Sudden death among young people with first-episode psychosis: An 8-10 year follow-up study

Trajectories of suicidality during a 2-year early-intervention program for first-episode psychosis: A longitudinal study

Little is known about the individual course of suicidal ideations and attempts (i.e., suicidality) after treatment initiation. We examined the trajectories of suicidality and associated risk factors over a 2-year early intervention program for first-episode psychosis in 450 patients (age range 18-35 years at admission) consecutively admitted from 2003 to 2017. Suicidality was assessed via systematic file review, while sociodemographic and clinical variables were assessed at admission. Latent class growth modelling identified three trajectories: low (69.6 %), initially high (22.9 %), and persistently high (7.6 %) suicidality. Patients who were younger, lived alone and were diagnosed with affective psychosis were significantly more likely to follow the initially high trajectory. Patients who attempted suicide up to 3 months before admission, lived alone and presented lower levels of the PANSS excited factor were significantly more likely to follow the persistently high trajectory. Attempting suicide up to 3 months before admission distinguished persistently high and initially high suicidality trajectories. Suicide risk during early intervention program for first-episode psychosis is heterogenous, with acute and enduring suicidal risk, suggesting the need to adapt suicide prevention strategies to these different risk profiles.

A protocol for the first episode psychosis outcome study (FEPOS): ≥15 year follow-up after treatment at the Early Psychosis Prevention and Intervention Centre, Melbourne, Australia

BACKGROUND

Specialist early intervention (SEI) service models are designed to treat symptoms, promote social and vocational recovery, prevent relapse, and resource and up-skill patients and their families. The benefits of SEI over the first few years have been demonstrated. While early recovery can be expected to translate to better long-term outcomes by analogy with other illnesses, there is limited evidence to support this from follow-up studies. The current study involves the long-term follow-up of a sub-set of first episode psychosis (FEP) patients, with a range of diagnoses, who were first treated at Orygen's Early Psychosis Prevention and Intervention Centre (EPPIC) between 1998 and 2000. The aim of this paper is to present the methodology for this follow-up study.

METHODS

Between January 1998 and December 2000, 786 patients between the ages of 15-29 years were treated at EPPIC, located in Melbourne, Australia. Our cohort consists of 661 people (82 were transferred/discharged and 43 were not diagnosed with a psychotic disorder at time of discharge). The 18-month treatment characteristics of this cohort have been extensively examined in the First Episode Psychosis Outcome Study (FEPOS). The ≥15 year outcomes of this cohort are being examined in this study, known as FEPOS15.

RESULTS

Participant follow-up is ongoing. In order to extend and assess broader outcomes of the cohort, data linkage with health-related databases will be conducted.

CONCLUSION

This study will provide a comprehensive evaluation of the long-term trajectory of psychotic disorders after treatment for FEP in a SEI service.

A systematic review of longitudinal studies of suicidal thoughts and behaviors in first-episode psychosis: course and associated factors

PURPOSES

To better assess and reduce suicidal risk in first-episode psychosis (FEP), we aimed to investigate the evolution of suicidal thoughts and behaviors (STBs) and associated factors in FEP.

METHOD

This systematic review (PROSPERO-CRD42020168050) meets PRISMA guidelines. PubMed, Medline, PsycINFO, Embase, EBM Reviews and references lists of relevant articles were searched (February 2020) to identify longitudinal studies, published in English or in French, that assessed the prevalence of STBs at entry to services and over follow-up, and examined factors associated with STBs among all persons with affective and non-affective FEP from a defined catchment area. Screening, data extraction and quality assessment using the adapted Newcastle Ottawa Scale were done independently by two reviewers. Results on prevalence and associated factors are presented by type of STB.

RESULTS

Of 3,177 references, 17 studies of 11 non-overlapping samples (n = 14,907) with varying lengths of follow-up (1-41.7 years) were included. The prevalence of STBs decreased over follow-up. Up to 21.6% made at least one suicide attempt, 27% had suicidal ideation, and 1-4.3% died by suicide during follow-up. Of 53 factors assessed across studies, only male sex, depressive symptoms, and STBs occurring early during follow-up were associated with subsequent STBs. Early intervention for psychosis decreased STBs in the first three years. Other factors were assessed in a single study, yielded conflicting results, or were not associated with STBs.

CONCLUSIONS

The high prevalence of STBs following onset of psychosis highlights the need for early detection and intervention and ongoing assessment of suicidal risk throughout follow-up, with attention to identified risk factors. The heterogeneity of the studies precluded a meta-analysis and several factors were each assessed by a single study. Additional well-designed longitudinal studies of STBs and associated factors are warranted.

The iHOPE-20 study: mortality in first episode psychosis-a 20-year follow-up of the Dublin first episode cohort

PURPOSE

Increased mortality rates have been found in those with a diagnosis of psychosis; studies suggest a shortened life expectancy of up to 20 years less than that of the general population. This study aimed to investigate the mortality of a first episode psychosis cohort at 20-year follow-up, compare it to that of the general Irish population, and explore whether the mortality gap has changed over time.

METHODS

171 individuals diagnosed with a first episode psychosis identified between 1995 and 1999 in a community mental health service were traced. Mortality was established by matching death certificates to deceased cohort members (using name, age at date of death, and address at date of death). Date of first presentation to service was used as date of entry point and date of death or end of follow-up as the end point.

RESULTS

Of the 171 cases there were 20 deaths during follow-up. Nine deaths were attributed to natural causes; 7 to unnatural causes; and 4 were unknown. Comparing standardised mortality rates at 20-year follow-up to those at 12 year showed a reduction in rates over time.

CONCLUSION

Findings suggest that the mortality gap in people with schizophrenia and other psychoses remains high, especially in young males.

Self-Reported Suicidal Ideation as a Predictor of Suicidal Behavior Among Outpatients With Diagnoses of Psychotic Disorders

OBJECTIVE

Individuals with psychotic disorders are at high risk of suicidal behavior. The study examined whether response to item 9 of the Patient Health Questionnaire (PHQ-9), which asks about thoughts of death or self-harm, predicts suicidal behavior among outpatients with diagnoses of psychotic disorders.

METHODS

Electronic health records (EHRs) from seven large integrated health systems were used to identify all outpatient visits by adults with a diagnosis of schizophrenia spectrum psychosis or unspecified psychosis from January 1, 2009, to June 30, 2015, during which a PHQ-9 was completed (N=32,982 visits by 5,947 patients). Suicide attempts over the 90 days following each visit were ascertained from EHRs and insurance claims. Suicide deaths were ascertained from state death certificate files.

RESULTS

Risk of suicide attempt within 90 days of an outpatient visit was .8% among patients reporting no thoughts of death or self-harm and 3.5% among those reporting such thoughts "nearly every day." Over 90 days of follow-up, 47% of suicide attempts occurred among those who reported any recent thoughts of death or self-harm at the sampled visit. Also, 59% of attempts occurred among those reporting thoughts of death or self-harm at the index visit or any visit in the prior year. The number of suicide deaths within 90 days (N=10) was too small to accurately assess the relationship between PHQ-9 item 9 response and subsequent suicide death.

CONCLUSIONS

Among outpatients with psychotic disorders, response to item 9 of the PHQ-9 accurately identified those at increased short-term risk of a suicide attempt.

Mortality Rates After the First Diagnosis of Psychotic Disorder in Adolescents and Young Adults

IMPORTANCE

Individuals with psychotic disorders have increased mortality, and recent research suggests a marked increase shortly after diagnosis.

OBJECTIVE

To use population-based data to examine overall and cause-specific mortality after first diagnosis of a psychotic disorder.

DESIGN, SETTING, AND PARTICIPANTS

This cohort study used records from 5 integrated health systems that serve more than 8 million members in 5 states. Members aged 16 through 30 years who received a first lifetime diagnosis of a psychotic disorder from September 30, 2009, through September 30, 2015, and 2 comparison groups matched for age, sex, health system, and year of diagnosis were selected from all members making an outpatient visit (general outpatient group) and from all receiving a first diagnosis of unipolar depression (unipolar depression group).

EXPOSURES

First recorded diagnosis of schizophrenia, schizoaffective disorder, mood disorder with psychotic symptoms, or other psychotic disorder in any outpatient, emergency department, or inpatient setting.

MAIN OUTCOMES AND MEASURES

Death within 3 years after the index diagnosis or visit date, ascertained from health system electronic health records, insurance claims, and state mortality records.

RESULTS

A total of 11 713 members with first diagnosis of a psychotic disorder (6976 [59.6%] men and 4737 [40.4%] women; 2368 [20.2%] aged 16-17 and 9345 [79.8%] aged 18-30 years) were matched to 35 576 outpatient service users and 23 415 members with a first diagnosis of unipolar depression. During the year after the first diagnosis, all-cause mortality was 54.6 (95% CI, 41.3-68.0) per 10 000 in the psychotic disorder group compared with 20.5 (95% CI, 14.7-26.3) per 10 000 in the unipolar depression group and 6.7 (95% CI, 4.0-9.4) per 10 000 in the general outpatient group. After adjustment for race, ethnicity, and preexisting chronic medical conditions, the relative hazard of death in the psychotic disorder group compared with the general outpatient group was 34.93 (95% CI, 8.19-149.10) for self-inflicted injury or poisoning and 4.67 (95% CI, 2.01-10.86) for other type of injury or poisoning. Risk of death due to heart disease or diabetes did not differ significantly between the psychotic disorder and the general outpatient groups (hazard ratio, 0.78; 95% CI, 0.15-3.96). Between the first and third years after diagnosis, all-cause mortality in the psychotic disorder group decreased from 54.6 to 27.1 per 10 000 persons and injury and poisoning mortality decreased from 30.6 to 15.1 per 10 000 persons. Both rates, however, remained 3 times as high as in the general outpatient group (9.0 per 10 000 for all causes; 4.8 per 10 000 for injury or poisoning).

CONCLUSIONS AND RELEVANCE

Increases in early mortality underscore the importance of systematic intervention for young persons experiencing the first onset of psychosis. Clinicians should attend to the elevated suicide risk after the first diagnosis a psychotic disorder.

Twelve-Month Health Care Use and Mortality in Commercially Insured Young People With Incident Psychosis in the United States

OBJECTIVE

To assess 12-month mortality and patterns of outpatient and inpatient treatment among young people experiencing an incident episode of psychosis in the United States.

METHOD

Prospective observational analysis of a population-based cohort of commercially insured individuals aged 16-30 receiving a first observed (index) diagnosis of psychosis in 2008-2009. Data come from the US Department of Health and Human Services' Multi-Payer Claims Database Pilot. Outcomes are all-cause mortality identified via the Social Security Administration's full Death Master File; and inpatient, outpatient, and psychopharmacologic treatment based on health insurance claims data. Outcomes are assessed for the year after the index diagnosis.

RESULTS

Twelve-month mortality after the index psychosis diagnosis was 1968 per 100000 under our most conservative assumptions, some 24 times greater than in the general US population aged 16-30; and up to 7372 per 100000, some 89 times the corresponding general population rate. In the year after index, 61% of the cohort filled no antipsychotic prescriptions and 41% received no individual psychotherapy. Nearly two-thirds (62%) of the cohort had at least one hospitalization and/or one emergency department visit during the initial year of care.

CONCLUSIONS

The hugely elevated mortality observed here underscores that young people experiencing psychosis warrant intensive clinical attention-yet we found low rates of pharmacotherapy and limited use of psychosocial treatment. These patterns reinforce the importance of providing coordinated, proactive treatment for young people with psychosis in US community settings.

Presence of minor and major mental health impairment in adolescence and death from suicide and unintentional injuries/accidents in men: a national longitudinal cohort study

OBJECTIVE

To examine the association between minor and major mental health impairment in late adolescence and death from suicide and unintentional injuries/accidents in men.

METHODS

In Norway, all men attend a compulsory military medical and psychological examination. We included 558 949 men aged 17-19 years at the time of military examination in 1980-1999 and followed them up for death from suicide and unintentional injuries/accidents until the end of 2013. We used Cox proportional hazard models to examine the association between the presence of minor and major mental health impairments at examination and death from suicide and unintentional injuries/accidents.

RESULTS

Compared to men with no mental health impairment, those with minor mental health impairment was associated with an increased risk of death from suicide (adjusted HR (HR_adj)=1.63, 95% CI 1.39 to 1.92), transport accidents (HR_adj=1.33, 95% CI 1.09 to 1.63), accidental poisoning (HR_adj=2.27, 95% CI 1.79 to 2.88) and other unintentional injuries/accidents (HR_adj=1.54, 95% CI 1.17 to 2.02). In men with major mental health impairment, the risk of death from suicide and accidental poisoning was elevated two times (HR_adj=2.29, 95% CI 1.85 to 2.85) and three times (HR_adj=3.53, 95% CI 2.61 to 4.79), respectively.

CONCLUSIONS

We found an increased risk of death from suicide and unintentional injuries/accidents in men who had minor and major mental health impairment at age 17-19 years.

Risk factors and study designs used in research of youths' suicide behaviour-an epidemiological discussion with focus on level of evidence

Abstract Introduction: Many different epidemiology study designs have been used to analyse risk factors for suicide behaviour. The purpose of this study was to obtain an insight into the current study design used in research on youths' risk factors for suicide behaviour and to rank the studies according to level of evidence (LoE).

METHODS

We searched PubMed and psycINFO in order to identify relevant individual studies.

RESULTS

We included 36 studies of children and youth on suicidal behaviour and ideation-many rank low on LoE. For suicide, cohort design was often used, and mental illness (depression, substance abuse and severity of mental illness) was the most common risk factor. Cohort studies are ranked 2b, which is high according to LoE. For suicide attempts, survey was often used, and psychopathology, substance abuse and being exposed to suicidal behaviour were the most common risk factors. For suicidal ideation, survey was the only design used, and substance abuse and psychopathology the most common risk factors. Surveys are ranked 4, which are low according to LoE. Many risk factors were broad and unspecific, and standard definitions of outcome and exposure were rarely used.

CONCLUSION

A good study of risk factors for suicidal behaviour would need a high LoE, as a high-powered longitudinal epidemiological study (cohort or case-control) of very specific risk factors. The factors would have high prevention potential, compared with more broad and unspecific risk factors, to which many people are exposed. We would recommend a cohort design (in high-risk populations) or a case-control design to identify risk factors, using clinical and/or register data instead of self-reported information, reporting adjusted estimates and using standard definition of suicidal outcome and risk factors.

Long-term follow-up of all-cause and unnatural death in young people with first-episode psychosis

OBJECTIVE

To determine mortality-related estimates and causes of death in young people with first-episode psychosis (FEP), and to identify baseline predictors of mortality.

METHOD

Mortality outcomes in 723 young people presenting to an early psychosis service were prospectively ascertained up to 20 years. Predictors of all-cause and unnatural death were investigated using survival techniques.

RESULTS

Forty-nine participants died by study end. Most deaths (n=41) occurred within 10 years of service entry. All-cause mortality was 5.5% at 10 years, rising to 8.0% after 20 years. Unnatural death rates at 10 and 20 years were 5.0% and 5.9%, respectively. Three risk factors consistently predicted all-cause mortality and unnatural deaths.

CONCLUSION

A substantial proportion of excess mortality was due to non-suicide unnatural death, and, later, natural deaths. This suggests that mental health services should expand their current focus on suicide to incorporate strategies to prevent accidental death and promote healthier lifestyles.

A five year diagnostic follow-up of 1,840 patients after a first episode non-schizophrenia and non-affective psychosis

OBJECTIVE

It is not clear which patients with a first psychotic episode will develop schizophrenia. We performed a diagnostic follow-up of patients treated for a first time non-affective, non-schizophrenia psychosis and explored potential predictors of a subsequent schizophrenia or schizoaffective diagnosis.

METHODS

This register-based cohort study comprises individuals born between 1973 and 1978 in Sweden, with a first hospital-treated psychosis excluding schizophrenia, schizoaffective disorder, bipolar disorder and depressive disorder with psychotic symptoms (n=1840). The patients were followed for five years regarding subsequent diagnoses. Psychiatric, social, family history of psychiatric illness, premorbid intellectual level, head injuries and obstetrical complications were investigated by logistic regression as predictors of schizophrenia or schizoaffective diagnosis.

RESULTS

During the follow-up, 18% were diagnosed with schizophrenia or schizoaffective disorder, 5% were diagnosed with bipolar disorder, whereas 29% were not re-admitted to a psychiatric clinic. Patients with a first-degree relative hospitalized for schizophrenia and/or bipolar disorder had an increased risk of subsequent diagnosis for schizophrenia or schizoaffective disorder (odds ratio 1.9 and 95% confidence interval 1.1 to 3.0)), whereas previous severe criminality was associated with a decreased risk (odds ratio 0.5, 95% confidence interval 0.3-0.8).

CONCLUSION

Diagnostic outcome was diverse after a first non-schizophrenia and non-affective psychosis. Family history of severe mental illness and no previous conviction for severe criminality were the strongest risk factors for a future schizophrenia or schizoaffective diagnosis.

Gender differences in first episode psychotic mania

BACKGROUND

The aim of this paper was to delineate the impact of gender on premorbid history, onset, and 18 month outcomes of first episode psychotic mania (FEPM) patients.

METHODS

Medical file audit assessment of 118 (male = 71; female = 47) patients with FEPM aged 15 to 29 years was undertaken on clinical and functional measures.

RESULTS

Males with FEPM had increased likelihood of substance use (OR = 13.41, p <.001) and forensic issues (OR = 4.71, p = .008), whereas females were more likely to have history of sexual abuse trauma (OR = 7.12, p = .001). At service entry, males were more likely to be using substances, especially cannabis (OR = 2.15, p = .047), had more severe illness (OR = 1.72, p = .037), and poorer functioning (OR = 0.96, p = .045). During treatment males were more likely to decrease substance use (OR = 5.34, p = .008) and were more likely to be living with family (OR = 4.30, p = .009). There were no gender differences in age of onset, psychopathology or functioning at discharge.

CONCLUSIONS

Clinically meaningful gender differences in FEPM were driven by risk factors possibly associated with poor outcome. For males, substance use might be associated with poorer clinical presentation and functioning. In females with FEPM, the impact of sexual trauma on illness course warrants further consideration.

Differentiating schizoaffective and bipolar I disorder in first-episode psychotic mania

OBJECTIVE

This study aims to differentiate schizoaffective disorder (SAD) and bipolar-I-disorder (BD) in first-episode psychotic mania (FEPM).

METHODS

All 134 patients from an epidemiological first-episode psychosis cohort (N=786) with FEPM and an 18-month follow-up final diagnosis of SAD (n=36) or BD (n=98) were assessed with respect to pre-treatment, baseline and outcome differences. Second, patients with baseline BD who shifted (shifted BD) or did not shift to SAD (stable BD) over the follow-up period were compared regarding pre-treatment and baseline differences.

RESULTS

SAD patients displayed a significantly longer duration of untreated psychosis (DUP; effect size r=0.35), a higher illness-severity at baseline (r=0.20) and more traumatic events (Cramer-V=0.19). SAD patients displayed a significantly higher non-adherence rate (Cramer-V=0.19); controlling for time in treatment and respective baseline scores, SAD patients had significantly worse illness severity (CGI-S; partial η²=0.12) and psychosocial functioning (GAF; partial η(2)=0.07) at 18-months, while BD patients were more likely to achieve remission of positive symptoms (OR=4.9, 95% CI=1.8-13.3; p=0.002) and to be employed/occupied (OR=7.7, 95% CI=2.4-24.4, p=0.001). The main discriminator of stable and shifted BD was a longer DUP in patients shifting from BD to SAD.

CONCLUSIONS

It is difficult to distinguish BD with psychotic symptoms and SAD in patients presenting with FEPM. Longer DUP is related to SAD and to a shift from BD to SAD. Compared to BD, SAD had worse outcomes and higher rates of non-adherence with medication. Despite these differences, both diagnostic groups need careful dimensional assessment and monitoring of symptoms and functioning in order to choose the right treatment.

Brief Psychiatric Rating Scale - Excited Component (BPRS-EC) and neuropsychological dysfunction predict aggression, suicidality, and involuntary treatment in first-episode psychosis

OBJECTIVE

Aggression, suicidality and involuntary treatment constitute severe clinical problems in first-episode psychosis (FEP). Although there are studies on prevalence and clinical predictors of these conditions, little is known on the influence of psychopathology and neuropsychological dysfunction.

METHOD

152 FEP inpatients were prospectively assessed using the Brief Psychiatric Rating Scale (BPRS) and a neuropsychological examination covering the domains 'processing speed', 'concentration and attention', 'executive function', 'working memory', 'verbal memory', 'verbal comprehension', 'logical reasoning', 'global cognition', and 'general intelligence'. Clinical data were collected retrospectively in a structured file audit trial.

RESULTS

Patients were aged 24.5±4.9years, and 112 (74%) were male. At admission, 13 (9%) patients presented with severe aggression, and 28 (18%) with severe suicidality. 31 patients (20%) received involuntary treatment. In multivariate analyses, aggression was predicted by BPRS-Excited Component (BPRS-EC; p=.001), suicidality was predicted by BPRS-EC (p=.013) and general intelligence (p=.016), and predictors for involuntary treatment were BPRS-EC (p=.001) and neuropsychological dysfunction in the domain 'concentration and attention' (p=.016).

CONCLUSION

Psychopathology and neuropsychological functioning independently predict dangerous behavior in FEP patients. Some correlations with neuropsychology (e.g., of aggression with concentration/attention) are absent in multivariate analyses and may thus constitute a proxy of psychopathological features. In addition to clinical data, BPRS-EC can be used as a predictor of dangerous behavior. Patients with severe aggression and suicidality show different patterns of neuropsychological dysfunction, indicating that suicidality should not be conceptualized as subtype of aggressive behavior.

Depressive symptoms in first episode schizophrenia spectrum disorder

BACKGROUND

Depressive symptoms in 'non-affective' first episode schizophrenia spectrum disorders (FES) are common, but poorly understood, resulting in a range of conceptual and clinical management issues. This study had three aims: (i) to determine the prevalence of moderate to severe depressive symptoms (defined as a Clinical Global Impressions Scale-Bipolar Disorder (CGI-BP depression) score >3) in a large representative sample of FES patients; (ii) to compare the clinical and functional characteristics of FES patients with and without these depressive symptoms at service entry; and (iii) to compare the characteristics of FES patients with and without persistent depressive symptoms.

METHODS

Medical file audit methodology was employed to collect information on 405 patients with FES treated at the Early Psychosis Prevention and Intervention Centre (EPPIC), Melbourne, Australia.

RESULTS

26.2% (n=106) of the patients had moderate to severe depression at service entry. At service entry and at discharge, those with depressive symptoms had greater insight into their illness but did not differ from those without depressive symptoms in terms of severity of overall psychopathology. Substance use was significantly less common in those with depressive symptoms at service entry and at discharge. Of those who were depressed at baseline, 14.2% (n=15) continued to have moderate to severe depressive symptoms at discharge.

DISCUSSION

Depressive symptoms are common in patients with FES. Understanding the nature and characteristics of depression in FES has important clinical implications for both early intervention and treatment.

Study protocol: The development of a pilot study employing a randomised controlled design to investigate the feasibility and effects of a peer support program following discharge from a specialist first-episode psychosis treatment centre

BACKGROUND

Young people with first-episode psychosis (FEP) are at risk of a range of negative outcomes. Specialist FEP services have been developed to provide comprehensive, multi-disciplinary treatment. However, these services are often available for a restricted period and the services that young people may be transferred to are less comprehensive. This represents a risk of drop out from treatment services in a group already considered to be at risk of disengagement. Peer support groups have been shown to improve social relationships among people with psychosis however individual peer support programs have not been tested on young people with first-episode psychosis; nor have they been tested at the point of discharge from services.

METHODS/DESIGN

The study is an 18-month randomised controlled trial being conducted at Orygen Youth Health Research Centre in Melbourne, Australia. The aim of the study is to test the feasibility and effects of a 6-month peer support intervention delivered to young people with FEP over the period of discharge. Participants are young people aged 15-24 who are being discharged from a specialist first-episode psychosis treatment centre. There is a 6-month recruitment period. The intervention comprises two hours of contact per fortnight during which peer support workers can assist participants to engage with their new services, or other social and community activities. Participants will be assessed at baseline and post intervention (6 months).

DISCUSSION

This paper describes the development of a randomised-controlled trial which aims to pilot a peer support program among young people who are being discharged from a specialist FEP treatment centre. If effective, the intervention could lead to benefits not only for participants over the discharge period, but for peer support workers as well.