Suicidal behaviours during treatment for first-episode psychosis: towards a comprehensive approach to service-based prevention

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.

Proportion of Antipsychotics with CYP2D6 Pharmacogenetic (PGx) Associations Prescribed in an Early Intervention in Psychosis (EIP) Cohort: A Cross-Sectional Study

BACKGROUND

Prescribing drugs for psychosis (antipsychotics) is challenging due to high rates of poor treatment outcomes, which are in part explained by an individual's genetics. Pharmacogenomic (PGx) testing can help clinicians tailor the choice or dose of psychosis drugs to an individual's genetics, particularly psychosis drugs with known variable response due to CYP2D6 gene variants ('CYP2D6-PGx antipsychotics').

AIMS

This study aims to investigate differences between demographic groups prescribed 'CYP2D6-PGx antipsychotics' and estimate the proportion of patients eligible for PGx testing based on current pharmacogenomics guidance.

METHODS

A cross-sectional study took place extracting data from 243 patients' medical records to explore psychosis drug prescribing, including drug transitions. Demographic data such as age, sex, ethnicity, and clinical sub-team were collected and summarised. Descriptive statistics explored the proportion of 'CYP2D6-PGx antipsychotic' prescribing and the nature of transitions. We used logistic regression analysis to investigate associations between demographic variables and prescription of 'CYP2D6-PGx antipsychotic' versus 'non-CYP2D6-PGx antipsychotic'.

RESULTS

Two-thirds (164) of patients had been prescribed a 'CYP2D6-PGx antipsychotic' (aripiprazole, risperidone, haloperidol or zuclopenthixol). Over a fifth (23%) of patients would have met the suggested criteria for PGx testing, following two psychosis drug trials. There were no statistically significant differences between age, sex, or ethnicity in the likelihood of being prescribed a 'CYP2D6-PGx antipsychotic'.

CONCLUSIONS

This study demonstrated high rates of prescribing 'CYP2D6-PGx-antipsychotics' in an EIP cohort, providing a rationale for further exploration of how PGx testing can be implemented in EIP services to personalise the prescribing of drugs for psychosis.

Applications of innovative technologies to the delivery of antipsychotics

Psychosis is a high-incidence pathology associated with a profound alteration in the perception of reality. The limitations of drugs available on the market have stimulated the search for alternative solutions to achieve effective antipsychotic therapies. In this review, we evaluate innovative formulations of antipsychotic drugs developed through the application of modern pharmaceutical technologies, including classes of micro and nanocarriers, such as lipid formulations, polymeric nanoparticles (NPs), solid dispersions, and cyclodextrins (CDs). We also consider alternative routes of administration to the oral and parenteral ones currently used. Improved solubility, stability of preparations, and pharmacokinetic (PK) and pharmacodynamic (PD) parameters confirm the potential of these new formulations in the treatment of psychotic disorders.

Suicidality and social problem-solving skills among individuals with first-episode psychosis participating in Coordinated Specialty Care

AIM

Although suicidal ideation may decrease over the course of participation in specialized clinical programmes for first-episode psychosis (FEP), it is unclear whether such improvements exceed those that occur during treatment as usual. Clarifying the mechanisms underlying reductions in suicidal ideation and behaviour among individuals with first-episode psychosis may highlight important strategies through which specialized clinical programmes can increase the potency of their services to reduce suicidality among this high-risk population. Thus, the goal of this study is to evaluate the longitudinal relationships between suicidality and social problem-solving skills among individuals with FEP participating in Coordinated Specialty Care.

METHODS

Within-subject mediational and moderational models were applied to explore the interrelationships and longitudinal course of suicidality, social problem-solving and duration of untreated psychosis (DUP).

RESULTS

Over the first 6 months of care, individuals with FEP experienced improvements in social problem-solving skills that were found to mediate concurrent reductions in suicidality. Although longitudinal changes in social problem-solving skills were moderated by DUP, these results should be interpreted cautiously as they may stem in part from a relatively limited number of participants with longer durations of illness.

CONCLUSIONS

Improvements in social problem-solving skills during participation in CSC may facilitate reductions in suicidality. Treatments targeting suicidality among individuals with FEP may thus benefit from working to enhance social problem-solving skills among these individuals. Further research is needed to clarify if and how DUP may influence the magnitude of change in social problem-solving skills during participation in CSC.

[Suicidal risk during the first psychotic episode]

Suicide is the most common cause of early mortality during the course of schizophrenia. The most recent data in the literature show that the risk of suicide is greater at the beginning of the course of schizophrenia. The risk of suicide during the first year is 12 times higher than that of the general population. Specifically, 2-5 % of people with first-episode psychosis will die by suicide in long-term follow-up studies. Regarding the presence of suicidal ideation that are a major factor of suicide in subjects suffering from psychotic disorders, their prevalence remains extremely worrying, since they are substantial and persistent. Consequently, suicide prevention should be a major and immediate objective in the management of the disease, as soon as the diagnosis has been made. Suicidal ideas are a potential precursor to the evolution towards acting out. Their evolution must be specifically assessed in each individual. Indeed, in the influential Danish OPUS study the authors reported heterogeneity in suicidal ideations in young patients with first episode of psychosis and identified three prototypical trajectories of suicidal ideations over the first 2 years in treatment. Particularly, nearly 40 % of patients with first-episode psychosis have persisting suicidal thoughts over the initial treatment period. Consequently, the authors recommend routine screening for suicidality when providing treatment for first-episode psychosis. The main risk factors for suicidal behavior in patients with a first episode are classical ones. Previous research has suggested that, in addition to young age and early course of illness, other important clinical predictors of suicide in individuals with schizophrenia include presence of depressive symptoms and misuse of substances, which are very common conditions in these patients. Lack of social support, loss, rejection, stigma, insight, fear of future losses, are all negative experiences experienced by patients starting a psychotic disorder. Negative connotations of the diagnosis of psychotic disorders, feelings of being trapped that can be directly related to feeling a burden can lead to suicidal crisis in these individuals. Then, the painful experience of the disease and its consequences associated with self-stigmatization and social rejection may induce hopelessness and suicidal thoughts in these young subjects. The quality of the insight and its evolution may worsen the depressive experience and suicidal risk and they therefore also require to be measured regularly. Thus, the clinical evaluation of patients entering psychosis should focus on those dimensions that are not directly related to the psychotic symptoms. At the precise evaluation of each patient must be associated personalized measures of prevention. It is now proposed that prevention strategies targeting suicidal behaviour in first-episode psychosis should not be universal. On a more general level, evidence-based data to support specific care programs are still lacking, and only few data are in favor of integrated care in patients presenting with first episode. It should also be kept in mind that the risk of suicide is extraordinarily high for all psychiatric patients during the first few months after discharge from hospital. This should encourage caregivers to offer intensive follow-up programs to their patients and to embrace recontact and follow-up initiatives using the tools of e-health. Last, programs for the early detection of schizophrenia seem to be beneficial for the prevention of suicide in these subjects.

Suicidal Ideation in First-Episode Psychosis (FEP): Examination of Symptoms of Depression and Psychosis Among Individuals in an Early Phase of Treatment

First-episode psychosis (FEP) is a particularly high-risk period for suicide, in which risk elevates by 60% within a first year of treatment as compared to later stages of illness. To date, much of the literature has focused on individuals with a longer duration of psychosis; thus, there is an urgency for research to examine suicide risk among individuals in FEP in the beginning stage of treatment. This study aimed to identify the relationships between demographic characteristics, symptoms of depression, psychosis (particularly positive symptoms of psychosis), and suicidal ideation among individuals in FEP. Secondary data were obtained from National Institute of Mental Health's Early Treatment Program of the Recovery After an Initial Schizophrenia Episode project (N = 404). Consistent with prior research, participants who experienced suicidal ideation during the study period reported having a longer duration of untreated psychosis and greater symptoms of depression. Further, positive symptoms of psychosis, namely hallucinations and delusions, were found to increase the odds of experiencing suicidal ideation. Findings point toward the implication that depression and positive symptoms of psychosis relate to the experience of suicidal ideation among individuals with a FEP and should be evaluated for and treated in the early stages of treatment.

Is It Possible to Predict the Future in First-Episode Psychosis?

The outcome of first-episode psychosis (FEP) is highly variable, ranging from early sustained recovery to antipsychotic treatment resistance from the onset of illness. For clinicians, a possibility to predict patient outcomes would be highly valuable for the selection of antipsychotic treatment and in tailoring psychosocial treatments and psychoeducation. This selective review summarizes current knowledge of prognostic markers in FEP. We sought potential outcome predictors from clinical and sociodemographic factors, cognition, brain imaging, genetics, and blood-based biomarkers, and we considered different outcomes, like remission, recovery, physical comorbidities, and suicide risk. Based on the review, it is currently possible to predict the future for FEP patients to some extent. Some clinical features-like the longer duration of untreated psychosis (DUP), poor premorbid adjustment, the insidious mode of onset, the greater severity of negative symptoms, comorbid substance use disorders (SUDs), a history of suicide attempts and suicidal ideation and having non-affective psychosis-are associated with a worse outcome. Of the social and demographic factors, male gender, social disadvantage, neighborhood deprivation, dysfunctional family environment, and ethnicity may be relevant. Treatment non-adherence is a substantial risk factor for relapse, but a small minority of patients with acute onset of FEP and early remission may benefit from antipsychotic discontinuation. Cognitive functioning is associated with functional outcomes. Brain imaging currently has limited utility as an outcome predictor, but this may change with methodological advancements. Polygenic risk scores (PRSs) might be useful as one component of a predictive tool, and pharmacogenetic testing is already available and valuable for patients who have problems in treatment response or with side effects. Most blood-based biomarkers need further validation. None of the currently available predictive markers has adequate sensitivity or specificity used alone. However, personalized treatment of FEP will need predictive tools. We discuss some methodologies, such as machine learning (ML), and tools that could lead to the improved prediction and clinical utility of different prognostic markers in FEP. Combination of different markers in ML models with a user friendly interface, or novel findings from e.g., molecular genetics or neuroimaging, may result in computer-assisted clinical applications in the near future.

The Positive and Negative Experiences of Caregiving for Siblings of Young People with First Episode Psychosis

Background: The impact of first episode psychosis (FEP) upon parents’ experience of caregiving has been well-documented. However, the determinants and nature of this remain poorly understood in siblings. It is hypothesized that siblings of young people with FEP are also impacted by caregiving and burden. This study aimed to characterize the experience of caregiving for siblings of young people with FEP.

Method: Survey methodology was used to explore the experience of 157 siblings in the first 18 months of their brother or sister’s treatment for FEP. Participants reported on their appraisal of the negative and positive aspects of caregiving as measured by the Experience of Caregiving Inventory (ECI). Descriptive statistics were used to establish the results for the total sample as well as for gender and birth order differences. A series of multivariate regression analyses were conducted to determine the relationships between illness characteristics and siblings’ experience of caregiving.

Results: Older brothers reported the lowest scores for negative experiences in caregiving and younger sisters reported the highest. Negative experiences in caregiving resulted in less warmth within the sibling relationship and impacted negatively upon quality of life. When the young person with FEP had attempted suicide and/or been physically violent, siblings experienced more caregiver burden. Multivariate analysis showed that female gender was a significant factor in explaining the impact of illness related variables on the experience of caregiving.

Conclusion: Suicide attempts and a history of violence resulted in higher caregiving burden for siblings regardless of whether they lived with the young person experiencing FEP or not. Female siblings are at higher risk of negative experiences from caregiving resulting in a reduced quality of life and a changed sibling relationship. Suicide attempts and violence are indicators for intensive case management to improve outcomes for the individual with FEP which may in turn reduce the burden experienced by the sibling. Clinicians can use these findings to identify siblings, assertively intervene and provide increased psychological support, psychoeducation and practical problem solving to reduce the burden. The caregiving role that they already play for their ill brother or sister should be recognized.

The pattern of suicide in the western Kingdom of Saudi Arabia: a retrospective study from 2008 to 2012

Suicide represents the dramatic end of human life mostly in young age. In a 5-year retrospective study in Jeddah in the western Kingdom of Saudi Arabia, 200 successful suicidal attempts demonstrated that hanging was the most common method of suicide with 72% of the cases, and males represented 77% of the total loses. Most fatalities were of the age range from 20s to 40s. Saudi cases constituted 18.5% of the death cases representing the second most common nationality of successful suicidal attempt in Jeddah after Indians who represented 23% of the entire study. Saudi fatalities were induced by hanging in 56% of the all Saudi deaths in contrast to about 83% in the Indian fatalities.