The challenge of suicidal behaviour in early psychosis

Characteristics of suicide attempts in young people undergoing treatment for first episode psychosis

OBJECTIVES

Understanding the characteristics of suicide attempts in people undergoing treatment for first episode psychosis (FEP) may have implications for risk management at a service level and local suicide prevention strategies. Although studies have focused on identifying individual-level risk factors for suicide attempts in this patient group, none have yet conducted an in-depth profile of suicide attempts. The aim of the present study was to examine the characteristics of suicide attempts in young people during the initial 18 months of treatment for FEP.

METHOD

A retrospective medical record audit study of a cohort of patients accepted for treatment at a specialist FEP service between 1/12/2002 and 30/11/2005.

RESULTS

Of 607 patients, 73 (12%) attempted suicide during treatment. Of these 73, most (72.6%) attempted suicide on one occasion. The majority of attempts (85.3%) occurred when patients were treated as outpatients and were in regular contact with the service. Suicide attempts tended to be impulsive (77.6%), triggered by interpersonal conflict or distress due to psychotic symptoms. Two thirds involved self-poisoning, usually by overdose of prescribed medications. All inpatient suicide attempts were by hanging or strangulation. Individuals infrequently sought help immediately before or after the attempt; if help-seeking occurred, informal sources of support were contacted.

CONCLUSIONS

To reduce the number of suicide attempts among individuals treated for FEP, psychiatric services could consider: restricting the amount of medication prescribed per purchase; individualised suicide risk management plans for all newly admitted patients, including those who do not appear to be at risk; stringent reviews of inpatient psychiatric units for potential ligature points; providing information and psycho-education for significant others in recognition and response to suicide risk; fostering patients' problem solving and conflict resolution skills; and regular risk assessment and close monitoring of patients, particularly during the high risk period of 3 months after a suicide attempt.

Temporal pattern of suicide risk in young individuals with early psychosis

Individuals with a first episode of psychotic illness are known to be at high risk of suicide, yet little is understood about the timing of risk in this critical period. The present study aimed to examine the temporal pattern of suicide risk in patients with early psychosis (EP) and to determine whether discrete periods of significantly elevated risk can be identified up to 24 months after commencing treatment. Suicidality ratings collected each month as part of patient routine assessment at the Early Psychosis Prevention and Intervention Centre (EPPIC) were retrieved from the service database for patients treated between December 2002 and December 2005 (N=696). Time-series analysis was performed on suicide risk estimated from the aggregated data of 94 individuals who met the study inclusion criteria. Suicide risk was highest in the first month of treatment, decreasing rapidly over the next 6 months and declining slightly thereafter. A power function adequately described this curvilinear trend. Fluctuations around the trend were unpredictable, except for a mild tendency to reverse from month to month, and did not reach statistical significance. The findings suggest limited scope for preventative interventions driven by chronology alone. Intensive routine suicide screening across the course of treatment may facilitate identification and early management of EP patients at suicide risk.

Untreated psychotic illness in the survivors of violent suicide attempts

BACKGROUND

Recent studies suggest that violence is more common in the first episode of psychosis than after treatment.

AIM

To estimate the proportion of survivors of violent suicide attempts during psychotic illness who had not previously received treatment with antipsychotic medication.

METHODS

An audit of the medical records of patients admitted to an inner city trauma centre after having survived a jump of more than 3 m or a self-inflicted gunshot wound or stab wound to a vital body part.

RESULTS

There were 88 survivors of violent suicide attempts. Thirty-seven of those had a psychotic illness, including 33 with a schizophrenia-spectrum psychosis. Of the 37, 18 (48.6%, 95% confidence interval (CI) 32.3-65.0%) had never received treatment for psychosis.

CONCLUSION

As first episode psychosis is less common than previously treated psychosis, there appears to be a higher risk of violent suicide attempts during the first episode of psychosis than later in the illness.