Suicidal changes in patients with first episode psychosis: clinical predictors of increasing suicidal tendency in the early treatment phase

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.

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.

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.

Sociodemographic and clinical risk factors associated with suicidal ideation and attempt during a 2-year early intervention program for first-episode psychosis

BACKGROUND

Identifying risk factors for suicidal ideation and attempt among first-episode psychosis patients is essential to prevent suicide in this high-risk population. We investigated risk factors at admission for suicidal ideation and attempt during a 2-year early intervention program.

METHODS

Our sample included patients aged 18-35 years who were consecutively admitted to an early intervention program (2003-2017). Sociodemographic and clinical variables were obtained from a longitudinal study, while data on suicidal ideation and attempt were collected via systematic file review. Univariable and multivariable logistic regressions assessed the association of these variables with suicide ideation and attempt.

RESULTS

Of 446 participants, 35 (7.8 %) attempted suicide during the 2-year follow up, including two resulting in death (0.45 %), and 168 (37.7 %) reported solely suicidal ideation. Multivariable analyses indicated living alone (OR = 4.01, CI = 2.11-7.63), affective psychosis (OR = 1.95, CI = 1.22-3.14) and depressive symptomatology (OR = 1.45, CI = 1.13-1.86) were associated with increased risk for suicidal ideation. Attempting suicide close to admission (OR = 10.29, CI = 3.63-29.22), living alone (OR = 4.17, CI = 1.40-12.35), and depressive (OR = 1.67, CI = 1.06-2.63) and positive symptomatology (OR = 1.60, CI = 1.02-2.50) were associated with increased risk for suicide attempt. Attempting suicide close to admission (OR = 11.65, CI = 4.08-33.30), being part of an ethnic minority (OR = 3.71, CI = 1.59-8.63), and presenting lower anxiety (OR = 0.58, CI = 0.36-0.94) were the only factors specifically associated with suicide attempt compared to ideation.

CONCLUSION

Close monitoring of patients who recently attempted suicide, live alone, are part of an ethnic minority, and present with affective and positive symptomatology may help reduce the risk of suicide-related outcomes during early intervention programs.

Auditory Hallucinations, Depressive Symptoms, and Current Suicidal Ideation or Behavior Among Patients with Acute-episode Schizophrenia

Suicide risk and auditory hallucinations are common in schizophrenia, but less is known about its associations. This cross-sectional study aimed to determine whether the presence and severity of auditory hallucinations were associated with current suicidal ideation or behavior (CSIB) among patients with schizophrenia. We interviewed 299 individuals with schizophrenia and acute symptoms and reviewed their medical records. Measurement included the Psychotic Symptom Rating Scale (PSYRATS-AH), the Calgary Depression Scale for Schizophrenia (CDSS), and the Positive and Negative Syndrome Scale. Logistic regression and path analysis were used. The CSIB prevalence was higher among patients with current auditory hallucination than those without (19.5% vs. 8.6%, crude odds ratio = 2.58, p = .009). Lifetime auditory hallucination experience (adjusted odds ratio [AOR] = 3.81; 95% CI: 1.45-10.05) or current auditory hallucination experience (AOR = 3.22; 95% CI: 1.25-8.28) can elevate the likelihood of CSIB while controlling for depressive symptoms and lifetime suicide-attempt history. Among those with auditory hallucinations, the emotional score of the PSYRATS-AH was positively associated with the CDSS score and there was a small indirect effect of the CDSS score on the association between the emotional domain score and CSIB (bias-corrected 95% CI, 0.02-0.20). In conclusion, the presence of auditory hallucinations was strongly associated with CSIB, independent of depressive symptoms and lifetime suicide attempts. Suicide risk assessment should consider auditory hallucination experience and patients' appraisal of its emotional characteristics. Future cohort studies are necessary to provide more conclusive evidence for the mediating pathways between auditory hallucinations and CSIB.HIGHLIGHTSThe presence of auditory hallucinations was associated with current suicidality.Auditory hallucinations' emotional severity was related to depressive symptoms.The severity of auditory hallucination was not directly associated with suicidality.

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.

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.

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.

Why Are Suicide Rates Increasing in the United States? Towards a Multilevel Reimagination of Suicide Prevention

Suicide, a major public health concern, takes around 800,000 lives globally every year and is the second leading cause of death among adolescents and young adults. Despite substantial prevention efforts, between 1999 and 2017, suicide and nonfatal self-injury rates have experienced unprecedented increases across the United States - as well as in many other countries in the world. This chapter reviews the existing evidence on the causes behind increased suicide rates and critically evaluates the impact of a range of innovative approaches to suicide prevention. First, we briefly describe current trends in suicide and suicidal behaviors and relate them to recent time trends in relevant suicide risk markers. Then, we review the existing evidence in suicide prevention at the individual and the population levels, including new approaches that are currently under development. Finally, we advocate for a new generation of suicide research that examines causal factors beyond the proximal and clinical and fosters a socially conscious reimagining of suicidal prevention. To this end, we emphasize the need for the conceptualization of suicide and suicidal behaviors as complex phenomena with causes at several levels of organization. Future interdisciplinary research and interventions should be developed within a multilevel causal framework that can better capture the social, economic, and political settings where suicide, as a process, unfolds across the life course.

Fatal and Non-fatal Self-Injury in the USA: Critical Review of Current Trends and Innovations in Prevention

PURPOSE OF REVIEW

To examine current trends in suicide and self-injury in the USA, as well as potential contributors to their change over time, and to reflect on innovations in prevention and intervention that can guide policies and programs to reduce the burden of suicide and self-injury in the USA.

RECENT FINDINGS

Suicide and non-fatal self-injury are on the rise in the USA. Reasons for such trends over time remain speculative, although they seem linked to coincident increases in mood disorders and drug use and overdose. Promising innovative prevention and intervention programs that engage new technologies, such as machine learning-derived prediction tools and computerized ecologic momentary assessments, are currently in development and require additional evidence. Recent increases in fatal and non-fatal self-harm in the USA raise questions about the causes, interventions, and preventive measures that should be taken. Most innovative prevention efforts target individuals seeking to improve risk prediction and access to evidence-based care. However, as Durkheim pointed out over 100 years ago, suicide rates vary enormously between societal groups, suggesting that certain causal factors of suicide act and, hence, should be targeted at an ecological level. In the next generation of suicide research, it is critical to examine factors beyond the proximal and clinical to allow for a reimagining of prevention that is life course and socially focused.

Suicidal Ideation in First-Episode Psychosis (FEP): Examination of Symptoms of Depression and Psychosis Among Individuals in an Early Phase of Treatment

First-episode psychosis (FEP) is a particularly high-risk period for suicide, in which risk elevates by 60% within a first year of treatment as compared to later stages of illness. To date, much of the literature has focused on individuals with a longer duration of psychosis; thus, there is an urgency for research to examine suicide risk among individuals in FEP in the beginning stage of treatment. This study aimed to identify the relationships between demographic characteristics, symptoms of depression, psychosis (particularly positive symptoms of psychosis), and suicidal ideation among individuals in FEP. Secondary data were obtained from National Institute of Mental Health's Early Treatment Program of the Recovery After an Initial Schizophrenia Episode project (N = 404). Consistent with prior research, participants who experienced suicidal ideation during the study period reported having a longer duration of untreated psychosis and greater symptoms of depression. Further, positive symptoms of psychosis, namely hallucinations and delusions, were found to increase the odds of experiencing suicidal ideation. Findings point toward the implication that depression and positive symptoms of psychosis relate to the experience of suicidal ideation among individuals with a FEP and should be evaluated for and treated in the early stages of treatment.

Depression during first episode psychosis and subsequent suicide risk: A systematic review and meta-analysis of longitudinal studies

BACKGROUND

Evidence suggests first episode psychosis (FEP) is associated with suicide, and the influence of depression on suicidal behaviour in cross sectional studies is clear. However the influence of depression during FEP on longer-term mortality is not certain. Existing evidence was synthesised to understand the influence of depressive symptoms during FEP on subsequent suicidal behaviour.

METHODS

Medline, Embase, PsycINFO, Cochrane Library, Web of Science, OpenGrey, and NICE Evidence were searched from inception to Jan 25, 2017. Longitudinal observational studies assessing the relationship between depressive symptoms during FEP with a measure of s at a specified follow-up time were included. Summary estimates were extracted. The Downs and Black Instrument was used to appraise study quality. Odds ratio (OR) of suicidal behaviour were calculated using random effects meta-analyses. The study protocol was registered with PROSPERO (CRD42017055881).

RESULTS

Of 4210 articles found, 23 fulfilled eligibility criteria. 13 were included in meta-analysis (n=3002). 428 participants demonstrated suicidal behaviour in the study periods. Odds of suicidal behaviour during follow-up were significantly higher among patients with depressive symptoms during FEP compared to those without (OR=1.59, 95% CI 1.14-2.21; I2=50.0%, p=0.02). Meta-regression demonstrated no evidence of influence of length of follow-up on results.

CONCLUSIONS

Depressive symptoms during FEP are associated with increased longer-term risk of suicidal behaviour. This association should be acknowledged during early management planning. Large-scale clinical trials are needed to identify efficacious management of depression during FEP.

Trajectories of suicidal ideation in patients with first-episode psychosis: secondary analysis of data from the OPUS trial

BACKGROUND

Heterogeneity in suicidal ideation over time in patients with first-episode psychosis is expected, but prototypical trajectories of this have not yet been established. We aimed to identify trajectories of suicidal ideation over a 3-year period and to examine how these trajectories relate to subsequent suicidality.

METHODS

We used longitudinal data from the prospective 10-year follow-up OPUS trial of young Danish patients with first-episode psychosis. Participants were recruited between January, 1998, and December, 2000, from all inpatient and outpatient mental health services in Copenhagen and Aarhus County, were aged between 18 and 45 years, and had a diagnosis in the schizophrenia spectrum. Randomisation was done by a computer-generated randomisation list, stratified in alternating blocks for five centres. In Aarhus, a secretary drew lots when the researcher phoned her. Patients were randomly assigned to a treatment group (modified assertive community treatment) or a control group (standard treatment at community mental health centres) and assessed at treatment initiation, and after 1, 2, 5, and 10 years. We included all patients' data on suicidal ideation from the first three assessments in a latent growth mixture modelling analysis to empirically identify trajectories of suicidal ideation. Multivariable logistic regression analyses were applied to estimate associations between trajectories and subsequent suicidality. This trial is registered with ClinicalTrials.gov, number NCT00157313.

FINDINGS

Three trajectories for suicidal ideation were identified in 521 patients. 317 of 521 members (61%) of the largest trajectory, low-decreasing, consisted of patients who initially reported suicidal ideation once-to-a-few-times in the past year followed by a decrease in suicidal ideation. 172 of 521 (33%) members of the frequent-stable trajectory reported suicidal ideation sometimes-to-frequently at the first assessment and remained stable over time. Finally, 32 of 521 (6%) members of the frequent-increasing trajectory reported frequent suicidal ideation initially followed by worsening. Compared with the low-decreasing class, the risk of persistent suicidal ideation was higher for patients in the frequent-stable and frequent-increasing classes at 5 years (Odds ratio=4·5, 95% CI 2·50-8·02 and 4·7, 1·55-14·24 respectively) and at 10 years (4·2, 2·42-7·13 and 3·2, 1·20-8·70 respectively). Also the risk of suicide attempt at 5 years was higher for patients in the frequent-stable (2·8, 1·07-7·43) and frequent-increasing classes (6·6, 1·69-25·54) compared with the low-decreasing class. There was no difference in suicide rate at 5 or 10 years between trajectories.

INTERPRETATION

Because up to 40% of patients experienced frequent suicidal ideations that persisted or increased during the first years of treatment, our findings warrant special focus on suicidal issues as an integral part of treatment along with treatment to target psychotic symptoms.

FUNDING

The Danish Council for Independent Research (Medical Sciences), Trygfonden, The Mental Health Services of the Capital Region of Denmark, The Danish Ministry of Health, The Danish Ministry of Social Affairs, the Psychiatry and Social Service Department in Central Denmark Region, and The Lundbeck Foundation.

Suicidal behavior and mortality in first-episode psychosis

Suicide is a serious public health problem, with more than 800,000 deaths taking place worldwide each year. Mental disorders are associated with increased risk of suicide. In schizophrenia and other psychotic disorders, the lifetime risk of suicide death is estimated to be 5.6%. The risk is particularly high during the first year of the initial contact with mental health services, being almost twice as high as in the later course of the illness. The most consistently reported risk factor for suicide among people with psychotic disorders is a history of attempted suicide and depression. Suicide risk in psychosis in Denmark decreased over time, most likely because of improved quality of inpatient and outpatient services. There is a high proportion of young people with first-episode psychosis who attempted suicide before their first contact with mental health services. This finding suggests that the mortality rates associated with psychotic disorders may be underreported because of suicide deaths taking place before first treatment contact. However, currently, no data exist to confirm or refute this hypothesis. Attempted suicide can be an early warning sign of later psychotic disorder. Data from different studies indicate that the risk of suicide attempt during the first year of treatment is as high as 10%. The most important risk factors for attempted suicide after the first contact are young age, female sex, suicidal plans, and a history of suicide attempt. Early intervention services are helpful in first-episode psychosis, and staff members should, in collaboration with the patients, monitor the risk of suicide and develop and revise crisis plans.

Early signs of worry: psychosis risk symptom visual distortions are independently associated with suicidal ideation

Previous studies have shown an association between suicidal behavior and schizophrenia. However, little is known about this association in those with psychotic experiences and symptoms that do not meet the criteria for full psychosis. The aim of the study was to investigate how psychosis risk symptoms are associated with suicidal ideation. Three-hundred and nine help-seeking adolescents (mean age 15.5 years) who were screened by an early intervention and detection team JERI in Helsinki University Central Hospital, Finland, were interviewed and asked to complete questionnaires of psychosis risk symptoms, suicidal ideation and depression. Psychosis risk symptoms were assessed by self-report and confirmed by interview with questions from PROD-screen, depression was measured with BDI-II questionnaire and suicidal ideation was derived from BDI-II questionnaire. In a logistic regression analysis psychosis risk symptom visual distortions explained independently (OR 4.33; 95% CI 1.28-14.64) suicidal ideation when age, gender, depression and psychosis risk symptoms thought disorders, persecuting feelings and auditory distortions were controlled for. Results suggest that visual distortions are independently associated with suicidal ideation in young people. This finding should be taken into account in assessing help-seeking adolescents.

Clinical characteristics in schizophrenia patients with or without suicide attempts and non-suicidal self-harm--a cross-sectional study

BACKGROUND

To investigate whether schizophrenia patients with both suicide attempts and non-suicidal self-harm have earlier age of onset of psychotic and depressive symptoms and higher levels of clinical symptoms compared to patients with only suicide attempts or without suicide attempt.

METHODS

Using a cross-sectional design, 251 patients (18-61 years old, 58% men) with schizophrenia treated at hospitals in Oslo and Innlandet Hospital Trust, Norway, were assessed with a comprehensive clinical research protocol and divided into three groups based on their history of suicide attempts and non-suicidal self-harm.

RESULTS

Suicide attempts were present in 88 patients (35%); 52 had suicide attempts only (29%) and 36 had both suicide attempts and non-suicidal self-harm (14%). When compared with nonattempters and those with suicide attempts without non-suicidal self-harm, patients with both suicide attempts and non-suicidal self-harm were more frequently women, younger at the onset of psychotic symptoms, had longer duration of untreated psychosis, and had higher levels of current impulsivity/aggression and depression. Patients with both suicide attempts and non-suicidal self-harm were more likely to repeat suicide attempts than patients with suicide attempts only.

CONCLUSIONS

Patients with both suicide attempts and non-suicidal self-harm had different illness history and clinical characteristics compared to patients with only suicide attempts or patients without suicidal behavior. Our study suggests that patients with both suicide attempts and non-suicidal self-harm represent a distinct subgroup among patients with schizophrenia and suicidal behavior with their early onset of psychotic symptoms, high rate of repeated suicidal behavior and significant treatment delay.

Hallucinations in acutely admitted patients with psychosis, and effectiveness of risperidone, olanzapine, quetiapine, and ziprasidone: a pragmatic, randomized study

BACKGROUND

Hallucinations are prevalent in schizophrenia and related psychotic disorders and may have severe consequences for the affected patients. Antipsychotic drug trials that specifically address the anti-hallucinatory effectiveness of the respective drugs in representative samples are rare. The aims of the present study were to investigate the rate and severity of hallucinations in acutely admitted psychotic patients at hospital admission and discharge or after 6 weeks at the latest, if not discharged earlier (discharge/6 weeks); and to compare the anti-hallucinatory effectiveness of risperidone, olanzapine, quetiapine, and ziprasidone with up to 2 years' follow-up.

METHODS

Adult patients acutely admitted to an emergency ward for psychosis were consecutively randomized to risperidone, olanzapine, quetiapine, or ziprasidone and followed for up to 2 years in a pragmatic design. Participants were assessed repeatedly using the hallucinatory behavior item of the Positive and Negative Syndrome Scale (PANSS).

RESULTS

A total of 226 patients, 30.5% of those assessed for eligibility, were randomized and 68% were hallucinating at baseline. This proportion was reduced to 33% at discharge/6 weeks. In the primary analyses based on intention to treat groups of patients experiencing frequent hallucinations, the quetiapine and ziprasidone groups both had faster decreases of the mean hallucination scores than the risperidone group.

CONCLUSIONS

Hallucinations are fairly responsive to antipsychotic drug treatment and differential anti-hallucinatory effectiveness may be found among existing antipsychotic drugs. If replicated, this could pave the way for a more targeted pharmacotherapy based on individual symptom profiles, rather than on the diagnostic category.

TRIAL REGISTRATION

ClinicalTrials.gov ID; NCT00932529.