Suicidal thinking and behaviours in First Episode Psychosis: Findings from a 3-year longitudinal study

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

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

Demographic and clinical characteristics of individuals with psychosis symptoms who died by suicide: Findings of a psychological autopsy study

Suicide is a critical public health concern among individuals with schizophrenia spectrum disorders (SSDs). Still, significant gaps remain in understanding relationships between suicide outcomes and both demographic and clinical characteristics. Data were examined from 57 adults of a psychological autopsy study who had psychosis symptoms and died between 1989 and 2017 in the Midwestern United States. This study compared demographic and clinical characteristics of those who died by suicide (n = 26) to those who died by natural (n = 26) or accidental (n = 5) causes. Those who died by suicide were more often younger, white/Caucasian, more educated, and more often employed than those who died by natural or accidental causes (p < .05). Furthermore, symptoms of depression, recurrent suicidal ideation, history of suicide attempt, and being in a first episode of psychosis were experienced significantly more by those who died by suicide in comparison to natural or accidental causes (p < .05). Findings highlight the need to consider depression in suicide risk for psychosis populations, intervene in early stages of psychosis illness, and implement suicide prevention strategies tailored to individuals with psychosis and SSDs. Implications point towards the need for tailored interventions to mitigate risk for suicide death in this vulnerable population.

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

INTRODUCTION

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

LIMITATIONS

Cross-sectional study design, self-reported questionnaires.

Association between suicidal ideation, negative symptoms and theory of mind in first episode psychosis

PURPOSE

Suicidal thoughts are common among patients with first episode psychosis (FEP). The impact of symptoms' severity and social cognition on suicidal risk should be a focus of attention. This study aimed at assessment of the severity of suicidal ideation in patients with FEP and its potential association with the theory of mind (ToM) impairment and symptoms' severity.

METHODS

Ninety-six participants were recruited consecutively and subdivided into three equal groups: FEP, schizophrenia, and healthy controls (HC). The symptoms' severity was assessed using Positive and Negative Syndrome Scale (PANSS) and Beck Depression Inventory (BDI). Suicidal ideation was evaluated using Beck Scale for Suicidal Ideation (BSSI). Reading the Mind in the Eyes revised version (RMET) was used to assess ToM.

RESULTS

Suicidal ideation was significantly higher only in FEP compared to HC (p = 0.001). Both FEP and schizophrenia had substantially lower performance than HC on RMET (p < 0.001). Higher depression (β = 0.452, p = 0.007) and negative symptoms (β = 0.433, p = 0.027) appeared to be significantly associated with increased suicidal ideation severity in FEP while RMET did not.

CONCLUSION

Patients with FEP and chronic schizophrenia have comparable deficits in theory of mind dimension of social cognition. The severity of negative and depressive symptoms potentially contributes to the increased risk of suicide in FEP.

Adverse outcome analysis in people at clinical high risk for psychosis: results from a 2-year Italian follow-up study

PURPOSE

Since January 2016, the Parma Department of Mental Health (in Italy) developed a specialized care program for Early Intervention (EI) in individuals at Clinical High Risk for Psychosis (CHR-P). As unfavorable outcomes other than transition to psychosis were not systematically reported in the current literature (thereby compromising more sophisticated prognostic stratifications), the aims of this research were (1) to investigate adverse outcome indicators (i.e., service disengagement, psychosis transition, hospitalization, prolonged functioning impairment, prolonged persistence of CHR-P criteria, suicide attempts) in an Italian CHR-P population enrolled within a specialized EI service across a 2-year follow-up period, and (2) to examine their relevant associations with sociodemographic and clinical characteristics of the CHR-P total sample at baseline.

METHODS

All participants were young CHR-P help-seekers aged 12-25 years. They completed the "Comprehensive Assessment of At-Risk Mental States" (CAARMS) and the Health of the Nation Outcome Scale (HoNOS). Both univariate and multivariate Cox regression analyses were performed.

RESULTS

164 CHR-P individuals were enrolled in this study. Across the follow-up, 30 (18.0%) dropped out the EI program, 23 (14%) transitioned to psychosis, 24 (14.6%) were hospitalized, 23 (14%) had a prolonged persistence of CHR-P criteria and 54 (47%) showed prolonged impairment in socio-occupational functioning.

CONCLUSION

As almost half of our participants did not functionally remit over time, sustained clinical attention for young CHR individuals people should be offered in the longer term, also to monitor unfavorable outcomes and to improve long-term prognosis.

Borderline personality disorder vs. schizophrenia spectrum disorders in young people recruited within an "Early Intervention in Psychosis" service: clinical and outcome comparisons

Borderline Personality Disorder (BPD) is under-recognized in First-Episode Psychosis (FEP) and its psychotic manifestations are difficult to differentiate from Schizophrenia Spectrum Disorders (SSD). The aim of this investigation was to compare clinical, sociodemographic, and outcome characteristics between FEP patients with BPD vs. FEP subjects with SSD both at baseline and across a 2-year follow-up period. Participants completed the Health of the Nation Outcome Scale (HoNOS), the Positive And Negative Syndrome Scale (PANSS), and the Global Assessment of Functioning (GAF) scale both at entry and every 12 months during the follow-up. A mixed-design ANOVA model was conducted to investigate the temporal stability of clinical scores within and between the two subgroups. Among 356 FEP participants, 49 had a BPD diagnosis. Compared to FEP/SSD (n = 307), FEP/BPD patients showed higher prevalence of employment, current substance use, and past attempted suicide. They had a lower equivalent dose of antipsychotic medication at entry and lower levels of negative symptoms. Finally, they had a higher 2-year drop-out rate and a significant improvement in psychopathological scores limited to the first year of treatment. BPD as categorical entity represents a FEP subgroup with specific clinical challenges. Appropriate treatment guidelines for this FEP subgroup are thus needed.

Anhedonia and suicidal ideation in young people with early psychosis: Further findings from the 2-year follow-up of the ReARMS program

Hedonic deficits have been extensively studied in schizophrenia, but little is known about their association with suicidal ideation in early psychosis. The aim of this research was to examine the relationship between anhedonia and suicidal thoughts across a 2-year follow-up period in people with First Episode Psychosis (FEP) and at Ultra High Risk (UHR) of psychosis. Ninty-six UHR and 146 FEP, aged 13-35 years, completed the Comprehensive Assessment of At-Risk Mental States (CAARMS) and the Beck Depression Inventory-II (BDI-II). The BDI-II "Anhedonia" subscale score to assess anhedonia and the CAARMS "Depression" item 7.2 subscore to measure depression were used across the 2 years of follow-up. Hierarchical regression analyses were performed. No difference in anhedonia scores between FEP and UHR individuals was found. In the FEP group, a significant enduring association between anhedonia and suicidal ideation was found at baseline and across the follow-up, independent of clinical depression. In the UHR subgroup, the enduring relationship between anhedonia and suicidal thoughts were not completely independent from depression severity. Anhedonia is relevant in predicting suicidal ideation in early psychosis. Specific pharmacological and/or psychosocial interventions on anhedonia within specialized EIP program could reduce suicide risk overtime.

The cognitive-phenomenological assessment of delusions and hallucinations at the early intervention in psychosis service stage: The results of a quality improvement project

AIM

Clinical assessments are vital for gaining an understanding of a patients' presenting problem. A priority for Early Intervention in Psychosis Service staff is understanding and supporting their patients' experiences of hallucinations and/or delusions. We aimed to identify what cognitive-phenomenology dimensions of hallucinations and delusions EIPS staff were assessing with their patients.

METHODS

We developed a brief checklist of cognitive-phenomenological dimensions of hallucinations and delusions called the Lived Experience Symptom Survey (LESS) based on relevant literature. As part of a Quality Improvement Project, we reviewed the health records of a sub-sample of EIPS patients using the LESS identifying whether each dimension was present or absent.

RESULTS

We found that all patients had been asked about the content of their hallucinations and/or delusions, and the majority had been asked about the valence of this content. Despite patients having experienced psychosis for almost 2 years on average, less than half of patients were asked about the potential or actual harm associated with these symptoms. All other cognitive-phenomenological dimensions were assessed inconsistently.

CONCLUSIONS

The assessment of hallucination and delusions in our EIPS was inconsistent and incomprehensive. These findings require replication in other EIPS' but may point to a need for guidelines and training around how to conduct a thorough assessment of hallucinations and delusions for current and future EIPS staff. Improved assessment of these symptoms will aid the development of risk assessments and treatment plans.

Anxious-depressive symptoms after a first episode of schizophrenia: Response to treatment and psychopathological considerations from the 2-year "Parma Early Psychosis" program

Depression is common in schizophrenia and is correlated with suicide risk and poor long-term outcomes. However, the presence of depressive symptoms is often underestimated in both research and treatment, particularly at the illness onset. The goals of this study were: (a) to longitudinally observe anxious-depressive symptom levels in patients with First Episode Schizophrenia (FES) during a 24 months of follow-up period, and (b) to examine their associations with other psychopathology and the intervention patients received in an "Early Intervention in Psychosis" (EIP) program during the follow-up period. The Global Assessment of Functioning (GAF) and the Positive And Negative Syndrome Scale (PANSS) were completed by 159 FES patients both at baseline and across the follow-up. Data were analyzed by linear regression analysis and Spearman's coefficients. Anxious-depressive symptoms had significant longitudinal associations with GAF deterioration and PANSS "Positive Symptoms", "Negative Symptoms" and "Disorganization" subscores. During the follow-up period, FES participants significantly improved the level of anxious-depressive symptoms. This was significantly associated with the number of case management and individual psychotherapy meetings the patient engaged in, as well as with lower antipsychotic doses prescribed during the follow-up period. In conclusion, anxious-depressive symptoms are prominent in FES and at the initial entry into EIP programs. Anxious-depressive symptom severity tends to diminish overtime, especially with the provision of specialized EIP treatments. However, since we did not have a control population studied in parallel, we cannot say whether these results are specific to the protocols of EIP programs or just to the intensity of engagement in care.

Depressed Mood in First Episode Schizophrenia: Findings From a 1-Year Follow-Up in an Italian Real-World Care Setting

Introduction: Depression in schizophrenia is associated with poor outcomes and suicide risk. However, it is overlooked in both research and clinical practice, especially in First Episode Schizophrenia (FES). Methods: In this letter to the editor, we reported relevant findings on relevant comorbid depressed mood in an Italian sample of FES patients during a 1-year follow-up period within an "Early Intervention in Psychosis" (EIP) program. The Positive And Negative Syndrome Scale (PANSS) was completed by 159 participant. Results: At baseline, 53 (33.3%) participants showed a relevant depressed mood (as measured with a PANSS "Depression" G6 item subscore of ≥ 5). At entry, a relevant depressed mood was associated with a greater percentage of females and a higher PANSS "Positive Symptoms" score. Across the follow-up, FES individuals improved their depression severity levels. This reduction was significantly related to improvments in positive symptoms levels. Conclusions: Depression is relatively common in FES, already at the recruitment in EIP services. However, its severity decreases overtime within specialized EIP programs.

Emotional abuse and perceived stress: The most relevant factors in suicide behavior in first-episode psychosis patients

People with a mental disorder have a higher risk of suicidal behavior. Little research has examined the role of childhood trauma in suicide behavior, and even fewer studies have assessed the specific relevance of subtypes of childhood trauma and suicidal behavior in first-episode psychosis (FEP). The aims of the present study were: 1) to compare suicide behavior between FEP and HC; 2) to study the relationship between the five types of ChT and suicide risk in FEP controlling for confounding sociodemographic, clinical, and psychosocial variables. 95 patients diagnosed with FEP and 92 healthy control (HC) were recruited as a part of the PROFEP study. ChT was evaluated using The Childhood Trauma Questionnaire-Short Form (CTQ) and suicide behavior through The Suicide Risk Scale of Plutchik (SRSP). Our results showed that patients with FEP presented more suicide behavior (ideation, attempt, and suicide risk) than HC. Emotional abuse was the most relevant type of ChT in suicide ideation and suicide risk. After controlling for other relevant variables, perceived stress seemed to play an important role in suicide ideations, suicide attempt, and suicide risk. The results highlight the importance of assessing and considering in the clinical practice ChT and the perceived stress.

Dynamic Patterns of Symptoms and Functioning in Predicting Deliberate Self-harm in Patients with First-Episode Schizophrenia-Spectrum Disorders Over 3 Years

OBJECTIVES

Patients with schizophrenia have a significant risk of self-harm. We aimed to explore the dynamic relationship between symptomatology, functioning and deliberate self-harm (DSH) and evaluate the feasibility of developing a self-harm risk prediction tool for patients with first-episode schizophrenia (FES).

METHODS

Patients with FES (n = 1234) were followed up for 36 months. Symptomatology, functioning, treatment adherence and self-harm information were obtained monthly over the follow-up period. A time-varying vector autoregressive (VAR) model was used to study the contribution of clinical variables to self-harm over the 36th month. Random forest models for self-harm were established to classify the individuals with self-harm and predict future self-harm events.

RESULTS

Over a 36-month period, 187 patients with FES had one or more self-harm events. The depressive symptoms contributed the most to self-harm prediction during the first year, while the importance of positive psychotic symptoms increased from the second year onwards. The random forest model with all static information and symptom instability achieved a good area under the receiver operating characteristic curve (AUROC = 0.77 ± 0.023) for identifying patients with DSH. With a sliding window analysis, the averaged AUROC of predicting a self-event was 0.65 ± 0.102 (ranging from 0.54 to 0.78) with the best model being 6-month predicted future 6-month self-harm for month 11-23 (AUROC = 0.7).

CONCLUSIONS

Results highlight the importance of the dynamic relationship of depressive and positive psychotic symptoms with self-harm and the possibility of self-harm prediction in FES with longitudinal clinical data.

Prevalence of suicidal behavior in young university students: A systematic review with meta-analysis

OBJECTIVE

to identify the prevalence of suicidal behavior in young university students.

METHOD

a systematic review with meta-analysis of cross-sectional studies based on the Joanna Briggs Institute proposal, and carried out in the PubMed, Web of Science, Scopus, PsycINFO and LILACS databases and in the Brazilian Digital Library of Theses and Dissertations, with no language or year restrictions. A total of 2,942 publications were identified. Selection, data extraction and methodological evaluation of the studies were performed by two independent researchers. The meta-analysis was performed considering the random effects model.

RESULTS

eleven articles were included in this review. The prevalence variation for suicidal ideation was from 9.7% to 58.3% and, for attempted suicide, it was from 0.7% to 14.7%. The meta-analysis showed a 27.1% prevalence for suicidal ideation in life, 14.1% for ideation in the last year, and 3.1% for attempted suicide in life.

CONCLUSION

the high prevalence of suicidal behavior, even with the considerable heterogeneity of the studies, raises the need to implement interventions aimed at preventing suicide and promoting mental health, especially in the academic environment.

Individual psychotherapy can reduce suicidal ideation in first episode psychosis: Further findings from the 2-year follow-up of the 'Parma Early Psychosis' programme

INTRODUCTION

Suicidal thinking is relevant in patients with First Episode Psychosis (FEP). However, longitudinal studies specifically examining treatment response for suicidal ideation in FEP are still relatively scarce, especially with long-term design and in real-world clinical settings. The aims of this research were (A) to longitudinally assess suicidal thoughts in people with FEP along a 2-year follow-up period and (B) to overtime investigate any significant association of suicidal ideation levels with the specific treatment components of an 'Early Intervention in Psychosis' (EIP) protocol along the 2 years of follow-up.

METHODS

At entry, 232 FEP participants (aged 12-35 years) completed the Brief Psychiatric Rating Scale (BPRS), including a 'Suicidality' item subscore. Multiple linear regression analysis was then performed.

RESULTS

Across the follow-up, FEP subjects showed a relevant decrease in suicidal thinking levels overtime. This was specifically predicted by the total number of individual psychotherapy sessions offered within the 2-year EIP protocol and antidepressant dose (at least as regards the first year of our intervention).

CONCLUSION

Suicidal ideation is clinically relevant in FEP but seems to improve overtime together with the provision of specific, patient-tailored and integrated EIP treatments, especially individual psychotherapy.

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.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Trajectories of suicidal ideation after first-episode psychosis: a growth mixture modeling approach

OBJECTIVE

The period immediately after the onset of first-episode psychosis (FEP) may present with high risk for suicidal ideation (SI) and attempts, although this risk may differ among patients. Thus, we aimed to identify trajectories of SI in a 2-years follow-up FEP cohort and to assess baseline predictors and clinical/functional evolution for each trajectory of SI.

METHODS

We included 334 FEP participants with data on SI. Growth mixture modeling was used to identify trajectories of SI. Putative sociodemographic, clinical, and cognitive predictors of the distinct trajectories were examined using multinomial logistic regression.

RESULTS

We identified three distinct trajectories: Non-SI trajectory (85.53% sample), Improving SI trajectory (9.58%), and Worsening SI trajectory (6.89%). Multinomial logistic regression model revealed that greater baseline pessimistic thoughts, anhedonia, and worse perceived family environment were associated with higher baseline SI followed by an Improving trajectory. Older age, longer duration of untreated psychosis, and reduced sleep predicted Worsening SI trajectory. Regarding clinical/functional evolution, individuals within the Improving SI trajectory displayed moderate depression at baseline which ameliorated during the study period, while the Worsening SI subgroup exhibited persistent mild depressive symptoms and greater functional impairment at follow-up assessments.

CONCLUSION

Our findings delineated three distinct trajectories of SI among participants with FEP, one experiencing no SI, another in which SI might depend on acute depressive symptomatology, and a last subset where SI might be associated with mild but persistent clinical and functional impairments. These data provide insights for the early identification and tailored treatment of suicide in this at-risk population.