Associations of suicidality with cognitive ability and cognitive insight in outpatients with Schizophrenia

Association between cognitive functioning, suicidal ideation and suicide attempts in major depressive disorder, bipolar disorder, schizophrenia and related disorders: A systematic review and meta-analysis

INTRODUCTION

Treatable mental disorders, such as psychotic, major depressive disorder (MDD), and bipolar disorder (BD), contribute to a substantial portion of suicide risk, often accompanied by neurocognitive deficits. We report the association between cognitive function and suicidal ideation/suicide attempts (SI/SA) in individuals with schizoaffective disorder, BD, and MDD.

METHODS

A systematic search was conducted on PubMed, Ovid and Scopus databases for primary studies published from inception to April 2024. Eligible articles that reported on the effect size of association between cognition and SI/SA were pooled using a random effects model.

RESULTS

A total of 41 studies were included for analysis. There was a negative association between executive functioning and SI/SA in schizoaffective disorder (SA: Corr = -0·78, 95 % CI [-1·00, 0·98]; SI: Corr = -0·06, 95 % CI [-0·85, 0·82]) and MDD (SA: Corr = -0·227, 95 % CI [-0·419, -0·017]; SI: Corr = -0·14, 95 % CI [-0·33, 0·06]). Results were mixed for BD, with a significant positive association between SA and global executive functioning (Corr = 0·08, 95 % CI [0·01, 0·15]) and negative association with emotion inhibition. Mixed results were observed for processing speed, attention, and learning and memory, transdiagnostically.

LIMITATIONS

There is heterogeneity across sample compositions and cognitive measures. We did not have detailed information on individuals with respect to demographics and comorbidities.

CONCLUSIONS

We observed a transdiagnostic association between measures of cognitive functions and aspects of suicidality. The interplay of cognitive disturbances, particularly in reward-based functioning, may underlie suicidality in individuals with mental disorders. Disturbances in impulse control, planning, and working memory may contribute to self-injurious behavior and suicide.

Association of empathy with clinical symptoms and cognitive function in chronic schizophrenia patients with and without suicide attempts

Cognitive impairment is recognized as a risk factor for suicide in schizophrenia (SZ) patients. Despite empathy being an important aspect of social cognition, the association between suicidal behavior and empathy has received little attention. We aimed to compare empathy and neurocognition in SZ patients with and without suicide attempts (SAs), and to explore the relationship between empathy, neurocognition, and clinical symptoms in SZ patients with and without SAs. Data on SAs and socio-demographic characteristics were collected from 628 chronic SZ patients. The patients' symptomatology was measured by the Positive and Negative Syndrome Scale (PANSS). Empathy and neurocognition were assessed with the Interpersonal Reactivity Index (IRI) and Repeatable Battery for the Assessment of Neuropsychological Status (RBANS), respectively. Patients with SAs performed better on all IRI domains (except for Perspective Taking) and total scores. Regression results showed that negative symptoms, positive symptoms, and duration of illness were independently associated with IRI total score in patients without SAs (adjusted R2 = 0.048). In patients without SAs, negative symptoms, general psychopathology, education, age, and sex were independently associated with RBANS total score (adjusted R2 = 0.265), while in patients with SAs, education, PANSS total score, and age at onset were independently associated with RBANS total score (adjusted R2 = 0.456). Our results show that SZ patients with SAs may have better empathic performance than patients without SAs. In chronic SZ patients, negative and positive symptoms may have different effects on cognition in the SAs and non-SAs groups.

Sex differences in the association between suicidal ideation and neurocognitive function in Chinese patients with schizophrenia

There is increasing evidence that sex differences exist in many clinical manifestations of patients with schizophrenia, including suicidal ideation (SI) and neurocognitive function. The present study was performed to explore the sex differences in the association between SI and neurocognitive function in Chinese patients with schizophrenia. A total of 1188 inpatients with schizophrenia were recruited from multicenter psychiatric hospitals. The Repeatable Battery for the Assessment of Neuropsychological Status (RBANS) was utilized to evaluate the neurocognitive function of all patients. The Positive and Negative Syndrome Scale (PANSS) was utilized to assess the psychopathology of patients. The Beck Scale for Suicide Ideation (BSSI) was used to assess the severity of SI. In male patients, the suicide risk score was significantly associated with PANSS negative symptoms (r = 0.167, p = 0.043), visuospatial subscale (r = - 0.261, p = 0.001), and RBANS total scores (r = - 0.172, p = 0.037). Furthermore, multivariate linear regression analysis showed that the visuospatial subscale (β = - 0.490, t = - 3.273, p = 0.001) was independently associated with the suicide risk score in male patients. In female patients, the suicide risk score was significantly correlated with PANSS positive symptoms (r = 0.249, p = 0.021), negative symptoms (r = 0.394, p < 0.001), general psychopathology (r = 0.276, p = 0.01) and PANSS total score (r = 0.365, p = 0.001). Multivariate linear regression analysis showed that PANSS negative symptoms (β = 1.849, t = 3.933, p = 0.001) were significantly associated with suicide risk scores in female patients. Our findings indicate that there are sex differences in the association between SI and neurocognitive function in patients with schizophrenia. Based on the findings of our study, gender-specific prevention and intervention strategies may make a difference in reducing SI in Chinese schizophrenia patients.

Can neurocognition, brain neurotrophic factor, triglyceride, and total cholesterol predict suicidal ideation in first-episode Han Chinese patients with schizophrenia?

OBJECTIVE

Previous studies have suggested that the suicide rate of patients with schizophrenia is high. This study investigates factors influencing suicidal ideation in first-episode schizophrenia patients, focusing on cognitive function, brain-derived neurotrophic factor (BDNF), triglyceride (TG), and total cholesterol (TC) in patients with first-episode schizophrenia.

METHODS

A total of 123 patients with first-episode schizophrenia and 38 healthy controls were included in the study. The patients were divided into suicidal and nonsuicidal ideation groups based on the Beck Scale for Suicidal Ideation, and they were assessed with Positive and Negative Syndrome Scale (PANSS). Cognitive function was assessed using the Chinese version of the MATRICS consensus cognitive battery (MCCB) and the serum BDNF, TG, and TC were detected. The main statistical methods include t-test, χ2 test, multivariate logistic regression analysis, receiver operating characteristic (ROC) curve analysis, and the DeLong test.

RESULTS

26.02% of patients exhibited suicidal ideation. Higher PANSS and TC levels were risk factors, while higher MCCB scores and BDNF levels were protective factors. ROC analysis indicated AUCs of 0.630, 0.724, and 0.762 for serum BDNF, PANSS, and MCCB, respectively, with a combined AUC of 0.870.

CONCLUSION

Serum BDNF level, PANSS score, and MCCB score can be used as auxiliary predictors of suicidal ideation in schizophrenic patients. Combining these three indicators can effectively predict suicidal ideation in schizophrenic patients.

Gender differences in prevalence and clinical risk factors of suicide attempts in young adults with first-episode drug-naive major depressive disorder

BACKGROUND

Suicide rates in adolescents with major depressive disorder (MDD) change with age and gender. Early adulthood is an important transitional stage between late adolescence and adulthood, in which an individual's mind gradually matures. However, there are fewer studies on prevalence and variables linked to the suicide attempts of young adults with MDD.

AIMS

To explore gender differences in the prevalence and risk factors associated with suicide attempts in young adults with first-episode drug-naive MDD.

METHOD

The Hamilton Rating Scale for Depression (HRSD), Hamilton Rating Scale for Anxiety (HRSA) and Positive Subscale of the Positive and Negative Syndrome Scale (PANSS) were used to assess depression, anxiety and psychotic symptoms respectively and various biochemical indicators were assessed.

RESULTS

Among 293 young adults with first-episode drug-naive MDD, the prevalence of suicide attempts was 15.45% (19/123) for males and 14.12% (24/170) for females. Males with suicide attempts had higher levels of thyroid-stimulating hormone (TSH) and higher PANSS Positive Subscale scores, whereas females with suicide attempts had higher TSH, serum total cholesterol, fasting blood glucose and diastolic blood pressure levels and higher scores on the HRSD, HRSA, PANSS Positive Subscale (all Bonferroni corrected P < 0.05). In males, PANSS Positive Subscale score (B = 0.17, P = 0.03, OR = 1.19, 95% CI 1.02-1.38) was a risk factor for suicide attempts.

CONCLUSIONS

There were significant gender differences in the risk factors for suicide attempts in young adults with first-episode drug-naive MDD.

Correlation analysis and gender differences of cognitive function based on mini-mental state examination (MMSE) and suicidal tendency in patients with schizophrenia

BACKGROUND

The aim of this study was to investigate the correlation and gender differences between cognition and suicidal tendency in patients with schizophrenia.

METHODS

A total of 554 patients with schizophrenia were recruited. The Mini-Mental State Examination (MMSE), Positive and Negative Syndrome Scale (PANSS), Interpersonal Reactivity Index (IRI), Toronto Alexithymia Scale (TAS), and Insomnia Severity Index (ISI) were used to assess clinical symptoms.

RESULTS

In male patients, MMSE score and the incidence of suicidal tendency were correlated (P = 0.04, OR = 1.06, 95%CI: 1.00-1.12). Among patients with cognitive dysfunction, IRI score (P = 0.01, OR = 1.04, 95%CI: 1.01-1.06), and types of antipsychotic drugs (P < 0.01, OR = 3.97, 95%CI: 1.76-8.97) in male patients were associated risk factors for suicidal ideation. Among patients without cognitive dysfunction, PANSS positive subscale score (P = 0.03, OR = 1.06, 95%CI: 1.01-1.11), and PANSS general psychopathology score (P = 0.02, OR = 1.05, 95%CI: 1.01-1.08) were associated risk factors for suicidal ideation in male patients and PANSS positive subscale score (P < 0.01, OR = 1.15, 95%CI: 1.05-1.26) were associated risk factors for suicidal ideation in female patients.

CONCLUSIONS

There were significant gender differences in the correlation between cognitive functioning and suicidal ideation in patients with schizophrenia. Cognitive function may play an important mediating role in other factors on suicide.

Systematic Review of the Link Between Social Cognition and Suicidal Ideation and Behavior in People With Serious Mental Illness

Background and Hypothesis

People with serious mental illness (SMI; psychotic and affective disorders with psychosis) are at an increased risk of suicide, yet there is limited research on the correlates of suicide in SMI. Social cognitive impairments are common among people with SMI and several studies have examined social cognition and suicidal ideation (SI) and behavior. This systematic review aims to evaluate the links between various domains of social cognition, SI, and suicidal behavior in SMI.

Study Design

Electronic databases (PubMed and PsycInfo) were searched through June 2023. Records obtained through this search (N = 618) were screened by 2 independent reviewers according to inclusion criteria. Relevant data were extracted, and study quality was assessed.

Study Results

Studies (N = 16) from 12 independent samples were included in the systematic review (N = 2631, sample sizes ranged from N = 20 to N = 593). Assessments of social cognition and SI and behavior varied widely between studies. Broadly, effects were mixed. Better emotion recognition of negative affect was linked to SI and a history of suicide attempts, though there is little consistent evidence for the relationship of emotion recognition and SI or behavior. On the other hand, better theory of mind ability was linked to SI and a history of suicide attempts. Furthermore, negative attributional bias was linked to current SI, but not a history of SI or attempt.

Conclusions

This review suggests mixed associations between social cognition, SI, and behavior in SMI. Future research should evaluate additional mediators and moderators of social cognition and suicide, employing prospective designs.

Association between suicidal ideation and cognitive function in young patients with schizophrenia spectrum disorder

Introduction

Suicide is a major concern for patients with recent-onset schizophrenia. We hypothesized that preserved cognitive function might be associated with a higher level of suicidality in patients with schizophrenia. We investigated the associations between cognitive function and suicidal ideation (SI) in young patients recently diagnosed with a psychotic disorder.

Methods

This study analyzed data from a naturalistic clinical cohort study that comprised 402 patients with schizophrenia spectrum disorder. Patients with a treatment duration of ≤5 years and an age range of 15-39 years were enrolled. Participants were categorized into two groups based on SI as assessed by the Columbia Suicidal Severity Rating Scale. We collected demographic and clinical data and administered psychiatric, neurocognitive, and social cognitive measures.

Results

Among participants, 52% reported experiencing SI. Patients with SI were significantly younger and had a longer duration of untreated psychosis (DUP) than those without it. The Positive and Negative Syndrome Scale-general psychopathology score was significantly higher in the SI group. Scores on the Calgary Depression Scale for Schizophrenia, Perceived Stress Scale, Beck Depression Inventory (BDI), and Beck Hopelessness Scale were significantly higher among patients with SI, while scores on the Subjective Well-being Under Neuroleptics-Short Form and Brief Resilience Scale were significantly lower compared to those without it. Patients with SI demonstrated significantly higher scores on the verbal and visual learning test, false belief task, picture stories task, and Controlled Oral Word Association Test. They also completed the Trail Making Test (TMT) parts A and B in significantly less time than those without it. After adjusting for age, DUP, and scores on the BDI, group differences in scores on the verbal and visual learning tests, TMT (parts A and B), and the false belief task, and the picture story task remained significant.

Discussion

Our results suggest that along with traditional risk factors, better cognitive function may also be a major risk factor for suicidality in patients with schizophrenia. Providing psychological support and cognitive interventions is essential for young patients with recent-onset schizophrenia spectrum disorders, particularly those with high levels of depression, hopelessness, perceived stress, low resilience, and good cognitive function.

Visuospatial ability and attention as risk factors for suicidal ideation in middle-aged and elderly schizophrenia patients: a cross-sectional study

BACKGROUND

Schizophrenia patients have a high risk of suicide, and their cognition function is impaired with increasing age. The association between neurocognitive and suicidality in schizophrenia patients are heterogeneous. We aimed to explore the relationship between neurocognitive function and suicidal ideation in schizophrenia patients across age groups.

METHODS

A total of 587 patients with schizophrenia were enrolled in this study. The schizophrenia patients were divided into young group (aged 18-44) and middle-aged and elderly group (aged 45-70). The schizophrenia patients were divided into suicidal ideation group and non-suicidal ideation group according to the evaluation results of the Beck Scale for Suicide Ideation. Insomnia symptoms were measured by the Insomnia Severity Index (ISI). Psychotic symptoms were measured by the Positive and Negative Syndrome Scale (PANSS), and cognitive function was measured by the Repeatable Battery for the Assessment of Neuropsychological Status (RBANS).

RESULTS

There was a negative correlation between the age and attention scores of RBANS (P = 0.018). The young schizophrenia patients had higher risk of suicidality than middle-aged and elderly schizophrenia patients (P = 0.001). In the logistic regression analysis, the scores of ISI and positive symptoms scores of PANSS were associated with suicidal ideation among young schizophrenia patients (All P < 0.05). Age, BMI, the scores of ISI, general symptoms scores of PANSS, visuospatial scores of RBANS and attention scores of RBANS were associated with suicidal ideation in middle-aged and elderly schizophrenia patients (All P < 0.05).

CONCLUSIONS

High visuospatial scores of RBANS and attention scores of RBANS were risk factors for suicidal ideation in middle-aged and elderly schizophrenia patients.

Are all reasons for living made equally? Reasons for living and dysfunctional attitudes in psychotic disorders and bipolar I

OBJECTIVES

Persons with schizophrenia, schizoaffective, or bipolar I disorder are more likely to die by suicide compared to the general population. Dysfunctional attitudes have been shown to be significant predictors of cognitive vulnerability to depression, hopelessness, and poor problem-solving skills, which predict suicidal ideation. Dysfunctional attitudes are common in persons with schizophrenia spectrum disorders (SSDs) and bipolar I. The Reasons for Living Inventory (RFLI) examines distinct reasons for not dying by suicide. This study's objectives were to examine the relationship between the RFLI subscales and dysfunctional attitudes among persons with SSDs and bipolar I. We hypothesized significant positive correlations between two RFLI subscales (Fear of Suicide and Fear of Social Disapproval) and total score on the Dysfunctional Attitude Scale (DAS). We did not expect significant correlations between other subscales.

DESIGN AND METHODS

This correlational, cross-sectional study examined baseline scores on the RFLI and dysfunctional attitudes (DAS) among N = 102 outpatients with SSDs or bipolar I.

RESULTS

Significant positive correlations were observed between RFLI subscales Fear of Suicide and Fear of Social Disapproval and DAS total scores. No other significant relationships were observed.

CONCLUSIONS

Certain reasons for living (i.e. fear of suicide and social disapproval) may be associated with dysfunctional attitudes among persons with SSDs or bipolar I. These, in turn, may place these individuals at a greater risk for suicide by increasing their cognitive vulnerability. These findings may inform clinical treatment targets for persons with SSDs and bipolar I.

Counting the Toll of Inflammation on Schizophrenia-A Potential Role for Toll-like Receptors

Toll-like receptors (TLRs) are a family of pattern recognition receptors (PRRs) that are ubiquitously expressed in the human body. They protect the brain and central nervous system from self and foreign antigens/pathogens. The immune response elicited by these receptors culminates in the release of cytokines, chemokines, and interferons causing an inflammatory response, which can be both beneficial and harmful to neurodevelopment. In addition, the detrimental effects of TLR activation have been implicated in multiple neurodegenerative diseases such as Alzheimer's, multiple sclerosis, etc. Many studies also support the theory that cytokine imbalance may be involved in schizophrenia, and a vast amount of literature showcases the deleterious effects of this imbalance on cognitive performance in the human population. In this review, we examine the current literature on TLRs, their potential role in the pathogenesis of schizophrenia, factors affecting TLR activity that contribute towards the risk of schizophrenia, and lastly, the role of TLRs and their impact on cognitive performance in schizophrenia.

The Relationship Between Suicidal Behavior, Neurocognitive Functions, and Insight in Patients with Schizophrenia

Background

In schizophrenia, the relationship between suicide and cognition is unclear. We aimed to assess cognitive functions and insight in schizophrenia patients with and without suicide attempts.

Methods

In our study consisting of 77 patients, 36 of the patients had attempted suicide at least once in their lives and the remaining 41 had never attempted suicide. Sociodemographic data scale, Beck Cognitive Insight Scale, and Cambridge Neurophysiological Assessment Battery were applied.

Results

In this study, patients with schizophrenia who attempted suicide had higher Beck Cognitive Insight Scale self-reflectiveness scores (P = .004), lower Beck Cognitive Insight Scale self-certainty scores (P = .040), and higher Beck Cognitive Insight Scale total score (P = .004). Delay aversion (P = .003) and risk-taking scores (P = .044) of Cambridge Neurophysiological Assessment Battery Cambridge gambling task were higher in patients who attempted suicide. In logistic regression analysis, as independent factors, the number of hospitalizations increased the risk of suicide 1.5 times per hospitalization (P = .021), Cambridge gambling task delay aversion increased the risk of suicide 8.4 times per score (P = .044), and the Beck Cognitive Insight Scale self-certainty score was shown as the factor that decreased the risk of suicide by 0.78 times (P = .024).

Conclusion

The causes of suicide attempts in schizophrenia still preserve its uncertainty. Our results proposed a statistically significant relationship between cognitive insight and increased suicide attempts. This study also sustains that cognitive impulsivity is associated with suicidal behavior in patients with schizophrenia.

Neurocognitive Suicide and Homicide Markers in Patients with Schizophrenia Spectrum Disorders: A Systematic Review

Suicide and homicide are considered important problems in public health. This study aims to identify the cognitive performance of suicidal and homicidal behaviors in people with schizophrenia spectrum disorders, as well as examining whether there are shared neuropsychological mechanisms. A systematic review of the recent literature was carried out from September 2012 to June 2022 using the Medline (via PubMed), Scopus, Embase, and Cochrane databases. Among the 870 studies initially identified, 23 were finally selected (15 related to suicidal behaviors and 8 to homicidal behaviors). The results evidenced a relationship between impairment of cognitive performance and homicidal behavior; meanwhile, for suicidal behaviors, no consistent results were found. High neuropsychological performance seems to act as a protective factor against violent behavior in people with schizophrenia spectrum disorders, but not against suicidal behavior; indeed, it can even act as a risk factor for suicidal behavior. To date, there is insufficient evidence that shared neurocognitive mechanisms exist. However, processing speed and visual memory seem to be affected in the presence of both behaviors.

Suicidal ideation in Chinese adults with schizophrenia: associations with neurocognitive function and empathy

BACKGROUND

Suicidal ideation is common among people diagnosed with schizophrenia spectrum disorders and may be related to neurocognitive, social cognitive, and clinical variables. This study aimed to investigate the relationships between suicidal ideation and both neurocognitive function and empathy.

METHODS

The sample for this cross-sectional study comprised 301 schizophrenic patients aged 18-44 years. All participants were administered the Beck Scale for Suicide Ideation-Chinese Version (BSI-CV), the Repeatable Battery for the Assessment of Neuropsychological Status (RBANS), the Interpersonal Reactivity Index (IRI), and the Positive and Negative Syndrome Scale (PANSS). The demographic and clinical data of the patients were also collected.

RESULTS

In total, 82 patients reported suicidal ideation. Compared to patients without suicidal ideation, patients with suicidal ideation showed significant differences in the IRI-Personal Distress subscale, PANSS-General Psychopathology symptom scores, and suicide attempts. Moreover, there were moderating effects of neurocognitive function and empathy on the relationship between suicide attempts and suicidal ideation.

CONCLUSIONS

These results indicate that the personal distress component of empathy, general psychopathology symptoms and suicide attempts are independent risk factors for suicidal ideation in Chinese adults with schizophrenia. Moreover, neurocognitive function may also be related to suicidal ideation through a moderating relationship. In order to reduce suicidal ideation among patients with schizophrenia, early screening of empathy and neurocognitive function is essential.

Metacognition and insight dynamics exploration in borderline personality disorder: Exploring the underlying dynamics

Metacognition and Insight are related to hard-to-treat disorders and among them is Borderline Personality Disorder (BPD). We recruited 190 BPD patients and measured Insight, Metacognition, Impulsivity, and BPD traits. Results showed BPD's significant links with Insight and Metacognition. Metacognition significantly correlated with two Impulsivity dimensions, whereas Insight significantly correlated with most of them. Regressions analysis revealed a significant relationship between Insight and Metacognition on Impulsivity and Borderline traits. Mediation analysis proved the indirect effect of Metacognition/Insight on Borderline traits through Impulsivity at a significative level. Both seem relevant for research and therapeutic application in BPD following different dynamics even if the limitation of our study stands in its gender ratio and possible comorbidity issues. Urgency appears as a critical factor to assess, notably with Positive emotion-based impulsivity.

Relationship between cognition and suicidal behavior in recent-onset psychosis

Suicidal behavior (SB) is common in first-episode psychosis (FEP), and cognitive impairment has also been described in psychosis. Despite well-established risk factors for SB in psychosis, the role of cognition and insight remains unclear. This study aimed to explore the relationship between history of SB and cognition in recent-onset FEP, distinguishing between neurocognition, social cognition, and metacognition, and including cognitive insight (CI) as a metacognitive variable. The sample consisted of 190 participants with recent-onset FEP recruited from two multicentric studies. Two groups were formed based on presence/absence of a history of SB. Demographic, clinical, and cognitive data were compared by group, including significance level adjustments and size effect calculation. No differences were found regarding demographic, clinical, neurocognitive, social cognition, and metacognitive variables except for CI (18.18 ± 4.87; t = -3.16; p = 0.0020; d = -0.635), which showed a medium effect size. Small to medium effect size were found for attributional style (externalizing bias) (1.15 ± 3.94; t = 2.07; d = 0.482), theory of mind (ToM) (1.73 ± 0.22; t = 2.04; d = -0.403), jumping to conclusions bias (JTC) (23.3 %; X² = 0.94; V = 0.178). In recent-onset psychosis, neurocognitive functioning was not related to the history of SB. As novelty, individuals with previous SB showed higher CI. Also, regarding social cognition and metacognition, individuals with prior SB tended to present extremely low externalizing bias, better ToM, and presence of JTC.

The differential associations of positive and negative symptoms with suicidality

BACKGROUND

Suicide is one of the leading causes of death in people with schizophrenia. Identifying risk factors for suicide in schizophrenia is therefore an important clinical and research priority.

METHOD

A cross-sectional secondary analysis was conducted on the DNA Polymorphisms in Mental Illness Study (DPIM) data. Suicidality data was extracted, and the number of positive and negative symptoms were established for a total of 1494 participants. Logistic and negative binomial regression analyses were conducted to assess for associations between positive or negative symptoms and suicidal ideation, attempt, or number of attempts, whilst adjusting for potential confounders.

RESULTS

Negative symptoms were associated with a reduction in the risk of suicidal ideation (odds ratio [OR]: 0.83; 95 % CI: 0.75-0.91) and suicide attempt (OR: 0.79; 95 % CI: 0.71-0.88) after adjusting for age and sex. Positive symptoms were associated with an increased risk of suicidal ideation (OR: 1.06; 95 % CI: 1.03-1.09), suicide attempt (OR: 1.04; 95 % CI: 1.00-1.07) and number of suicide attempts (incidence rate ratio [IRR]: 1.05; 95 % CI: 1.01-1.08). Further adjusting for depressive symptoms slightly increased the magnitude of associations with negative symptoms but attenuated associations between positive symptoms and suicidality to the null.

CONCLUSIONS

Negative symptoms are associated with a reduced risk of suicidality, whilst positive symptoms are associated with an increased risk of suicidality. Depressive symptoms may confound or mediate these associations.

Impaired insight in schizophrenia: impact on patient-reported and physician-reported outcome measures in a randomized controlled trial

BACKGROUND

Impaired insight poses a challenge in the treatment of patients with schizophrenia because of its potential to jeopardize therapeutic engagement and medication adherence. This study explored how insight impairment, graded from none to extreme, is related to patient-reported mental health status, depression, and neurocognition in schizophrenia.

METHODS

In a post hoc analysis of the Clinical Antipsychotic Trials of Intervention Effectiveness (CATIE) study (NCT00014001), insight was measured using the Positive and Negative Syndrome Scale (PANSS) Item G12 (lack of insight). Additional assessments for this analysis included the 12-Item Short-Form Health Survey (SF-12) Mental Component Summary (MCS), physician- and patient-reported Clinical Global Impression-Severity (CGI-S), MATRICS Consensus Cognitive Battery, and Calgary Depression Scale for Schizophrenia. Relationships between patient-reported outcomes and PANSS total and Item G12 ratings were evaluated.

RESULTS

Among 1431 CATIE study participants in this analysis, increasingly impaired insight at baseline was significantly associated with better patient-reported quality of life (QoL), lower baseline depression, and greater divergence between physician- and patient-reported illness severity. Patients with more severely impaired insight reported milder illness compared with physician reports, particularly those with moderate-severe to extreme impairment (PANSS Item G12 rating ≥ 5), approximately 10% (138/1431) of CATIE participants. For the 90% of patients with PANSS Item G12 ratings < 5, patient-reported QoL decreased with increasing symptoms. SF-12 MCS scores were linearly related to baseline PANSS total score only in patients with PANSS total score < 90 (moderately ill or better), and better symptom scores were associated with higher QoL. No significant relationship between insight and neurocognition was observed.

CONCLUSIONS

In the small subgroup (10%) of CATIE study patients with schizophrenia and PANSS Item G12 ratings ≥5, moderate-severe-severe/extreme insight impairment was associated with significantly more positive perception of QoL and illness severity by the patient versus the treating physician. This was not observed in the remaining 90% of patients with normal to moderately impaired insight, suggesting that poor insight as a threat to the validity of self-report is uncommon.

Psychopathology and Poor Clinical Insight in Psychotic Patients: Does the Diagnosis Matter?

ABSTRACT

Poor clinical insight is one of the most common features of schizophrenia spectrum disorders and plays a critical role in prognosis and treatment. Considering the biological and phenomenological overlap between schizophrenia and bipolar I disorder with psychotic features (BID) and increasing incidents of methamphetamine-induced psychotic disorder (MIPD) patients in Iran, it is necessary to have a clear picture of insight among these three groups. The aim of the present study was to compare clinical insight and other aspects of illness among three different disorders: schizophrenia, BID, and MIPD. In addition, we sought to examine the relationship of the severity of psychotic symptoms with clinical insight in each group. A total of 115 male inpatients, including 48 persons diagnosed with schizophrenia, 35 persons diagnosed with BID, and 32 persons diagnosed with MIPD, were selected. All participants completed the Scale to Assess Unawareness of Mental Disorder and the Positive and Negative Syndrome Scale. The results of analysis of variance indicated that schizophrenia patients reported higher rates of illness duration and number of hospital admissions in comparison to the MIPD and BID groups. In addition, persons diagnosed with BID reported more of these outcomes than MIPD groups. However, the three groups showed similar patterns in terms of age of onset and educational, marital, and occupational statuses. The results also revealed that awareness of the disorder was more impaired in schizophrenia patients compared with BID and MIPD patients and in MIPD compared with BID groups. However, the level of awareness of the effect of medication, the awareness of social consequences, and the total score of clinical insight were similar across the three diagnostic groups. As expected, poor clinical insight was correlated with high levels of positive, negative, and cognitive symptoms in the schizophrenia group; with high levels of positive, cognitive, and depressive symptoms in the BID group; and with high levels of positive and excitement symptoms in MIPD. In addition, hierarchical linear regression analyses revealed that only cognitive symptoms in the schizophrenia group and excitement symptoms in the MIPD group significantly predicted the overall score of clinical insight. In the BID group, both cognitive and depressive symptoms significantly predicted clinical insight. These findings suggest that there are differing levels of poor clinical insight in schizophrenia, MIPD, and BID and that poor clinical insight found within each group may have different antecedents.

An Update on Clinical Insight, Cognitive Insight, and Introspective Accuracy in Schizophrenia-Spectrum Disorders: Symptoms, Cognition, and Treatment

INTRODUCTION

Poor insight, or unawareness of morbid changes in cognition, emotional states, or behavior, is commonly observed among people with schizophrenia. Poor insight represents a persistent barrier to wellness because it interferes with treatment and self-direction. Paradoxically, good insight may also be a barrier to health when awareness of these changes leads to depression or self-stigma.

AREAS COVERED

This paper builds upon this previous work by exploring these issues in schizophrenia separately as they have appeared in published research over the last three years in three different kinds of insight: clinical, cognition, and introspective accuracy. Specifically, studies are reviewed that address: the adverse effects of poor insight, the paradoxical effects of good insight, correlates with other forms of cognition, and emerging treatments.

EXPERT OPINION

The evidence continues to offer a nuanced picture of the complex effects of good insight in schizophrenia. Incremental improvements were also found in the development of novel integrative treatment approaches. This work also highlights the intricacy of the concept of insight, the need for further exploration of the effects of culture, and conceptual work that distinguishes the points of convergence and divergence of these forms of insight.

Introspective accuracy for substance use across a year of treatment for first episode psychosis

Substance use exacerbates psychosis, mania, depression, and poor functioning in people with first episodes of psychosis (FEP) and is associated with poor treatment outcomes, even when it does not reach the level of a formal disorder. Impaired insight and substance use are common issues that may interfere with treatment outcomes among people experiencing FEP, yet both are treatable. Improvements in these domains are associated with better outcomes. Low insight could increase risk for substance use by impairing the ability to self-appraise and assess consequences. Introspective accuracy (IA) is understudied in this area and is one way of considering self-appraisal. This study is an archival review using data collected from NAVIGATE, a coordinated specialty care program treating people with FEP. IA was operationalized as the difference between clinician and client ratings of substance use. We tested whether IA changed over one year of treatment and whether those changes occurred alongside changes in symptoms and illness self-management. No changes in IA were detected in relation to illness self-management. Changes in IA for substance use occurred midway through treatment-individuals with greater symptom remission had more overconfident IA. Prior research on insight has shown a paradox where greater insight accompanies more symptoms. However, past research has also shown a relationship between IA and functional outcomes, like illness self-management, and that overconfidence in one domain can positively bias clinician ratings in another. Our findings suggest either a positive bias for ratings associated with overconfident IA or an insight paradox type effect.

A qualitative systematic review of neurocognition in suicide ideators and attempters: Implications for cognitive-based psychotherapeutic interventions

BACKGROUND

Growing evidence suggests cognitive deficits may represent neurocognitive markers with predictive utility in identifying those at risk for suicide. Characterizing these deficits may offer the opportunity to develop targeted interventions.

AIM

The aim of this systematic qualitative review is to provide a synthesis of the published data on neurocognition in suicide ideators and attempters in order to clarify which neurocognitive targets may be most relevant to address using cognitive-based psychotherapeutic strategies in patients at risk for suicide.

RESULTS

A total of 63 studies met criteria for inclusion. The most consistent findings were in depressed suicide attempters, where deficits in executive subdomains of inhibition, selective attention and decision-making, as well as in working memory, were identified. In contrast, no clear pattern of neurocognitive deficits emerged from studies in suicide ideators across diagnoses.

CONCLUSIONS

More studies are needed to clarify the role of cognitive deficits in specific subtypes of individuals at risk for suicide. The findings are discussed in the context of promising research on cognitive remediation and other psychological interventions.

Relationship between social cognition, general cognition, and risk for suicide in individuals with a psychotic disorder

OBJECTIVE

Cognitive alterations putatively contribute to the risk for suicide in individuals with psychosis. Yet, a comprehensive assessment of social- and general-cognitive abilities in a large sample is lacking.

METHODS

Seven-hundred-fifteen individuals diagnosed with a psychotic disorder performed tasks of facial emotion recognition, Theory of Mind, and general cognitive functioning (sustained attention, set-shifting, IQ-tests and verbal learning) as part of the Genetic-Risk-and-Outcome-of-Psychosis (GROUP) study. Presence of past suicide attempt/s and/or current suicidal ideation was reported by 261 individuals and 454 individuals reported no suicide attempt or ideation. We used general linear models to investigate group differences in task performance. All analysis were controlled for age, sex, education, and psychotic symptom severity.

RESULTS

Individuals with suicide attempt and/or ideation showed better performance on the facial emotion recognition task and lower performance on tasks of sustained attention and verbal learning, compared to individuals without suicide attempt and/or ideation, without a clear effect of attempt or ideation. Theory of Mind performance was also better for individuals with suicide attempt and/or ideation, with largest differences between individuals who reported both attempts and ideation compared to individuals without suicide attempt and/or ideation. No effect of suicide attempt and/or ideation was found on misperception of facial emotions, IQ and set-shifting. Overall, effect sizes were small.

CONCLUSION

Higher sensitivity to social-emotional cues together with weakened attentional control and learning capacity was observed in individuals with psychosis and suicide attempt and/or ideation. This may suggest that insufficient capacity for regulating perceived social stress contributes to suicidal thoughts and behavior.

Co-occurring Deficits in Clinical and Cognitive Insight in Prolonged Schizophrenia-Spectrum Disorders: Relationship to Metacognitive Deficits

People diagnosed with schizophrenia have been broadly observed to experience deficits in clinical and cognitive insight; however, less is understood about how these deficits are related. One possibility is that these deficits co-occur among people when other deficits in cognition are present, such as in executive function, social cognition, and metacognition, which may either promote the development of both forms of poor insight or allow one to negatively influence the other. To explore this possibility, we conducted a cluster analysis using assessments of clinical and cognitive insight among 95 adults with a schizophrenia spectrum disorder. As predicted, this analysis yielded a group with concurrently poor clinical and cognitive insight (n = 36). Additional groups were found with concurrently good clinical and cognitive insight (n = 28) and poor clinical insight and good cognitive insight (n = 31). Groups were then compared on assessments of executive function, social cognition, and metacognition. The group with concurrently lower levels of cognitive and clinical insight had significantly poorer metacognition relative to the other groups. In particular, they tended to form more fragmented and less integrated ideas about themselves and others. No differences were found for executive function or social cognition. The result may suggest that while clinical and cognitive insight is partially orthogonal phenomena, relatively lower levels of metacognition, or difficulties forming integrated ideas about oneself and others, maybe a condition leading to the confluence of lower clinical and cognitive insight. Interventions targeting metacognition may be of particular use for this group.

Suicidal ideation, suicide attempts, and neurocognitive dysfunctions among patients with first-episode schizophrenia

OBJECTIVE

To determine whether suicidal ideation or suicide attempts are linked to poor neurocognitive function among individuals with first-episode schizophrenia (FES).

METHOD

We performed a cross-sectional study on 159 Chinese inpatients (M_age  = 27.1 years; 52.2% females) with minimal-treated FES and collected their suicidal history through interviews and medical records. Neurocognitive performance, psychopathology, and depressive symptoms were assessed using the MATRICS Consensus Cognitive Battery, the Positive and Negative Syndrome Scale, and the Calgary Depression Scale for Schizophrenia, respectively.

RESULTS

Approximately 1/10 FES inpatients had any suicide attempts, and more than 1/4 reported lifetime suicidal ideation. Inpatients with a suicide attempt or suicidal ideation scored significantly worse in the overall seven neurocognitive domains compared with those without past suicidal ideation or a suicide attempt. Linear regression suggested that suicide attempts were mainly associated with lower scores in working memory and speed of processing, after adjusting for education levels. The associations remained robust after further controlling for psychopathological and depressive symptoms.

CONCLUSION

First-episode schizophrenia patients with suicide attempts had more severely impaired neurocognitive performances in specific domains. Fundamental neurocognitive dysfunctions should be assessed, detected, and treated after their suicide risk assessments.

Exploring the relationship of insight with psychopathology and gender in individuals with schizophrenia spectrum disorders with structural equation modelling

To model the influence of psychopathology on insight deficits in schizophrenia spectrum patients with a gender-stratified analysis. Five hundred sixteen patients (65.1% men) with schizophrenia spectrum disorders were evaluated in four centres of the metropolitan area of Barcelona (Catalonia). Psychopathological assessment was performed using different PANSS factors. Insight and its three main dimensions were assessed by means of the Scale of Unawareness of Mental Disorder: awareness of the disease (SUMD-1), of the effect of medication (SUMD-2) and of the social consequences of the disease (SUMD-3). Structural equation models (SEMs) were used to fix the model in the total sample and by gender. Additional analyses included age, duration of illness (DOI) and education status (ES). There were no significant differences between men and women in the three main dimensions of insight. The SEMs in the total sample showed a modest fitting capacity. Fitting improved after a gender-stratified analysis (particularly in women). In men, positive and excited symptoms were associated with poorer insight in all SUMD dimensions, whereas depressive symptoms were associated with better insight. ES in men was also associated with better SUMD-2 or SUMD-3. In contrast, in women, symptoms did not have a negative effect on SUMD-1 or SUMD-2. However, positive symptoms were associated with a poorer SUMD-3, whereas depressive symptoms were associated with better SUMD-3. Moreover, education level was also associated with a better SUMD-3. A gender approach improved the comprehension of the model, supporting the relevance of gender analysis in the study of insight.

Effectiveness of Suicide-Focused Psychosocial Interventions in Psychosis: A Systematic Review and Meta-Analysis

OBJECTIVE

Suicide ideation, plan, attempt, and death are significant and prevalent concerns among individuals with psychosis. Previous studies have focused on risk factors, but few have systematically evaluated the effect of psychosocial interventions on these experiences among individuals with psychosis. This study evaluated the effectiveness of psychosocial interventions in reducing suicide ideation, plan, attempt, and death among individuals with psychotic symptoms.

METHODS

Eight electronic databases were systematically searched from inception until June 30, 2019. Identified studies included both randomized controlled trials and controlled trials without randomization that examined psychosocial interventions for suicide ideation, plan, attempt, and death among individuals with psychotic symptoms. A random-effects model was used to pool the effect sizes for synthesis.

RESULTS

Eleven studies with 14 effect sizes (N=4,829 participants) were analyzed. The average age of participants ranged from 21 to 51, and most participants identified as male and non-Hispanic Caucasian or Chinese and were in an early or first-episode stage of illness. On average, participants who received psychosocial interventions were less likely than their counterparts in the control group to report suicide ideation, plan, and attempt and die by suicide (odds ratio [OR]=0.57, 95% confidence interval [CI]=0.41-0.78). Subgroup analyses further revealed significant reductions in suicide ideation (OR=0.73, 95% CI=0.55-0.97) and suicide death (OR=0.45, 95% CI=0.30-0.68) among intervention participants.

CONCLUSIONS

Preliminary evidence indicated that psychosocial interventions are effective in reducing suicide ideation, plan, attempt, and death among individuals with psychotic symptoms. Intervention characteristics, however, varied across studies, which suggests a lack of consensus on best clinical practices.

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.

Characterizing the phenomenology of passive suicidal ideation: a systematic review and meta-analysis of its prevalence, psychiatric comorbidity, correlates, and comparisons with active suicidal ideation

BACKGROUND

Compared to active ideation, passive ideation remains relatively understudied and its clinical importance poorly defined. The weight that should be accorded passive ideation in clinical risk assessment is therefore unclear.

METHODS

We conducted a systematic review and meta-analysis of the prevalence of passive ideation, its psychiatric comorbidity, associated sociodemographic characteristics, as well as psychological and environmental correlates. For reference, pooled effects were also calculated for direct comparisons of passive and active ideation with respect to potential correlates. Relevant articles published since inception to 9 September 2019 were identified through a systematic search of MEDLINE and PsycINFO.

RESULTS

A total of 86 studies were included in this review. The prevalence of passive ideation was high across sample types, ranging from 5.8% for 1-year prevalence to 10.6% for lifetime prevalence in the general population. Passive ideation was strongly associated with sexual minority status, psychiatric comorbidity, psychological characteristics implicated in risk, and suicide attempts. Preliminary evidence exists for a large association with suicide deaths. The effect sizes for individual correlates of passive and active ideation were largely equivalent and mostly non-significant in head-to-head comparisons.

CONCLUSIONS

Passive ideation is a prevalent clinical phenomenon associated with significant psychiatric comorbidity. Current evidence also suggests notable similarities exist between passive and active ideation in terms of psychiatric comorbidity and psychological and other characteristics traditionally associated with risk.

Single-Session Mobile-Augmented Intervention in Serious Mental Illness: A Three-Arm Randomized Controlled Trial

Psychosocial interventions for serious mental illness are resource intensive and poorly accessible. Brief interventions (eg, single session) that are augmented by follow-on automated mobile health intervention may expand treatment access. This was a randomized single-blind controlled trial with 255 individuals diagnosed with schizophrenia or bipolar disorder. Participants were randomized to one of three conditions: CBT2go, which combined one individual session of cognitive behavioral therapy with automated thought challenging/adaptive behavior delivered through mobile devices; Self-Monitoring (SM), which combined single-session illness psychoeducation with self-monitoring of symptoms; and treatment-as-usual (TAU). Participants were assessed at baseline, 6 weeks (midpoint), 12 weeks (posttreatment), and 24 weeks (follow-up) with our primary outcome global psychopathology (Brief Psychiatric Rating Scale-expanded version [BPRS-24]), and secondary outcomes community functioning (Specific Level of Function; SLOF) and defeatist performance beliefs (DPBs). We also collected data on adverse events. Outcome analyses on the primary outcome, BPRS Total score, indicated a significant time (0-24 wk) by group interaction with significant but modest improvement comparing two active conditions (CBT2go and SM) relative to TAU. Effects of CBT2go were not different from SM. There was a significant time × group interaction with better SLOF scores in CBT2go across 24 weeks, but not in SM. There were no time-by-group effects on DPBs. DPBs decreased in the CBT2go condition but not in SM. These results indicated that single intervention augmented by mobile intervention was feasible and associated with small yet sustained effects on global psychopathology and, when inclusive of CBT, community function compared with usual care.

Exploration of Treatment-Resistant Schizophrenia Subtypes Based on a Survey of 204 US Psychiatrists

OBJECTIVE

To explore and describe potential subgroups within the treatment-resistant schizophrenia (TRS) population, using data from a survey of US psychiatrists.

METHODS

Psychiatrists completed an online survey of demographic/clinical characteristics and treatment history for two of their patients with TRS. Patients were stratified according to number of suicide attempts, number of hospitalizations, employment status, and TRS onset time frame.

RESULTS

Of the 408 patients with TRS described by psychiatrists, 37.5% had ≥1 suicide attempt, 78.9% had ≥2 hospitalizations, 74.5% were unemployed, 45.0% had TRS onset within 5 years of first treatment (a further 8.0% had TRS from first treatment), and 31.5% had TRS onset after 5 years (15.5% unknown). Patients with ≥1 (vs 0) suicide attempts had statistically significantly more psychiatric (3.6 vs 2.2) and physical (2.2 vs 1.6) comorbidities. Patients with ≥2 (vs ≤1) hospitalizations were statistically significantly more likely to have hallucinations, conceptual disorganization, social withdrawal, and cognitive dysfunction, and had more psychiatric (3.0 vs 1.9) and physical (2.0 vs 1.1) comorbidities. Unemployed (vs employed) patients were statistically significantly more likely to have delusions, hallucinations, blunted affect, social withdrawal, and cognitive dysfunction, and had more psychiatric (2.9 vs 2.3) and physical (2.1 vs 1.2) comorbidities. Patients with TRS onset ≤5 (vs >5) years were statistically significantly younger (35.0 vs 43.7 years), less likely to have hallucinations and social withdrawal, and had fewer psychiatric (2.6 vs 3.3) and physical (1.7 vs 2.3) comorbidities.

CONCLUSIONS

Greater clinical burden in TRS is associated with greater illness severity and chronicity markers, suggesting a dimensional gradient from non-TRS to mild-moderate and more severe forms of TRS. Time to onset of TRS may have implications for outcomes, with data indicating greater burden in those with late-onset TRS. Accumulation of illness over time may be more important than time to onset.

Identification of risk factors for suicidal ideation in patients with schizophrenia

Patients with schizophrenia have a high risk for suicide, and therefore, identification of risk factors for suicidal ideation (SI) may be helpful to reduce suicide rate. This study aimed to detect which clinical symptoms and biochemical parameters were most strongly associated with SI. A total of 174 patients and 35 healthy controls were enrolled in our study. Patients were evaluated by the Positive and Negative Syndrome Scale (PANSS), Scale of Assessment Negative Symptoms (SANS) and the Calgary Depression Scale for Schizophrenia (CDSS) for psychiatric and depressive symptoms, and the Repeatable Battery for the Assessment of Neuropsychological Status (RBANS) for cognitive function. We examined the levels of prolactin (PRL) and metabolic parameters in all participants. Our results showed a significantly increased level of PRL in patients compared to the controls before (t = 10.414, P < 0.001) and after (F = 31.308, P < 0.001) covariates were controlled for. In addition, we found that patients with SI had significantly higher PRL levels than those without SI (t = 2.586, P = 0.011). And there were positive correlations between serum PRL levels (r = 0.194, P = 0.010), serum fasting triglyceride levels (TG) (r = 0.188, P = 0.013), and RBANS visuospatial skill subscores (r = 0.162, P = 0.036) and SI severity. Finally, the stepwise multiple linear regression analysis revealed that SI severity was significantly associated with PRL levels, fasting TG levels and RBANS visuospatial skill subscores. This study provides support that greater cognitive ability, specifically visuospatial skill, PRL and TG, may confer an elevated risk for more severe SI in schizophrenia patients.

Social cognition and short-term prediction of suicidal ideation in schizophrenia

Despite recent research acknowledging social cognition as an important feature of interpersonal functioning in schizophrenia, little work has evaluated the role of social cognition in suicidal ideation and behavior in psychosis. In a short-term longitudinal study, we evaluated the association between concurrent and near term suicidal ideation with social cognition, including emotion recognition and related biases (ER-40; BLERT), attribution biases (AIHQ), and evaluations of trustworthiness (trustworthiness task) in a sample of 179 outpatients with schizophrenia or schizoaffective disorder. Adjusting for severity of positive and general mental health symptoms, greater reactivity to extreme stimuli (trustworthiness measure), BLERT negative affect accuracy, and AIHQ Blame Scores were associated with suicidal ideation at baseline. AIHQ Blame Scores also longitudinally predicted the presence of ideation 2 weeks later and were highest among participants with ideation across the two time points. The present findings provide support that biased interpretations, and, concurrently with ideation, reactivity and selective accuracy to negative stimuli, are associated with suicidal ideation in schizophrenia. Further understanding the role of social cognitive ability and biases on suicidal ideation could contribute to the understanding of social cognition as a treatment target in prevention of suicidal behavior in schizophrenia.

The dynamic relationship between insight and suicidal behavior in first episode psychosis patients over 3-year follow-up

Studies have established the high risk of suicide in first episode psychosis (FEP). Between 15% and 26% of FEP patients attempt suicide at least once before their first contact with psychiatric services and 2-5% die from suicide. Also, many patients with schizophrenia spectrum disorders lack insight into having a mental disorder. However, the relationship between insight changes and suicidal behavior in FEP remains poorly understood. In the present study information about suicidal behavior over a 3 years period was available on a cohort of 397 FEP patients, of whom 270 were assessed in the three dimensions of insight (into mental illness, the need for treatment, and the social consequences) at baseline, 1 and 3 years after treatment initiation. Survival analyses examined time to suicidal behavior in relation to (i) insight at baseline, (ii) the closest insight measure to the suicide attempt, and (iii) changes in insight during the follow-up. No associations were found between baseline insight dimensions and time to suicidal behavior. However, poor insight at the evaluation closest to the suicide attempt was associated with an increased risk of suicide. Stability of insight did not affect the risk of suicidal behavior, while changes in either direction were linked with an increased risk of suicidal behavior, particularly worsening insight. Insight in psychosis is a dynamic concept and we demonstrated the relationship between insight and suicide risk to be equally dynamic. Poor insight seems to increase the risk, especially when insight levels change. Repeated insight assessment to detect change from early psychosis may play a role in suicide prevention.

Interpersonal beliefs related to suicide and facial emotion processing in psychotic disorders

Deficits in social cognition are present in psychotic disorders; moreover, maladaptive interpersonal beliefs have been posited to underlie risk of suicidal ideation and behavior. However, the association between social cognition and negative appraisals as potential risk factors for suicidal ideation and behavior in psychotic disorders has not been assessed. In a pilot study, we assessed accuracy and error biases in facial emotion recognition (Penn ER-40), maladaptive interpersonal beliefs as measured by the Interpersonal Needs Questionnaire (INQ), and current suicide ideation and history of past attempts in a sample of 101 outpatients with psychotic disorders (75 schizophrenia/schizoaffective; 26 bipolar disorder). INQ scores were positively associated with history of suicide attempts and current ideation. INQ scores were inversely related with emotion recognition accuracy yet positively correlated with bias toward perceiving anger in neutral expressions. The association between biases pertaining to anger and INQ scores persisted after adjusting for global cognitive ability and were more evident in schizophrenia than in bipolar disorder. The present findings suggest that maladaptive beliefs are associated with a tendency to misperceive neutral stimuli as threatening and are associated with suicidal ideation and behavior. Although better cognitive ability is associated with higher rates of suicide attempts in psychotic disorders, biases in misinterpreting anger in others may be a specific deficit related to formation of maladaptive beliefs about others, which, in turn, are associated with history of suicide attempts.