Psychosis as a risk factor for suicidal thoughts and behaviors: a meta-analysis of longitudinal studies

Trajectories of suicidal risk among individuals with first-episode psychosis: Relationship to recovery and symptoms

This study examined trajectories of suicide-risk and their relationship to symptoms, recovery, and quality of life over time. Data was obtained from the Recovery after an Initial Schizophrenia Episode Early Treatment Program (RAISE-ETP) study. 404 individuals with first-episode psychosis (FEP) completed measures of suicide-risk, depression, positive symptoms, recovery, and quality of life at baseline, 6mo, 12mo, 18mo, and 24mo. Latent class analysis was used to identify temporal trajectories of suicide-risk. General linear mixed models for repeated measures were used to examine the relationship between the latent trajectories of suicide-risk and clinical variables. Results identified three latent trajectories of suicide-risk (low-risk, worsening, and improving). The low-risk and improving classes experienced improvements in depression, positive symptoms, quality of life, and recovery over time. The worsening class experienced improvements in positive symptoms and quality of life, but no change in depression or recovery. These results suggest that some individuals with FEP are at risk for persistent depression and worsening suicide-risk during treatment despite experiencing improvements in positive symptoms and quality of life. These findings have important clinical implications, as persistent depression and worsening suicide-risk might be masked by the primary focus on positive symptoms and quality of life in most FEP clinics.

A call to action: informing research and practice in suicide prevention among individuals with psychosis

Although it is well established that individuals living with psychosis are at increased risk for suicidal ideation, attempts, and death by suicide, several gaps in the literature need to be addressed to advance research and improve clinical practice. This Call-to-Action highlights three major gaps in our understanding of the intersection of psychosis and suicide as determined by expert consensus. The three gaps include research methods, suicide risk screening and assessment tools used with persons with psychosis, and psychosocial interventions and therapies. Specific action steps to address these gaps are outlined to inform research and practice, and thus, improve care and prognoses among persons with psychosis at risk for suicide.

Patient clinical and demographic factors associated with involuntary psychiatric admission in the northern territory top end

OBJECTIVE

Australia has inadequate publicly available data regarding the use of involuntary psychiatric care. This study examined the association between patient clinical/demographic factors and involuntary psychiatric admission following initial psychiatric assessment in Royal Darwin Hospital.

METHOD

Retrospective review of 638 psychiatric assessments followed by covariate analysis of patient variables associated with involuntary psychiatric admission.

RESULTS

Most of the 225 psychiatric admissions were involuntary (92%). Male patients and those with a preferred language other than English had the highest risk of being admitted involuntarily (RR 1.09, χ2 [1] = 3.9, p = .048, and RR 1.11, p = .036, respectively).

CONCLUSIONS

Further research regarding the influence of patient demographics and clinical factors on rates of involuntary admissions, particularly for Aboriginal patients, is recommended. The findings prompt discussion on strategies to improve monitoring of involuntary care and barriers to voluntary treatment.

An ecological momentary cognitive assessment study of over-attribution of threat and suicide risk factors in people with serious mental illness

INTRODUCTION

People with serious mental illness (SMI; schizophrenia, schizoaffective disorder, bipolar disorder) are at increased risk of suicidal ideation (SI). Over-attribution of social threat, or attributing threatening emotions to neutral faces, may contribute to social isolation through increased social avoidance and decreased social approach motivation. These factors are related to suicide, as well as perceived burdensomeness (PB) and thwarted belongingness (TB). This study examined how over-attribution of threat relates to PB, TB, and social motivations.

METHOD

N = 273 participants with SMI were assessed for current SI and behavior, and were stratified into SI (N = 130) vs. non-SI (N = 143) groups. Participants completed smartphone surveys (via ecological momentary assessments [EMA]) 3×/day for 10 days. They also completed the Mobile Ecological Test of Emotion Recognition (METER) 1×/day. Linear mixed models and multi-level mediation tested the relationships between over-attribution of threat, METER performance, PB/TB, and social motivations.

RESULTS

Participants with and without SI did not significantly differ in over-attribution of threat or METER performance. In separate models, there was a relationship of over-attribution of threat with increased PB (B = 1.00, SE = 0.21, t = 4.72, p < .001), reduced social approach motivation (B = -0.74, SE = 0.22, t = -3.33, p < .001), and increased social avoidance (B = 0.90, SE = 0.24, t = 3.70, p < .001), all significant when adjusting for facial affect recognition ability. A model examining social motivations as a mediator between over-attribution of threat and PB/TB was not significant.

CONCLUSION

These results suggest that over-attribution of threat relates to interpersonal constructs related to SI irrespective of facial affect abilities. This study may inform understanding of social cognitive processes related to suicide in SMI.

Sleep disturbance and suicidal ideation mediated by psychotic-like experiences in adolescents: a two-wave longitudinal study

STUDY OBJECTIVES

Sleep disturbance may cause suicidal ideation (SI). This study aimed to examine their co-occurrence rate among adolescents and investigate whether psychotic-like experiences (PLEs) mediate this association.

METHODS

A total of 17 722 Chinese adolescents were included in this two-wave longitudinal study. The baseline survey (time 1, T1) was conducted between April 21 and May 12, 2021, and the follow-up survey (time 2, T2) was implemented between December 17 and 26, 2021. At T1, participants completed questionnaires to assess their sleep disturbance, sleep duration, PLEs, SI, depressive symptoms, and sociodemographic characteristics. At T2, participants reported their PLEs, SI, and negative life events.

RESULTS

The SI prevalence decreased from 20.2% (T1) to 18.4% (T2). Participants with SI showed significantly higher prevalence of sleep disturbance and short sleep duration compared to those without SI. Baseline sleep disturbance and short sleep duration were both associated with the increased risk of SI 6 months later. These longitudinal links were mediated by PLEs, independent of baseline covariates and negative life events.

CONCLUSIONS

These findings provide a novel insight into the mechanism linking sleep problems and suicidality, and stress the significance of assessing and addressing sleep problems and PLEs for adolescent suicide prevention and intervention.

The relationship between cyberbullying perpetration/victimization and suicidal ideation in healthy young adults: the indirect effects of positive and negative psychotic experiences

BACKGROUND

Even though not all cyber bullies or victims think of (or consider) suicide, they clearly appear to be at an increased risk. One possible strategy to reduce suicide risk is to decrease cyberbullying occurrence; but this approach has its limitations, as it is certainly an illusion to believe that cyberbullying could be controlled or eliminated in a digitalized world. Another alternative and interesting strategy is to consider mediating factors that may indirectly affect suicidality. To this end, our purpose was to test the hypothesis that positive and negative psychotic experiences (PEs) mediate the relationship from cyberbullying perpetration/victimization to suicidal ideation (SI).

METHOD

The study followed a cross-sectional design, and was conducted during the period from June to September 2022. A total of 3103 healthy community participants from Lebanon were included (mean age 21.73 ± 3.80 years, 63.6% females).

RESULTS

After adjusting over potential confounders, mediation analysis models showed that both positive and negative PEs partially mediated the associations between cyberbullying victimization/perpetration and SI. Higher cyberbullying perpetration and victimization were significantly associated with greater positive and negative PEs; more severe positive and negative PEs were significantly associated with higher levels of SI. Higher cyberbullying victimization and perpetration were significantly and directly associated with higher levels of SI.

CONCLUSION

In light of our preliminary findings, there appears to be an urgent need for a new focus on carefully assessing and addressing attenuated psychotic symptoms in healthy individuals engaged in cyberbullying either as victims or bullies and who present with SI. It is important that school counselors and decision-makers consider a holistic approach taking into account both external/environmental (bullying) and internal/individual (PEs) factors in their suicide prevention programs. Future longitudinal research in larger samples are still required to confirm our findings and further elucidate the mechanisms underlying the relationship between cyberbullying and 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.

Suicidal Ideation and Non-Suicidal Self-Injury Following Early Childhood Psychotic Experiences in Preadolescent Children at Familial High Risk of Schizophrenia or Bipolar Disorder-The Danish High Risk and Resilience Study, VIA 11

BACKGROUND AND HYPOTHESIS

Suicide is a leading cause of death in youth and is often preceded by suicidal ideation (SI) and non-suicidal self-injury (NSSI). Identifying early markers of risk for SI and NSSI could improve timely identification of at-risk individuals.

STUDY DESIGN

Children (mean age 11.9, SD 0.2) at familial high risk of schizophrenia (N = 171), or bipolar disorder (N = 104), and controls (N = 174) were assessed for psychotic experiences (PE), SI, NSSI, and Axis I mental disorders in face-to-face interviews in early and middle childhood (age 7 and 11).

STUDY RESULTS

Having 2 types of early childhood PE predicted middle childhood SI after accounting for previous SI, NSSI, and mental disorders (OR 2.8, 95% CI 1.1-6.9; P = .03). Two PE predicted NSSI (OR 3.0, 95% CI 1.2-7.7; P = .02) in excess of previous SI, NSSI, mental disorders, and familial risk. Persistent and incident PE predicted SI (OR 3.2, 95% CI, 1.1-8.8; P = .03; OR 3.8, 95% CI, 1.3-11.5; P = .02) in the fully adjusted model. Nineteen percent of children with persistent PE reported middle childhood SI vs 3.8% of those who never reported PE. In children with early childhood mental disorders, those who reported 2 PE had 4.4-fold increased odds of later SI (95% CI, 1.2-16.7; P = .03) after adjustments. PE were nondifferentially associated with outcomes across familial risk groups.

CONCLUSIONS

Early childhood PE index elevated risk for subsequent SI and NSSI beyond what can be attributed to presence of mental disorders. Mental health screenings and clinical assessments should include early childhood PE.

Risk factors for suicidality across psychosis vulnerability spectrum

BACKGROUND

Suicide is a leading cause of death in individuals with psychotic disorders. Risk factors for suicidality across the psychosis vulnerability spectrum are insufficiently known.

METHODS

For patients (n = 830), siblings (n = 664) and controls (n = 444), suicidality was assessed by the use of a clinical interview. Multilevel modelling was used to investigate risk factors of suicidality. Lastly, risk factor × familial risk interaction effects were examined.

RESULTS

Multivariable models revealed a significant relation between suicidality and depressive symptoms across all three groups, and childhood trauma in patients and siblings. The association between suicidality and psychotic-like experiences is more pronounced in siblings compared to controls.

CONCLUSION

Across the psychosis vulnerability spectrum, depressive symptoms and childhood trauma have been associated with suicidality. Clinicians should pay attention to suicidality in individuals at high familial risk for psychosis with psychotic-like experiences.

Exploring the Relationship Between Suicidality and Persistent Negative Symptoms Following a First Episode of Psychosis

BACKGROUND AND HYPOTHESIS

Suicide is a leading cause of death in first-episode psychosis (FEP), with an elevated risk during the first year following illness onset. The association between negative symptoms and suicidality remains contentious. Some studies suggest that negative symptoms may be associated with lower suicidality, while others fail to find an association between the two. No previous studies have specifically investigated suicidality in Persistent Negative Symptoms (PNS) and its associated subgroups.

STUDY DESIGN

In a large cohort of FEP patients (n = 515) from an early intervention service, we investigated suicidality in those with PNS, secondary PNS (ie, sPNS; PNS with clinical-level positive, depressive, or extrapyramidal symptoms), and non-PNS (all other patients) over 24 months. Patients were categorized into PNS groups based on symptoms from month 6 to month 12, and suicidality was evaluated using the Brief Psychiatric Rating Scale (BPRS).

STUDY RESULTS

Covarying for age and sex, we found that sPNS had higher suicidality relative to PNS and non-PNS throughout the 24-month period, but PNS and non-PNS did not differ. These differences were maintained after adjusting for depressive symptoms.

CONCLUSION

We observed that PNS did not significantly differ from non-PNS. However, we identified sPNS as a group with elevated suicidality above and beyond depression, suggesting that sPNS would benefit from targeted intervention and that PNS categorization identifies a subgroup for whom negative symptoms are not associated with lower suicidality.

Suicide risk among individuals at Ultra-High Risk (UHR) of psychosis in a developing North African country: A 12-month naturalistic prospective cohort study from the TRIP project

BACKGROUND

The limited studies that focused on suicidality in individuals at Ultra-High Risk (UHR) of psychosis were predominantly cross-sectional, emerging from Western countries. We aimed to examine suicide risk among Tunisian UHR and First Episode Psychosis (FEP) patients at baseline, and to evaluate the evolution and correlates of suicidal ideation over a 12-month period in the UHR group exclusively.

METHODS

35 UHR (aged 22.8 ± 4.0 years, 45.7% male) and 33 FEP (aged 27.3 ± 4.8 years, 63.6% male) participants were included. The Comprehensive Assessment of at Risk Mental States, the Positive and Negative Syndrome Scale (PANSS), The Rosenberg Self-Esteem Scale, and The Multidimensional Scale of Perceived Social Support were used.

RESULTS

No significant differences were found between the UHR and the FEP groups with regard to levels of suicidal ideation at baseline. Suicidal ideation scores showed a significant decrease over time in UHR participants (p=.014; η2=0.242). An increase in total PANSS scores at 1 year (Beta=0.03; p=.048; 95%CI 0.001, 0.060; η2=0.182) significantly increased suicidal ideation scores at 1 year in the UHR group.

CONCLUSION

Our findings contribute to the limited body of evidence on this topic by providing new prospective data from a population, country and region that has never been researched previously.

Impact of Treatment Initiation and Engagement on Deliberate Self-Harm Among Individuals With First-Episode Psychosis

OBJECTIVE

Individuals with psychosis are at increased risk for suicide, with the greatest risk being present during the first few months after diagnosis. The authors aimed to examine whether treatment initiation within 14 days of diagnosis and treatment engagement within 90 days of initiation reduce the risk for deliberate self-harm (DSH) among individuals with first-episode psychosis (FEP).

METHODS

A retrospective longitudinal cohort design was adopted by using Ohio Medicaid claims for 6,349 adolescents and young adults ages 15-24 years with FEP. Logistic regression was used to examine factors associated with treatment initiation and engagement. Cox proportional hazard models were used to estimate the impact of treatment initiation and engagement on DSH. Propensity score weighting was used to control for sociodemographic and clinical covariates.

RESULTS

Approximately 70% of the sample initiated treatment, 55% of whom engaged in treatment. Treatment initiation and engagement were associated with both demographic and clinical variables. Treatment initiation significantly reduced the hazard of DSH (average treatment effect in the entire population: hazard ratio [HR]=0.62, 95% CI=0.47-0.81; average treatment effect among those treated: HR=0.64, 95% CI=0.52-0.80). In contrast, treatment engagement was not significantly associated with DSH.

CONCLUSIONS

These results suggest that the initial treatment contact is essential for reducing DSH among adolescents and young adults with FEP. Additionally, the finding that treatment engagement did not reduce DSH suggests that standard clinical care may not be sufficient for reducing DSH in this population. These findings highlight the need for suicide-specific interventions for individuals with FEP.

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

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

Suicidal behavior across a broad range of psychiatric disorders

Suicide is a leading cause of death worldwide. In 2020, some 12.2 million Americans seriously contemplated suicide, 3.2 million planned suicide attempts, and 1.2 million attempted suicide. Traditionally, the approach to treating suicidal behavior (SB) has been to treat the "underlying" psychiatric disorder. However, the number of diagnoses associated with SB is considerable. We could find no studies describing the range of disorders reported to be comorbid with SB. This narrative review summarizes literature documenting the occurrence of SB across the lifespan and the full range of psychiatric diagnoses, not only BPD and those that comprise MDE, It also describes the relevance of these observations to clinical practice, research, and nosology. The literature searches contained the terms "suicid*" and each individual psychiatric diagnosis and identified 587 studies. We did not include case reports, case series, studies only addressing suicidal ideation or non-suicidal self-injury (NSSI), studies on self-harm, not distinguishing between SB and NSSI and studies that did not include any individuals that met criteria for a specific DSM-5 diagnosis (n = 366). We found that SB (suicide and/or suicide attempt) was reported to be associated with 72 out of 145 diagnoses, although data quality varied. Thus, SB is not exclusively germane to Major Depressive Episode (MDE) and Borderline Personality Disorder (BPD), the only conditions for which it is a diagnostic criterion. That SB co-occurs with so many diagnoses reinforces the need to assess current and past SB regardless of diagnosis, and supports the addition of charting codes to the DSM-5 to indicate current or past SB. It also comports with new data that specific genes are associated with SB independent of psychiatric diagnoses, and suggests that SB should be managed with specific suicide prevention interventions in addition to treatments indicated for co-occurring diagnoses. SB diagnostic codes would help researchers and clinicians document and measure SB's trajectory and response to treatment over time, and, ultimately, help develop secondary and tertiary prevention strategies. As a separate diagnosis, SB would preclude situations in which a potentially life-threatening behavior is not accounted for by a diagnosis, a problem that is particularly salient when no mental disorder is present, as is sometimes the case.

Exploring psychological and psychosocial correlates of non-suicidal self-injury and suicide in college students using network analysis

BACKGROUND

Non-suicidal self-injury (NSSI) and suicide are a serious health concern in young people. Remarkable progress has been made in understanding the correlates and risk factors for suicidality. However, it remains unclear the complex interplay between different factors and which factors are most saliently associated with NSSI and suicide risk and should be targeted for interventions.

METHODS

This study utilized network analysis to examine the interrelationship between NSSI, suicide and a variety of psychological (e.g., depression, psychotic-like experiences) and psychosocial (e.g., childhood maltreatment, family dysfunction, being bullied and social support) correlates in a sample of Chinese first year college students (n = 2328).

RESULTS

The severity of depressive symptoms was the only factor connected to both NSSI and suicide. Other psychiatric factors like psychotic experiences could only act in an indirect way via the bridging effect of depression. Emotional abuse, compared with other forms of childhood adversities, was found to be the most influential maltreatment form associated with suicidal ideation and attempts. Finally, social support showed the potential to lower the risk of self-injury and suicide in young people.

LIMITATIONS

Only a subset of risk and resilience factors of NSSI and suicide were included. Causal inference was impossible due to the cross-sectional design.

CONCLUSIONS

Our findings highlighted the importance of identifying risk groups with mental illnesses or negative childhood events, and providing additional support during the key time of transitioning into higher education.

Factors associated with suicide attempts in first-episode psychosis during the first two years after onset

The risk of suicide in first-episode psychosis (FEP) is high. However, there are many unknowns about this phenomenon and the risk factors associated with higher risk are not well-understood. Therefore, we aimed to determine the baseline sociodemographic and clinical factors associated with suicide attempts in FEP patients over two-years after psychosis onset. Univariate and logistic regression analyses were performed. Between April 2013 and July 2020, 279 patients treated at the FEP Intervention Program at our hospital (Hospital del Mar, Spain) were enrolled and 267 completed the follow-up. Of these, 30 patients (11.2%) made at least one suicide attempt, mostly during the untreated psychosis period (17 patients, 48.6%). Several variables-prior history of suicide attempts and low functionality, depression, and feelings of guilt at baseline-were all significantly associated with suicide attempts. These findings suggest that targeted interventions, especially in prodromal stages, could play a key role in identifying and treating FEP patients with a high suicide risk.

Mediation effect of insomnia symptoms between positive psychotic like experiences and suicidal ideation among Lebanese young adults

BACKGROUND

Psychotic symptoms reported by healthy individuals in the general population are referred to as psychotic-like experiences (PLEs) and have been proven to increase the risk of suicidal ideation (SI) in these individuals. As it is well established that PLEs and insomnia share a bidirectional association and also that insomnia is linked to SI, we hypothesized that insomnia may represent a mediator underlying the relationship between PLEs and SI. Our aim was to validate this hypothesis among Lebanese young adults.

METHODS

A total of 3103 young adults (mean age 21.73 ± 3.80 years; 63.6% females) recruited from all Lebanese governorates completed a self-administered online questionnaire. PLEs were assessed using the CAPE-42 scale, SI using the Columbia Suicide Rating Scale, and insomnia using the Insomnia Severity Index). We conducted a mediation analysis using SPSS PROCESS v3.4 model 4 with three pathways. Variables that showed a p < 0.25 in the bivariate analysis were entered in the path analysis.

RESULTS

A total of 1378 participants (44.4%) had insomnia; 18.8% had SI; 42.5% reported at least one positive PE 'nearly always', and 30.5% reported at least one negative PE with this frequency. The results of the mediation analysis showed that insomnia severity partially mediated the association between positive dimension and SI; higher positive dimension was significantly associated with more insomnia severity, which was, in turn, significantly associated with more SI. Finally, more positive dimension was significantly and directly associated with more SI.

CONCLUSION

These preliminary findings might encourage the implementation of new preventive measures to reduce SI among PLEs patients. Treating symptoms of insomnia might help reduce the risk of suicide.

Contributing risk factors of common psychiatric disorders in the Pakistani population

With an increasing incidence of psychiatric disorders worldwide, there is a need for a better understanding of the population-specific contributing risk factors that are associated with common psychiatric conditions. This study aimed to assess the correlation between socioeconomic, environmental and clinical features associated with major depression (MDD n = 479), bipolar disorder (BD n = 222) and schizophrenia (SHZ n = 146), in the Pakistani population. Multinomial logistic regression and Pearson's correlation were applied to assess the association and correlation between demographic, socioeconomic, environmental, and clinical features of MDD, BD and SHZ. In the present study, MDD was found to be more prevalent than BD and SHZ. The average age at onset (AAO), was observed to be earlier in females with BD and SHZ, in addition, females with a positive family history of MDD, BD and SHZ also had an earlier AAO. The fitted multinomial logistic regression model indicated a significant association of; aggression, tobacco use, drugs abuse, history of head injuries and family history with BD as compared to MDD, while insomnia and suicidality were significantly associated with MDD. Strong positive correlations were observed mainly between age/AAO, AAO/tobacco use and aggression/insomnia in all three cohorts. In conclusion, the present study identifies possible contributing socio-demographic, biological and environmental factors that are correlated and associated with the psychiatric conditions in the Pakistani population.

Psychotic experiences, emotion regulation, and suicidal ideation among Chilean adolescents in the general population

Psychotic experiences are associated with increased risk for suicide. Despite this well-established finding, very little is known about factors that contribute to this relationship. The current study investigated the relationship between psychotic experiences, emotion regulation, and suicidal ideation among 1,590 Chilean adolescents in the general population. Participants completed self-report measures of psychotic experiences (Community Assessment of Psychic Experiences), emotion regulation (Emotion Regulation Questionnaire), depression (Patient Health Questionnaire-9), and suicidal ideation (Columbia Suicide Severity Rating Scale). Statistical analyses included Mann-Whitney U tests, point-biserial correlations, logistic regression, and moderation analyses. Results suggest that paranoid ideation, bizarre experiences, and perceptual abnormalities were moderately associated with suicidal ideation. Additionally, greater expressive suppression and cognitive reappraisal were associated with suicidal ideation. Results from the logistic regression indicate that paranoid ideation, perceptual abnormalities, and expressive suppression have the strongest relationship with suicidal ideation, even when controlling for depression and relevant demographic variables. Additionally, paranoid ideation interacted with expressive suppression to predict suicidal ideation, with expressive suppression having the strongest relationship with suicidal ideation when paranoid ideation was low to moderate. Taken together, these findings support the broader literature suggesting that emotion regulation might be a transdiagnostic risk factor for suicidal ideation. Additional longitudinal research is needed to examine whether expressive suppression and other maladaptive emotion regulation strategies serve as a mechanism for suicidal ideation both in the general population and among individuals with psychotic experiences.

Cannabis and Intentional Self-injury: a Narrative Review

Purpose of Review

Observational studies assessing the association of cannabis use with subsequent intentional self-injury have reported mixed findings. Longitudinal studies examining the association of cannabis use with subsequent suicide death are notably rare. Our objective was to review longitudinal studies examining cannabis use and subsequent self-harm, suicide attempt, or suicide death.

Recent Findings

Few population-based studies have focused on self-harm with considerable variability across studies in how this outcome has been operationalized. Studies assessing the association between cannabis use and suicide attempt are equivocal in their conclusions and heterogenous in terms of samples utilized and assessment of confounding bias. The results of one meta-analysis were suggestive of dose dependency. For suicide death, the findings are inconsistent, and there is reason for concern of selection bias.

Summary

The existing evidence base on these associations is not yet rigorous enough to allow drawing conclusions on causality. However, cannabis might be seen as an adverse prognostic marker for intentional self-injury.

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.

Risk Factors for Suicide Attempt During Outpatient Care in Adolescents With Severe and Complex Depression

Background: Young people receiving tertiary mental health care are at elevated risk for suicidal behavior, and understanding which individuals are at increased risk during care is important for treatment and suicide prevention. Aim: We aimed to retrospectively identify risk factors for attempted suicide during outpatient care and predict which young people did or did not attempt during care. Method: Penalized logistic regression analysis was performed in a small high-risk sample of 84 young people receiving care at Orygen's Youth Mood Clinic (age: 14-25 years, 51% female) to predict suicide attempt during care (N = 16). Results: Prediction of suicide attempt during care was only moderately accurate (Area Under the Receiver Operating Curve range 0.71; sensitivity 0.57) using a combination of sociodemographic, psychosocial, and clinical variables. The features that best discriminated both groups included suicidal ideation during care, history of suicide attempt prior to care, changes in appetite reported on the PHQ-9, history of parental separation, and parental mental illness. Limitation: Replication of findings in an independent validation sample is needed. Conclusion: While prediction of suicide attempt during care was only moderately successful, we were able to identify individual risk factors for suicidal behavior during care in a high-risk sample.

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

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

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

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

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.

Risk Factors for Deliberate Self-harm and Suicide Among Adolescents and Young Adults With First-Episode Psychosis

Little is known about the risk factors for deliberate self-harm (DSH) and suicide among adolescents and young adults with first episode psychosis (FEP) and the longitudinal course of DSH following the initial onset of illness. This study identifies risk factors for DSH and suicide death among Medicaid-covered adolescents and young adults with FEP along with the periods of greatest risk for DSH after diagnosis. A retrospective longitudinal cohort analysis was performed using Medicaid claims data merged with death certificate data for 19 422 adolescents and young adults (aged 15-24 years) diagnosed with the onset of FEP between 2010 and 2017. DSH per 1000 person-years and standardized mortality rates for suicide were determined. Hazard ratios of DSH and suicide were estimated by Cox proportional hazard models. During follow-up, 2148 (11.1%) individuals had at least one self-harm event and 22 (0.1%) died by suicide. The hazards of DSH were significantly higher for those with a previous DSH, suicidal ideation, child abuse and neglect, comorbid medical and psychiatric diagnoses, and prior mental health care. The median follow-up time for those who had DSH was 208.0 days (SD: 526.5 days) in adolescents and 108.0 days (SD: 340.0 days) in young adults. Risk of DSH was highest in the first 3 months following FEP. Individuals with FEP are at high risk for self-harm and suicidal behavior, and recognition of who among these individuals and when following illness onset they are at greatest risk may guide more precise clinical recognition and intervention.

Building and evaluating suicide attempt prediction models using risk factors

This study identified risk factors of suicide attempts for the purpose of building prediction models and evaluating their performance. The participants of this secondary data analysis study were 11 671 adults aged 19 years or older. The prediction models consisted of risk factors identified through multiple logistic regression analysis, and performance was analyzed in terms of calibration, discrimination, and clinical usefulness. The risk factors for suicide attempts were suicide plan and suicidal ideation for males, and suicide plan and depression diagnosis for females. The prediction models constructed with these risk factors showed good calibration and discrimination, with over 0.90 of the area under the curves. At the cutoff point of 0.5%, the sensitivity of the full model was 90.9% for males and 82.4% for females. The net benefit was positive at a threshold probability under 30% for males and 40% for females. Given the acceptable performance of the suicide attempt prediction models, they can be used to assess suicide attempt risk and detect the population at high risk in the community at an early stage, with limited human resources.

Ecological momentary assessment of interpersonal theory of suicide constructs in people experiencing psychotic symptoms

BACKGROUND

People with psychotic disorders are at an increased risk of suicide, but there is little understanding of suicidal ideation (SI) in this population. The Interpersonal Psychological Theory of Suicide posits that perceived burdensomeness (PB) and thwarted belonginess (TB) contribute to SI. To our knowledge there are no studies using ecological momentary assessment (EMA) to assess these interpersonal risk factors in a sample of individuals with psychotic disorders. This study investigated the validity and variability of PB and TB, and whether SI, EMA-measured psychotic symptoms, mood, and social context relate to PB and TB.

METHOD

Ninety-six participants with a psychotic disorder, including mood disorders with psychosis completed in-lab assessments of current SI, and then EMA surveys on a smartphone 3×/day for 10 days, answering questions about burdensomeness, belongingness, symptoms (i.e., hearing voices, experiencing suspiciousness), mood (i.e., happy, sad), and social context.

RESULTS

Burdensomeness varied within-participants less than belongingness (t (95) = -3.74, p=< .001). Participants with SI had higher mean burdensomeness ratings (t (94) = -2.70, p < .01) and lower mean belongingness ratings (t (94) = 3.68, p < .001) than did participants without SI. Being with others, greater psychotic experiences, less happiness, and greater sadness related to greater burdensomeness. SI status, being alone, greater psychotic experiences, less happiness, and greater sadness related to less belongingness.

CONCLUSIONS

This study examined the real-time influences of SI and psychotic symptoms on burdensomeness and belongingness. Hearing voices, suspiciousness, mood, and SI are related to interpersonal suicide-related risk factors. In this sample, social context had a differential effect on burdensomeness and belongingness.

Suicidality Over the First 5 Years of Psychosis: Does Extending Early Intervention Have Benefits?

OBJECTIVE

We aimed to investigate whether individuals with first-episode psychosis (FEP) receiving extended early intervention (EI) were less likely to experience suicidal ideation and behaviors than those transferred to regular care after 2 years of EI. Another objective was to examine the 5-year course of suicidality in FEP.

METHODS

We conducted a secondary analysis of a randomized controlled trial where 220 patients were randomized after 2 years of EI to receive extended EI or regular care for the subsequent 3 years. Suicidality was rated using the Brief Psychiatric Rating Scale. Linear mixed model analysis was used to study time and group effects on suicidality.

RESULTS

Extended EI and regular care groups did not differ on suicidality. There was a small decrease in suicidality over time, F(7, 1038) = 1.84, P = 0.077, with an immediate sharp decline within a month of treatment, followed by stability over the remaining 5 years. Patients who endorsed suicidality at entry (46.6%) had higher baseline positive, negative, and depressive symptoms. The 5-year course fell in 3 groups: never endorsed suicidality (33.9%), endorsed suicidality at low-risk levels (43.1%), and endorsed high-risk levels (23.0%). The high-risk group had a higher proportion of affective versus nonaffective psychosis diagnosis; higher baseline positive and depressive symptoms; higher 5-year mean depression scores, and fewer weeks of positive symptom remission over the 5-year course.

CONCLUSIONS

The first month of treatment is a critical period for suicide risk in FEP. Although early reductions in suicidality are often maintained, our findings make the case for sustained monitoring for suicide risk management.

A direct comparison of theory-driven and machine learning prediction of suicide: A meta-analysis

Theoretically-driven models of suicide have long guided suicidology; however, an approach employing machine learning models has recently emerged in the field. Some have suggested that machine learning models yield improved prediction as compared to theoretical approaches, but to date, this has not been investigated in a systematic manner. The present work directly compares widely researched theories of suicide (i.e., BioSocial, Biological, Ideation-to-Action, and Hopelessness Theories) to machine learning models, comparing the accuracy between the two differing approaches. We conducted literature searches using PubMed, PsycINFO, and Google Scholar, gathering effect sizes from theoretically-relevant constructs and machine learning models. Eligible studies were longitudinal research articles that predicted suicide ideation, attempts, or death published prior to May 1, 2020. 124 studies met inclusion criteria, corresponding to 330 effect sizes. Theoretically-driven models demonstrated suboptimal prediction of ideation (wOR = 2.87; 95% CI, 2.65-3.09; k = 87), attempts (wOR = 1.43; 95% CI, 1.34-1.51; k = 98), and death (wOR = 1.08; 95% CI, 1.01-1.15; k = 78). Generally, Ideation-to-Action (wOR = 2.41, 95% CI = 2.21-2.64, k = 60) outperformed Hopelessness (wOR = 1.83, 95% CI 1.71-1.96, k = 98), Biological (wOR = 1.04; 95% CI .97-1.11, k = 100), and BioSocial (wOR = 1.32, 95% CI 1.11-1.58, k = 6) theories. Machine learning provided superior prediction of ideation (wOR = 13.84; 95% CI, 11.95-16.03; k = 33), attempts (wOR = 99.01; 95% CI, 68.10-142.54; k = 27), and death (wOR = 17.29; 95% CI, 12.85-23.27; k = 7). Findings from our study indicated that across all theoretically-driven models, prediction of suicide-related outcomes was suboptimal. Notably, among theories of suicide, theories within the Ideation-to-Action framework provided the most accurate prediction of suicide-related outcomes. When compared to theoretically-driven models, machine learning models provided superior prediction of suicide ideation, attempts, and death.

Sleep quality moderates the association between psychotic-like experiences and suicidal ideation among help-seeking university students

Suicide is a leading cause of death for young adults, and college-enrolled students are at markedly high risk for suicide. Psychotic-like experiences (PLEs) and sleep difficulties are prevalent among college students and have been linked to increased suicidal ideation (SI). This cross-sectional study examined the relation between PLEs and SI, moderated by sleep quality, in a sample of 442 students at a university counseling center. The Behavioral Health Measure-43 (BHM-43) was used to evaluate mental health symptoms, including sleep quality and SI. The PRIME Screen-Revised was used to measure PLEs. Regression results indicated that higher PRIME scores statistically predicted greater SI. There was a significant interaction between PRIME and sleep quality in predicting SI. Among individuals with greater sleep difficulties, PLEs were positively, significantly associated with SI. The PRIME was not a significant predictor of SI at lower levels of sleep difficulties (i.e. better sleep quality). This interaction effect remained significant when controlling for age and the BHM-43 depression and bipolar subscales. Findings suggest that sleep difficulties may be linked to increased SI for individuals with PLEs, and better sleep may be protective. Further research is needed to explore treatment targeting PLEs and/or sleep to mitigate suicide risk among university students.

Externalizing the threat from within: A new direction for researching associations between suicide and psychotic experiences

A recent suicidal drive hypothesis posits that psychotic experiences (PEs) may serve to externalize internally generated and self-directed threat (i.e., self-injurious/suicidal behavior [SIB]) in order to optimize survival; however, it must first be demonstrated that such internal threat can both precede and inform PEs. The current study conducted the first known bidirectional analysis of SIB and PEs to test whether SIB could be considered as a plausible antecedent for PEs. Prospective data were utilized from the Environmental Risk (E-Risk) Longitudinal Twin Study, a nationally representative birth cohort of 2232 twins, that captured SIB (any self-harm or suicidal attempt) and PEs at ages 12 and 18 years. Cross-lagged panel models demonstrated that the association between SIB at age 12 and PEs at age 18 was as strong as the association between PEs at age 12 and SIB at age 18. Indeed, the best representation of the data was a model where these paths were constrained to be equal (OR = 2.48, 95% CI = 1.63-3.79). Clinical interview case notes for those who reported both SIB and PEs at age 18, revealed that PEs were explicitly characterized by SIB/threat/death-related content for 39% of cases. These findings justify further investigation of the suicidal drive hypothesis.

Differential Experiences of Mental Health among Trans/Gender Diverse Adults in Michigan

Transgender and gender diverse individuals experience high rates of health disparities, as compared with their cisgender (non-transgender) counterparts. One area in which these disparities is most grave is that of mental health, with some studies indicating transgender and gender diverse individuals as having a 40% rate of lifetime suicide attempts and similarly high rates of depression, anxiety, and suicidal ideation. These rates vary further within this population, with differential rates seen across sociodemographic factors, including race/ethnicity, gender, sexual orientation, disability status, education level, and income. This study explores mental health experiences across different social identities, using data from the 2018 Michigan Trans Health Survey (N = 659), a community-based participatory action research project collected in Michigan, United States, analyzed using chi-square tests of independence and logistic regressions. Findings indicate incredibly high rates of mental health concerns; 72.2% had been diagnosed with depression in their lifetime and 73.0% had been diagnosed with anxiety in their lifetime. In the past year, 49.9% had had non-suicidal self-injury (NSSI) thoughts, 45.4% had suicidal thoughts, 26.3% engaged in NSSI, and 7.7% had attempted suicide. Bivariate regressions showed some nuanced experiences of rates of mental health diagnoses and experiences, such as greater odds of experiencing all mental health disparities among those with disabilities, and differential odds across gender in regard to ever having a depression diagnosis, non-suicidal self-injury thoughts and engaging in non-suicidal self-injury behavior. This indicates a need for social workers, counselors, therapists, and other human services professionals to act more intentionally and with an intersectional lens when it comes to exploring the mental health of transgender and gender diverse persons.

The Suicide Risk Heading in DSM-5: Promising Start or Flubbed Launch?

The text of DSM-5 includes a new heading-Suicide Risk-meant to educate users about the suicide risk posed by specific mental disorders. But, how well do the Suicide Risk sections fulfill their didactic intent? A review of the sections shows that topical coverage is uneven, noteworthy disorders are omitted, and there are inaccurate statements. In addition, the text frequently uses pejorative terms for suicidal behavior and self-injury. Although the DSM-5 Task Force should be lauded for giving concentrated attention to psychiatry's most lethal outcome, DSM-5 has limited utility for educating students about the suicide risk posed by mental disorders. I make four recommendations to improve the manual's focus on suicide risk and redress the use of stigmatizing terminology.

Determinants of Suicidality in the European General Population: A Systematic Review and Meta-Analysis

Close to one million people commit suicide each year, with suicidal attempts being the main risk factor for suicide. The aim of this systematic review and meta-analysis is to achieve a greater understanding of suicidality in the general population of Europe by studying associated factors and their statistical significance with suicidality, as well as the effect of the temporal moment in which suicidality is observed in a relationship. A search strategy was carried out in electronic databases: Proquest's Psychology Database, Scopus, PsycINFO, Medline and Embase. Odds ratios (ORs), publication bias, influential studies on heterogeneity and analysis moderators were calculated. Twenty-six studies were included after meeting the inclusion criteria. Factors statistically associated with suicidality are female gender, age over 65 years, unemployment, low social support, adulthood adversity, childhood adversity, family history of mental disorder, any affective disorder, major depression, anxiety/stress/somatoform disorders, tobacco and substance use, any mental disorder and body mass index. As a limitation, a high heterogeneity between studies was found. Factors associated with suicidality in the general population are relevant for understanding the suicidal phenomenon.

Suicidal thoughts and behavior (STB) and psychosis-risk symptoms among psychiatrically hospitalized adolescents

BACKGROUND

Individuals in the early stages of psychosis have a markedly high risk for suicidal thoughts and behavior (STB). It is not well understood if STB among those with psychosis-risk symptoms is accounted for by co-occurring psychopathology (e.g., depression), unique experiences specific to psychosis-spectrum symptomatology (e.g., hallucinations, delusions), or combined effects of different factors. This cross-sectional study explored the link between psychosis-spectrum symptoms, co-occurring disorders, and STB.

METHODS

This record review included 569 adolescents (mean age = 14.83) admitted to a psychiatric inpatient hospital due to exhibiting behavior indicating they were an imminent threat to themselves or others. Upon intake to the hospital, participants completed a diagnostic interview and self-report measures of suicidal ideation, suicide attempt history, and psychosis-spectrum symptoms. The primary analysis used linear regression to predict suicidal ideation from psychosis-spectrum symptom scores, controlling for known characteristics associated with STB including specific psychiatric disorders (i.e. depressive, anxiety, post-traumatic stress, and psychotic disorders), biological sex, and race.

RESULTS

Psychosis-spectrum symptoms predicted suicidal ideation above and beyond the significant effects of a depressive disorder diagnosis and sex, as well as the non-significant effects of anxiety, PTSD, full-threshold psychosis, and race. Item-level correlations demonstrated that several psychosis-spectrum symptoms were significantly associated with ideation and lifetime suicide attempts.

CONCLUSIONS

Results indicate that within this sample of psychiatrically hospitalized youth, psychosis-risk symptoms were uniquely linked to STB. These findings suggest that attention to psychosis-spectrum symptoms, including several specific psychosis-risk experiences, may be clinically important for better assessment and treatment of suicidal youth.

Examining the mechanisms by which adverse life events affect having a history of self-harm, and the protective effect of social support

BACKGROUND

Psychological models of suicide emphasize perceptions of negative stressors, hopelessness and self-harm as key antecedents to suicidal thoughts/acts. Such models also emphasize the potential protective role of social support in these pathways. However, such pathways have not been tested using population level data. Hence, this study aimed to redress this gap.

METHODS

Questionnaire data regarding 24,444 patient suicide deaths were analysed. All individuals died between 1996 and 2015 and were seen by secondary mental health services in England within 12 months before their death. Mediation analyses, using fitted logistic regression models, investigated direct and indirect pathways between negative stressors, hopelessness and a proxy measure of suicide, namely, self-harm history. In addition, the buffering effects of social support were examined in these pathways.

RESULTS

There was a direct effect of negative life events on suicidal behaviors. Supporting contemporary psychological models of suicide, a mediated effect via hopelessness and a protective effect of social support were identified. Social support buffered the pathway between stressful life events and hopelessness, with hopelessness decreasing as social support increased.

LIMITATIONS

Causal inferences are inappropriate as the design was cross-sectional. A proxy measure of suicidality was utilized (history of self-harm) as all individuals had died by suicide.

CONCLUSIONS

This is the first time that population data has been used to test psychological pathways to suicidal acts involving negative stressors, hopelessness and social support. Psychological interventions should focus on increasing social support following negative life events together with ameliorating perceptions of hopelessness.

Psychotic Symptoms Predict Suicidal Behavior Postdischarge in High Risk Psychiatric Inpatients

BACKGROUND

Psychotic disorders, as well as psychotic symptoms, are associated with a greater lifetime risk of suicidal behavior (SB). It is not known, however, whether psychotic symptoms are independent predictors for short-term SB.

METHODS

Data were collected from 201 psychiatric inpatients at Mount Sinai Beth Israel Hospital. Self-reported psychotic symptoms were assessed using the Brief Symptom Inventory (BSI). Postdischarge SB defined as an aborted, interrupted, or actual suicide attempt was assessed using the Columbia-Suicide Severity Rating Scale (C-SSRS), during the 4 to 8 weeks following discharge from an inpatient psychiatric unit (n=127, 63% retention). Logistic regressions were performed to assess the relationships between psychotic symptoms and SB, controlling for primary psychiatric disorders.

RESULTS

Self-reported psychotic symptoms were associated with subsequent postdischarge SB. There was no significant difference between the SB versus no SB groups on the basis of primary psychiatric disorder. Self-reported psychotic symptoms remained an independent and significant predictor of postdischarge SB when the analysis controlled for primary psychiatric disorder.

CONCLUSIONS

These results suggest that psychotic symptoms are a dimensional predictor of near-term postdischarge SB and are a necessary component of suicide risk assessment during inpatient hospitalization, independent of psychiatric diagnosis.

Suicidal Ideation in People With Psychosis Not Taking Antipsychotic Medication: Do Negative Appraisals and Negative Metacognitive Beliefs Mediate the Effect of Symptoms?

Between 5% and 10% of people with psychosis will die by suicide, a rate which is 20-75 times higher than the general population. This risk is even greater in those not taking antipsychotic medication. We examined whether negative appraisals of psychotic experiences and negative metacognitive beliefs about losing mental control mediated a relationship between psychotic symptoms and suicidal ideation in this group. Participants were diagnosed with schizophrenia spectrum disorders, antipsychotic-free for 6 months at baseline, and were participating in an 18-month randomized controlled trial of cognitive therapy vs treatment as usual. We conducted a series of mediation analyses with bootstrapping on baseline (N = 68), follow-up data (9-18 mo; n = 49), and longitudinal data (n = 47). Concurrent general symptoms were directly associated with suicidal ideation at baseline, and concurrent negative symptoms were directly associated with suicidal ideation at 9-18 months. Concurrent positive, negative, general, and overall symptoms were each indirectly associated with suicidal ideation via negative appraisals and/or negative metacognitive beliefs, at baseline and 9-18 months, except for negative symptoms at baseline. Controlling for baseline suicidal ideation and treatment allocation, baseline general symptoms were indirectly associated with later suicidal ideation, via baseline negative appraisals and negative metacognitive beliefs. Baseline negative metacognitive beliefs also had a direct association with later suicidal ideation. These findings suggest the clinical assessment of suicidal ideation in psychosis may be enhanced by considering metacognitive beliefs about the probability and consequences of losing mental control.

Mediators Linking Childhood Adversities and Trauma to Suicidality in Individuals at Risk for Psychosis

Suicidality is highly prevalent in patients at clinical high risk (CHR) for psychosis. Childhood adversities and trauma are generally predictive of suicidality. However, the differential effects of adversity/trauma-domains and CHR-criteria, i.e., ultra-high risk and basic symptom criteria, on suicidality remain unclear. Furthermore, the underlying mechanisms and, thus, worthwhile targets for suicide-prevention are still poorly understood. Therefore, structural equation modeling was used to test theory-driven models in 73 CHR-patients. Mediators were psychological variables, i.e., beliefs about one's own competencies as well as the controllability of events and coping styles. In addition, symptomatic variables (depressiveness, basic symptoms, attenuated psychotic symptoms) were hypothesized to mediate the effect of psychological mediators on suicidality as the final outcome variable. Results showed two independent pathways. In the first pathway, emotional and sexual but not physical adversity/trauma was associated with suicidality, which was mediated by dysfunctional competence/control beliefs, a lack of positive coping-strategies and depressiveness. In the second pathway, cognitive basic symptoms but not attenuated psychotic symptoms mediated the relationship between trauma/adversity and suicidality. CHR-patients are, thus, particularly prone to suicidality if adversity/trauma is followed by the development of depressiveness. Regarding the second pathway, this is the first study showing that adversity/trauma led to suicidality through an increased risk for psychosis as indicated by cognitive basic symptoms. As insight is generally associated with suicidality, this may explain why self-experienced basic symptoms increase the risk for it. Consequently, these mediators should be monitored regularly and targeted by integrated interventions as early as possible to enhance resilience against suicidality.