CHR-P). Secondary aims were to investigate methods, severity, and functions of self-injurious behavior in these populations.

Study Design

Studies quantifying the prevalence of SH/NSSI in individuals with SSD or at CHR-P were included in this review. MEDLINE, EMBASE, and PsycInfo were searched for eligible studies June 10, 2022 and systematically screened by two independent reviewers. Risk of bias was assessed using the Joana Briggs Institute Critical Appraisal Checklist for Prevalence Studies by two independent reviewers. A meta-analysis of the lifetime prevalence of SH/NSSI was conducted using generalized linear mixed model with the logit transformation.

Study Results

Thirty-two studies were included in this review (n = 15 440), 4 of which included individuals at CHR-P (n = 397). The meta-analysis showed a pooled lifetime prevalence of SH of 31.0% (95% CI: 22.1%; 41.6%) in individuals with SSD (n = 2822) and 39.7% (95% CI: 17.5%; 70.0%) in individuals at CHR-P (n = 397). These estimates should be interpreted with caution due to substantial heterogeneity. Cutting was the most frequent method of SH/NSSI and SH command hallucinations may be an overlooked cause of self-injurious behavior in these patients.

Conclusions

Self-injurious behavior is a highly prevalent, and possibly overlooked concern, in individuals with SSD and at CHR-P.

Suicidal behaviour after first-episode psychosis: results from a 1-year longitudinal study in Portugal

BACKGROUND

Suicide is one of the main causes of excess of premature death in psychotic patients. Published studies found that suicide risk begins in ultra-high risk of psychosis and continues in early years of the disease. Previous studies identifying predictive and risk factors associated with suicidality in first-episode psychosis (FEP) are highly inconsistent. Also, there are relatively few longitudinal studies on suicidal behaviour in FEP. The aim of this study was to examine prevalence, evolution and predictors of suicidal behaviour at baseline and the 12-month follow-up in patients presenting with FEP.

METHODS

One hundred and eighteen patients presenting with FEP were recruited from two early psychosis units in Portugal. A comprehensive assessment examining socio-demographic and clinical characteristics was administered at baseline and the 12-month follow-up. Odds ratio were calculated using logistic regression analyses. McNemar test was used to evaluate the evolution of suicidal behaviour and depression prevalence from baseline to 12 months of follow-up.

RESULTS

Follow-up data were available for 60 participants from the 118 recruited. Approximately 25.4% of the patients had suicidal behaviour at the baseline evaluation, with a significant reduction during the follow-up period to 13.3% (p = 0.035). A multivariate binary logistic regression showed that a history of suicidal behaviour and depression at baseline independently predicted suicidal behaviour at baseline, and a history of suicidal behaviour and low levels of total cholesterol predicted suicidal behaviour at the 12-month follow-up. A significant proportion of patients also had depression at the baseline evaluation (43.3%), with the last month of suicidal behaviour at baseline independently predicting depression at this time.

CONCLUSIONS

The findings of our study indicate that suicidal behaviour was prevalent on the year after FEP. Patients with a history of suicidal behaviour, depression at baseline and low levels of cholesterol should undergo close evaluation, monitoring and possible intervention in order to reduce suicide risk in the early phases of psychosis.

Predicting factors for non-suicidal self-injury in patients with schizophrenia spectrum disorders and the role of substance use

Non-suicidal self-injury (NSSI) has been shown as a characteristic feature in many clinical populations in recent years and schizophrenia is one of the most common psychiatric disorders which is associated with NSSI. In this study, we aimed to investigate predictors of NSSI in patients with schizophrenia spectrum disorders (SSD) and the role of lifetime substance use disorder (SUD). A sample of 165 patients with a diagnosis of SSD who were in remission participated in the study. Lifetime NSSI was assessed using the Inventory of Statements About Self-injury (ISAS). Lifetime SUD were evaluated. Logistic regression analysis was conducted to predict NSSI. SUD was found to be related to NSSI in patients with SSD, and it was associated with an approximately fourfold increase in the risk of NSSI. The rates of lifetime SUD in our sample and in the NSSI (+) group were 38.2 % and 55.6 %, respectively. The most commonly abused substances among patients with NSSI were cannabis and synthetic cannabinoids. The prevalence of NSSI was 43.6 % in our sample. 'Self-cutting' was the most common type and 'affect regulation' was the most common function of NSSI. One of the most significant risk factors for NSSI was a previous history of suicide attempts. SUD appears to be a significant predictor of NSSI in patients with SSD. Further investigation of treatable risk factors such as SUD which are related to NSSI is needed. It is also essential to screen SSD patients for NSSI due to the probable relation to high risk of suicide.

Extreme challenges: psychiatric inpatients with severe self-harming behavior in Norway: a national screening investigation

BACKGROUND

Extreme self-harming behavior is a major challenge for patients and health services. Nevertheless, this patient population is poorly described in research literature.

AIMS

The aim of this study was to assess the volume of patients with extensive psychiatric hospitalization due to extreme self-harming behaviors, the extent of severe medical sequelae, and collaboration problems within health services.

METHODS

In a national screening investigation, department managers in 83 adult psychiatric inpatient institutions across all health regions in Norway were invited to participate in a brief, prepared, telephone interview.

RESULTS

Sixty-one interviews were completed. Extensive hospitalization (prolonged or multiple) due to extreme self-harm was reported for the last year in all health regions and in 427 individual cases. Mean number of cases did not differ by region. Psychiatric hospitalizations were more frequent in hospital units than mental health centers. In 109 of the cases, self-harming behavior had severe medical consequences, including five deaths. In 122 of the cases, substantial collaboration problems within the health services were reported (disagreements on diagnosis, treatment needs and resources). Extensive (long-term) hospitalization was particularly associated with the combination of severe medical sequelae and collaboration problems.

CONCLUSION

This investigation confirms a noteworthy, nationwide, population of severely self-harming inpatients with extensive health service use, prevalent severe medical complications, and unsatisfactory collaboration within health services. These preliminary results are alarming, and indicate a need for more profound understanding of highly complex and severe cases.

Preliminary evidence that vortioxetine may improve sleep quality in depressed patients with insomnia: a retrospective questionnaire analysis

Insomnia is a frequent symptom in depressed patients. It can present with difficulty in initiating and/or maintaining sleep. We retrospectively evaluated a group of 15 patients affected by major depressive disorder and complaining of insomnia, who started vortioxetine (VOR) treatment for their depressive symptoms. The following questionnaires were captured at baseline and follow-up: Pittsburgh Sleep Quality Index, Epworth Sleepiness Scale and Beck Depression Inventory. Pittsburgh Sleep Quality Index total score significantly decreased between follow-up and baseline (P < 0.01), and in several subitems related to sleep quality and continuity. Moreover, Epworth Sleepiness Scale decreased between follow-up and baseline (P < 0.01). Finally, Beck Depression Inventory reduction was also evident between follow-up and baseline (P < 0.01). This retrospective analysis showing the significant effect of VOR on both depressive symptoms and insomnia in patients showing comorbid major depressive disorder and insomnia invites further research in order to confirm this preliminary evidence. We hypothesize that the VOR mechanism of action may explain the improvement of subjective sleep, other than depressive symptoms.

Management of depression in patients with schizophrenia spectrum disorders: a critical review of international guidelines

OBJECTIVES

Depression is a frequent but potentially treatable clinical dimension in patients with schizophrenia spectrum disorders (PWS). However, there is a lack of consensual recommendations regarding the optimal strategy to manage depression in PWS. In this study, we aimed to compare the various proposed strategies to define a core set of valid care recommendations for depression management in PWS.

METHODS

After a systematic search of the literature, the methodological quality of 10 international guidelines from four continents was compared using a validated guideline appraisal instrument (AGREE II). Key recommendations for the management of depression in PWS were subsequently reviewed and discussed.

RESULTS

The methodological quality of the guidelines was heterogeneous. Although all guidelines proposed pharmacotherapy, psychosocial interventions were a minor concern. Waiting for antipsychotic effects mostly was recommended during the acute phase of schizophrenia. During the postpsychotic phase of the illness, a switch to a second-generation antipsychotic and/or the adjunction of an antidepressant were the primary recommendations. Cognitive behavioural therapy and other medications were considered with strong variations.

CONCLUSIONS

Further studies are needed to strengthen the level of evidence for antidepressive approaches in PWS. The inclusion of PWS as stakeholders is also considered to be a major issue for future guideline development.

Insight and suicidality in psychosis: A cross-sectional study

AIMS

We aimed to test whether specific insight dimensions are associated with suicidality in patients with psychotic disorders.

METHODS

143 patients with schizophrenia spectrum disorders were recruited. Suicidality was assessed by item 8 of the Calgary Depression Scale for Schizophrenia (CDSS). Insight was measured by the Scale of Unawareness of Mental Disorder (SUMD) and the Markova and Berrios Insight Scale. Bivariate analyses and multivariable logistic regression models were conducted.

RESULTS

Those subjects aware of having a mental illness and its social consequences had higher scores on suicidality than those with poor insight. Awareness of the need for treatment was not linked with suicidality. The Markova and Berrios Insight scale total score and two specific domains (awareness of "disturbed thinking and loss of control over the situation" and "having a vague feeling that something is wrong") were related to suicidality. However, no insight dimensions survived the multivariable regression model, which found depression and previous suicidal behaviour to predict suicidality.

CONCLUSIONS

Suicidality in psychosis was linked with some insight dimensions: awareness of mental illness and awareness of social consequences, but not compliance. Depression and previous suicidal behaviour mediated the associations with insight; thus, predicting suicidality.

Psychological resilience in people experiencing schizophrenia and suicidal thoughts and behaviours

Background: Negative stressors can aggravate the impact of schizophrenia. However, some people find ways of combating such stressors. There is a dearth of research examining factors which enable individuals with schizophrenia to show psychological resilience.Aims: The goal of this study was to investigate resilience to negative stressors in people with disorders on the schizophrenia spectrum using a qualitative methodology.Methods: Data were collected from 23 participants who had experienced schizophrenia and suicidal thoughts and behaviours. Semi-structured interviews followed a topic guide. Participants were asked (i) what resilience meant to them, (ii) which stressors they had experienced over 12 months and (iii) how they had counteracted those stressors. Thematic analysis was conducted to identify re-occurring themes across interviews.Results: A continuum of psychological mechanisms described participants' views about the meaning of resilience which ranged from passive acceptance to resistance (e.g. withstanding pressure), and then to active strategies to counter stressors (e.g. confronting). These themes were also evident in narratives expressing personal resilience strategies but, additionally, included emotional coping techniques. External factors were highlighted that supported resilience including social support, reciprocity and religious coping.Conclusions: People with schizophrenia develop ways of being resilient to negative events which should inform therapeutic interventions.

Gender differences in suicidal behaviour in patients with first-episode psychosis

AIM

Prior research shows contradictory gender patterns in suicidal behaviour among patients with first-episode psychosis. The aim of this study was to investigate gender differences in the prevalence of suicidal behaviour (suicidal ideation, suicide plans and suicide attempts) and to delineate risk factors for suicidal behaviour among consecutively included male and female patients with first-episode psychosis in the TIPS II early detection study.

METHODS

Patients with first-episode psychosis (n = 246) from a hospital catchment area with a system for early detection were assessed and compared on baseline sociodemographical and clinical variables according to gender. Current (past 1 month) and lifetime prevalence of suicidal behaviour were assessed.

RESULTS

Current and lifetime rates of suicidal behaviour were high (50.8% and 65.9%, respectively) and higher among females (lifetime: 78.3 %, past month: 64.2 %) versus males (lifetime: 56.4 %, past month: 40.7 %). Depressive symptoms and female gender were associated with both lifetime and current risk for suicidal behaviour. Lifetime prevalence was also associated with a longer duration of untreated psychosis and young age after controlling for other risk factors.

CONCLUSIONS

Suicidal behaviour was frequent among patients with first-episode psychosis, with a higher prevalence of suicidal behaviour in females. Depressive symptoms and female gender were significantly associated with suicidal behaviour.

Selective review of age-related needs of women with schizophrenia

OBJECTIVE

Recognizing that needs differ between men and women with schizophrenia and that they vary over time, this review attempts to categorize the needs that are relevant to younger and to older women.

METHOD

This is a selective literature review focusing on topic areas the two authors determined to be most germane to women with schizophrenia. Articles were selected on the basis of currency, comprehensiveness, and study design. Particular attention was paid to the voices of the women themselves.

RESULTS

There is considerable overlap between the needs of younger and older women with schizophrenia, but as a general rule, younger women require preventive strategies to stop the escalation of illness while older women require recovery interventions to regain lost hopes and abilities.

CONCLUSIONS

There is clinical utility in cataloguing the needs of younger and older women with schizophrenia and conceptualizing interventions according to gender and age rather than viewing needed services along purely diagnostic lines.

Investigation of the genetic interaction between BDNF and DRD3 genes in suicidical behaviour in psychiatric disorders

OBJECTIVES

Suicide is a serious public health concern, and it is partly genetic. The brain-derived neurotrophic factor (BDNF) gene has been a strong candidate in genetic studies of suicide (Dwivedi et al., Arch Gen Psychiatry 2010;60:804-815; Zai et al., Prog Neuropsychopharmacol Biol Psychiatry 2012;34:1412-1418) and BDNF regulates the expression of the dopamine D3 receptor.

OBJECTIVE

We examined the role of the BDNF and DRD3 genes in suicide.

METHODS

We analysed four tag single-nucleotide polymorphisms (SNPs) in BDNF and 15 SNPs in the D3 receptor gene DRD3 for possible association with suicide attempt history in our Canadian sample of Schizophrenia (SCZ) patients of European ancestry (N = 188).

RESULTS

In this sample, we found a possible interaction between the BDNF Val66Met and DRD3 Ser9Gly SNPs in increasing the risk of suicide attempt(s) in our SCZ sample. Specifically, a larger proportion of SCZ patients who were carrying at least one copy of the minor allele at each of the Val66Met and Ser9Gly functional markers have attempted suicides compared to patients with other genotypes (Bonferroni P < 0.05). However, we could not replicate this finding in samples from other psychiatric populations.

CONCLUSIONS

Taken together, the results from the present study suggest that an interaction between BDNF and DRD3 may not play a major role in the risk for suicide attempt, though further studies, especially in SCZ, are required.

Self-inflicted needle injuries to the eye: a curing pain

There are few reports of severe self-injury to eyes in patients with schizophrenia. We report on a 41-year-old woman, primarily visiting for symptoms of endophthalmitis resulting from self-inflicted needles. Further evaluations established the diagnosis of schizophrenia because of arguing and commenting on auditory hallucinations and negative symptoms including social isolation, decreased self-care, blunt affect, and a monotone voice. The patient had been suffering from auditory hallucinations for several years and found relief in bodily pain caused by needles. The patient received 6 mg of risperidone. Hallucinations were resolved and self-injury behaviour was not repeated.

Association analysis between suicidal behaviour and candidate genes of bipolar disorder and schizophrenia

BACKGROUND

The present study investigated associations between the strongest joint genetic risk variants for bipolar disorder (BD) and schizophrenia (SCZ) and a history of suicide attempt in patients with BD, SCZ and related psychiatric disorders.

METHODS

A history of suicide attempt was assessed in a sample of 1009 patients with BD, SCZ and related psychosis spectrum disorders, and associations with the joint genetic risk variants for BD and SCZ (rs2239547 (ITIH3/4-region), rs10994359 (ANK3) and rs4765905 (CACNA1C)) were investigated. Previously reported susceptibility loci for suicide attempt in BD were also investigated. Associations were tested by logistic regression with Bonferroni correction for multiple testing.

RESULTS

The risk allele in rs2239547 (ITIH3/4-region) was significantly associated with a history of suicide attempt (p=0.01) after multiple testing correction (p threshold<0.017). The previous suicide attempt susceptibility loci were only nominally associated, but had the same direction of risk in the replication sample (sign test, p=0.02).

LIMITATIONS

Relatively small sample size and retrospective clinical assessment.

CONCLUSIONS

We detected a novel association between suicide attempt and the ITIH3/4-region in a combined group of patients with BD, SCZ and related psychosis spectrum disorders. This may be useful in understanding molecular mechanisms of suicidal behaviour in severe mental disorders, although replication is warranted.

Clinical characteristics in schizophrenia patients with or without suicide attempts and non-suicidal self-harm--a cross-sectional study

BACKGROUND

To investigate whether schizophrenia patients with both suicide attempts and non-suicidal self-harm have earlier age of onset of psychotic and depressive symptoms and higher levels of clinical symptoms compared to patients with only suicide attempts or without suicide attempt.

METHODS

Using a cross-sectional design, 251 patients (18-61 years old, 58% men) with schizophrenia treated at hospitals in Oslo and Innlandet Hospital Trust, Norway, were assessed with a comprehensive clinical research protocol and divided into three groups based on their history of suicide attempts and non-suicidal self-harm.

RESULTS

Suicide attempts were present in 88 patients (35%); 52 had suicide attempts only (29%) and 36 had both suicide attempts and non-suicidal self-harm (14%). When compared with nonattempters and those with suicide attempts without non-suicidal self-harm, patients with both suicide attempts and non-suicidal self-harm were more frequently women, younger at the onset of psychotic symptoms, had longer duration of untreated psychosis, and had higher levels of current impulsivity/aggression and depression. Patients with both suicide attempts and non-suicidal self-harm were more likely to repeat suicide attempts than patients with suicide attempts only.

CONCLUSIONS

Patients with both suicide attempts and non-suicidal self-harm had different illness history and clinical characteristics compared to patients with only suicide attempts or patients without suicidal behavior. Our study suggests that patients with both suicide attempts and non-suicidal self-harm represent a distinct subgroup among patients with schizophrenia and suicidal behavior with their early onset of psychotic symptoms, high rate of repeated suicidal behavior and significant treatment delay.