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

A cognitive-behavioral treatment for suicide prevention among adults with schizophrenia spectrum disorders in community mental health: Study protocol for a pilot feasibility and acceptability randomized clinical trial

BACKGROUND

Suicide is among the leading causes of death for adults with schizophrenia spectrum disorders (SSDs), and there is a paucity of evidence-based suicide prevention-focused interventions tailored for this vulnerable population. Cognitive-Behavioral Suicide Prevention for psychosis (CBSPp) is a promising intervention developed in the UK that required modifications for delivery in community mental health (CMH) settings in the United States of American. This pilot trial evaluates the feasibility, acceptability, and preliminary effectiveness of our modified CBSPp intervention in comparison to services as usual (SAU) within a CMH setting in a Midwestern state of the USA.

METHODS

This is a single-site randomized pilot trial with a planned enrollment of 60 adults meeting criteria for both SSD and SI/A. Eligible participants will be randomized 1:1 to either 10 sessions of CBSPp or SAU. Clinical and cognitive assessments will be conducted within a 4-waive design at baseline (prior to randomization and treatment) and approximately 1 month (mid-treatment), 3 months (post-treatment), and 5 months (follow-up) after baseline assessment. Qualitative interviews will also be conducted at post-treatment. The primary objective is to determine whether CBSPp is feasible and acceptable, involving examinations of recruitment rate, treatment engagement and adherence, retention and completion rates, and experiences in the CBSPp treatment and overall study. The secondary objective is to preliminarily evaluate whether modified CBSPp is associated with reductions in clinical (suicide ideation, suicide attempt, symptoms of psychosis, depression, and emergency/hospital service, hopelessness, defeat, and entrapment) and cognitive (information processing biases, appraisals, and schemas) outcomes in comparison to SAU from baseline to post-treatment assessment.

DISCUSSION

This randomized pilot trial will provide clinically relevant information about whether CBSPp can improve SI/A, depression, and psychosis among adults with SSDs. Testing this modified cognitive-behavioral suicide prevention-focused intervention has the potential for a large public health impact by increasing the intervention's utility and usability in CMH where many individuals with SSDs receive care, and ultimately working towards reductions in premature suicide death.

TRIAL REGISTRATION

ClinicalTrials.gov NCT#05345184. Registered on April 12, 2022.

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.

Emotional distress and dysregulation as treatment targets to reduce suicide in psychosis: a scoping review

There is a pressing need for effective treatments that address the high rate of suicide observed among people with psychosis. In this scoping review we highlight two suicidogenic treatment targets that have been relatively neglected in people with psychotic disorders: emotional distress and emotion dysregulation. We review the research on these constructs in psychosis and their relationship to suicide in this population, and then make clinical recommendations based on research findings. Emotional distress and emotional dysregulation may be promising treatment targets for suicide among people with psychosis.

The mediating role of psychological flexibility in the relationship between psychotic symptom severity and depression in individuals diagnosed with schizophrenia

WHAT IS KNOWN ABOUT THE SUBJECT?: Psychotic symptoms and depression are common problems in people diagnosed with schizophrenia. Psychological flexibility is a skill that facilitates coping with difficulties. There is limited research on the role of psychological flexibility in the relationship between psychotic symptoms and depression in people diagnosed with schizophrenia. WHAT DOES THE ARTICLE ADD TO EXISTING KNOWLEDGE?: This article investigates the role of psychological flexibility in the link between psychotic symptom severity and depression in people diagnosed with schizophrenia. The article shows that psychological flexibility partially mediates the relationship between psychotic symptom severity and depression. The article suggests that interventions aimed at improving psychological flexibility may be beneficial in reducing depressive symptoms in people diagnosed with schizophrenia. WHAT ARE THE IMPLICATIONS FOR PRACTICE?: Mental health nurses should consider psychotic symptom severity and psychological flexibility when assessing and intervening for depressive symptoms in people diagnosed with schizophrenia. Mental health nurses should receive training to improve psychological flexibility and pass this skill on to their patients. Mental health nurses should continue to research the effectiveness and outcomes of interventions aimed at improving psychological flexibility.

ABSTRACT

INTRODUCTION: Psychological flexibility may help people diagnosed with schizophrenia (PWS) cope with their psychotic symptoms and reduce their depressive symptoms, but the mechanism of this effect is unclear.

AIM

To investigate whether psychological flexibility mediates the relationship between psychotic symptom severity and depression in PWS.

METHOD

A cross-sectional study was conducted, in which a total of 111 PWS were assessed with DSM-5 Clinician-Rated Dimensions of Psychosis Symptom Severity, Calgary Depression Scale for Schizophrenia and Acceptance and Action Questionnaire. Data analysis was performed using SPSS 25 and PROCESS macro.

RESULTS

Significant correlations were found between psychotic symptoms, depression and psychological flexibility. Psychological flexibility partially mediated the relationship between psychotic symptom severity and depression.

DISCUSSION

Psychological flexibility could weaken the impact of psychotic symptom severity on depression in PWS. Higher psychotic symptoms were associated with lower psychological flexibility and higher depression.

IMPLICATIONS FOR PRACTICE

Interventions to improve psychological flexibility may prevent depressive symptoms in PWS. Psychiatric nurses can use psychological flexibility as a goal for evaluation and intervention.

The relationship between sleep and suicidality in schizophrenia spectrum and other psychotic disorders: A systematic review

Individuals with Schizophrenia Spectrum Disorders (SSDs) have significantly higher rates of suicidal thoughts, attempts, and death by suicide in comparison to the general population. Sleep disturbances (reduced duration, timing and quality of sleep) are risk factors for suicidality in the general population, with research indicating the relationship is both immediate and accumulative. Sleep disturbances are also considered to be implicated in the onset and exacerbation of psychotic symptoms in SSDs. Reducing the risk of suicidality in SSDs remains an important public health priority, thus exploration of contributing risk factors is warranted. Sleep monitoring may also offer an adjunct risk monitoring method to suicidality assessments in SSDs, and a potential treatment target for psychotic symptoms. This review aimed to explore proximal and longitudinal relationships between self-reported and objectively measured sleep and suicidality in SSDs and other psychotic disorders. A comprehensive search of four databases was conducted. Eleven studies met the inclusion criteria (10 cross sectional and 1 longitudinal). Narrative synthesis indicated that self-reported sleep disturbances and sleep disorders (e.g. insomnia) were associated with increased risk of suicidal ideation and attempt. However, one study employing polysomnography did not find sleep to be associated with suicidality. Methodological limitations of the evidence base include: i) little experimental or longitudinal evidence, (ii) self-report and/or single item assessment of sleep disturbance, (iii) limited use of validated measures of suicidality, (iv) considerable research in long-term schizophrenia but sparse evidence in early psychosis. Future research should explore (i) cross-sectional and longitudinal relationships between specific aspects of suicidality and objective sleep parameters, (ii) use qualitative or mixed-methods designs to disentangle the nuances and bidirectionality in the sleep-suicide relationship, (iii) explore the psychological processes underpinning or mediating the sleep-suicide relationship in SSDs.

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.

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.

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.

Incidence, prevalence, and trajectories of suicidal ideation among clients enrolled in early intervention services for first episode psychosis in New York State

Knowledge on how suicidal ideation (SI) varies following first episode psychosis (FEP) onset is scarce. We identified 1-year trajectories of SI and baseline predictors of emergent SI among all 1298 clients aged 16-30 years enrolled between October 2013-December 2018 in OnTrackNY, a program providing early intervention services for FEP across New York State. Clinicians recorded baseline clinical and sociodemographic variables and quarterly assessments of SI over a one-year follow-up. We examined baseline correlates of baseline SI and of 1-year SI trajectory. Among clients not reporting baseline SI, we examined predictors of subsequent emergent SI. Baseline SI was reported by 349 (26.9 %) clients and associated with schizoaffective disorder, previous self-injurious behavior, any alcohol or substance use, higher symptom severity, poorer social functioning, and Non-Hispanic White, Asian or Hispanic ethnoracial background. Two hundred and two (15.6 % overall) clients stopped being suicidal within 6 months of follow-up. Persistent SI was reported by 147 (11.3 % overall) clients and, among clients not discharged before one year of follow-up, was associated with schizoaffective disorder, any alcohol use, being female, and being Hispanic or White Non-Hispanic. Among 949 (73.1 %) clients not reporting baseline SI, subsequent emergent SI was reported by 139 (10.7 % overall) and predicted at baseline by schizoaffective disorder, higher symptom severity, recent homelessness, and not being Hispanic. In conclusion, SI is highly prevalent and varies markedly over time among FEP early intervention clients. These results highlight the importance of ongoing assessment for SI among individuals experiencing FEP - even in the absence of baseline SI.

Lost in Translation: Challenges in the Diagnosis and Treatment of Early-Onset Schizophrenia

Early-onset schizophrenia (EOS) is a heterogeneous condition that has a serious, insidious clinical course and poor long-term mental health outcomes. The clinical presentations are highly complex due to the overlapping symptomatology with other illnesses, which contributes to a delay in the diagnosis. The objective of the review is to study if an earlier age of onset (AAO) of EOS has poor clinical outcomes, the diagnostic challenges of EOS, and effective treatment strategies. The review provides a comprehensive literature search of 5966 articles and summarizes 126 selected for empirical evidence to methodically consider challenges in diagnosing and treating EOS for practicing clinicians. The risk factors of EOS are unique but have been shared with many other neuropsychiatric illnesses. Most of the risk factors, including genetics and obstetric complications, are nonmodifiable. The role of early diagnosis in reducing the duration of untreated psychosis (DUP) remains critical to reducing overall morbidity. Many specific issues contribute to the risk and clinical outcomes. Therefore, issues around diagnostic ambiguity, treatment resistance, nonadherence, and rehospitalizations further extend the DUP. There is hesitancy to initiate clozapine early, even though the empirical evidence strongly supports its use. There is a growing body of research that suggests the use of long-acting injectables to address nonadherence, and these measures are largely underutilized in acute settings. The clinical presentations of EOS are complex. In addition to the presence of specific risk factors, patients with an early onset of illness are also at a higher risk for treatment resistance. While there is a need to develop tools for early diagnosis, established evidence-based measures to address nonadherence, psychoeducation, and resistance must be incorporated into the treatment planning.

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.

A cognitive-behavioral suicide prevention treatment for adults with schizophrenia spectrum disorders in community mental health: Preliminary findings of an open pilot study

Suicide is a leading cause of death among schizophrenia spectrum disorder populations. This open pilot study examined a modified cognitive-behavioral suicide prevention treatment for clients in community mental health. Providers (n=5) were trained to deliver the treatment and clients (n=5) received it in 10 individual therapy sessions. Clients experienced improvements in suicide ideation, depression, hopelessness, general symptoms of psychosis, entrapment, defeat, approaches to coping, psychological stress, impulsivity, and the number of treatment barriers from baseline to post-treatment. Qualitative findings reinforced quantitative results of client improvements and provided important suggestions to strengthen the intervention and its delivery in community mental health.

Depression, suicide intent, and plan among adults presenting in an emergency department after making a suicide attempt: Exploratory differences by psychosis symptom experience

Rates of suicide are significantly higher for individuals with schizophrenia spectrum disorders (SSDs) than those in the general population. With limited understandings of factors contributing to engaging in a suicide attempt among the psychosis population in the literature, the current study sought to preliminarily explore depression, suicide intent, and suicide plan among adults with and without psychosis symptom experiences who presented to an emergency department (ED) after making a suicide attempt. Electronic health record data were collected from the ED of an academic healthcare system in the Midwestern United States between 2011 and 2022. Patients included 1178 adults who arrived after making a suicide attempt. Trained research assistants conducted chart reviews and data were explored in SPSS28. A significantly smaller proportion of patients with psychosis had depressive symptoms and endorsed having suicide intent prior to their attempt in comparison to patients without psychosis. A smaller trending (p < .10) proportion of patients with psychosis endorsed having a suicide plan prior to their attempt than those with psychosis. Exploratory findings highlight the importance of EDs assessing for suicide risk beyond traditional approaches among patients with psychosis symptom experiences, including considerations for the potential of individuals not experiencing depression, suicide intent, or a suicide plan. Future research is particularly needed to examine psychosis symptomatology and the experience of distress as potential contributing factors to suicide behavior and death among patients with psychosis symptoms to better inform suicide risk assessment and intervention efforts.

Depression Mediates the Relationships between Hallucinations, Delusions, and Social Isolation in First-Episode Psychosis

Social isolation is common among individuals with schizophrenia spectrum and other psychotic disorders. Research indicates that social isolation relates to poorer mental health outcomes, depression, and negative symptoms, with less known about its relationship with positive symptoms. This study examined depression as a mediator in the relationships between positive symptoms (i.e., hallucinations and delusions) and social isolation among an early treatment phase sample in the United States. Data were obtained from the Recovery After an Initial Schizophrenia Episode project of the National Institute of Mental Health's Early Treatment Program. Participants (N = 404) included adults between ages 15 and 40 in a first episode of psychosis. Data were analyzed using structural equation modeling in Mplus (Version 8). The study showed that delusions (b = .095, SE = 0.04, p < .05) and hallucinations (b = .076, SE = 0.03, p < .01) were directly related to depression, and that both delusions (b = .129, SE = 0.06, p < .05) and depression (b = .254, SE = 0.09, p < .05) were directly related to social isolation. Findings of this study determined that depression functioned as a mediator in the relationships between positive symptoms and social isolation. Targeting psychosis symptomatology and depression in treatment, improving social skills and social support networks, and considering the role of stigma in social isolation are of great importance in the prevention of poorer mental health outcomes.

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.

Relationship Between Affective Temperaments and Suicide Risk in Patients With First-Onset Major Depressive Disorder

Background

People may endorse suicidal behavior during a major depressive episode. Affective temperaments may play a role in this risk. We explored the relationship between affective temperaments and suicide and identified some traits that can predict suicide risk in depression.

Materials and Methods

We analyzed the results of the Temperament Evaluation of the Memphis, Pisa, Paris, and San Diego Auto-questionnaire (TEMPS-A) in 284 participants recruited from a psychiatric clinic and the community in Beijing and compared the subscale scores (temperaments of cyclothymic, dysthymic, anxious, irritable, and hyperthymic) among major depressive disorders (MDDs) vs. the general population as well as depressive patients with vs. without suicide risk, using Student's test, chi-square test, rank-sum test, and multivariable regression modeling.

Results

The incidence of suicidal risk in depressive subjects was 47.62% (80/168). Being unmarried (p < 0.001), unemployed (p = 0.007), and temperaments of dysthymic, cyclothymic, anxious, and irritable scores (all p < 0.001) were significantly more prevalent in patients with depression than in the general population. Young age (p < 0.001), female sex (p = 0.037), unmarried (p = 0.001), more severe depression (p < 0.001), and dysthymic, anxious, and cyclothymic temperament (all p < 0.05) were significantly more prevalent in patients with depressive disorder than those without suicide risk. The logistic regression analysis showed that younger age (odds ratio [OR] = 0.937, 95% CI 0.905∼0.970), female sex (OR = 2.606, 95% CI 1.142∼5.948), more severe depression (OR = 1.145, 95% CI 1.063∼1.234), cyclothymic temperament (OR = 1.275, 95% CI 1.102∼1.475), and dysthymic temperament (OR = 1.265, 95% CI 1.037∼1.542) were all independently associated with high suicidal risk in patients with first-onset major depression (p < 0.05).

Conclusion

Temperament traits differ between the general population and people suffering from MDD. Subjects with MDD who have much more severe depressive symptoms and a cyclothymic or dysthymic temperament were at a high risk of suicide.

Modifying a cognitive behavioral suicide prevention treatment for adults with schizophrenia spectrum disorders in community mental health

Suicide is among the leading causes of death for adults with schizophrenia spectrum disorders. Given a paucity of evidence-based interventions tailored for psychosis, we sought to modify a promising Cognitive-Behavioral Suicide Prevention for psychosis (CBSPp) treatment for adults in US community mental health (CMH) settings using community-based participatory research methods. This article presents our modification methodology, stakeholder data and scholarly expert input, and CBSPp adaptations prior to future intervention testing. Stakeholder data (n = 25) were collected from clients, providers, and peer advocates in a CMH setting in Michigan. Findings were subsequently presented to a panel of scholarly experts in the fields of suicide and psychosis research, intervention research, and implementation science for input. Emerging themes from stakeholders include logistic, perceptual, and clinical challenges in the process of introducing this treatment in a CMH setting. Consistent with literature, buy-in and support for the delivery of a new treatment emerged as important factors in modifying and implementing CBSPp. A final modification list is presented in this paper and collaborations among stakeholders, researchers, and scholarly experts are essential to navigate psychosocial treatment innovation barriers with an overall goal of improving access, feasibility, and quality of this suicide prevention treatment.

Patient Journey of Veterans with Schizophrenia: An Analysis of Treatment Patterns, Healthcare Resource Utilization and Costs

INTRODUCTION

Little is known about the burden of schizophrenia among United States veterans early after diagnosis. This retrospective study describes treatment patterns, healthcare resource utilization (HRU) and healthcare costs among veterans with a recent schizophrenia diagnosis.

METHODS

Adults with a schizophrenia diagnosis recorded between 1 April 2014 and 31 December 2017 and no history of schizophrenia over the preceding 12 months were identified from a Veterans Health Administration (VHA) database. Continuous enrollment in the VHA was required for ≥ 12 months before and after the index date when the first schizophrenia diagnosis code was identified. Baseline characteristics and follow-up treatment patterns, HRU and costs were examined descriptively.

RESULTS

The study population (20,389 patients) had a high baseline mental health comorbidity burden. Despite a schizophrenia diagnosis, 32.1% of patients received no antipsychotic medication during the follow-up period. Among those with ≥ 1 antipsychotic prescription fill, 64.0% received ≥ 1 oral antipsychotic (OAP) therapy and 11.6% received ≥ 1 long-acting injectable (LAI). A delay was observed between diagnosis and treatment for both OAPs (39.0 ± 67.2 days) and LAIs (69.4 ± 96.2 days). Adherence to therapy (defined as proportion of days covered ≥ 80%) was greater with LAIs (34.5%) vs OAPs (27.3%). Inpatient stays were reported for 33.8% of patients during the 12-month follow-up period, and 5.5% of patients had readmissions. All-cause inpatient stay costs with 12-month follow-up equaled $7999 per patient per year.

CONCLUSIONS

These data indicate that pharmacotherapy after a recent diagnosis of schizophrenia in the VHA system is suboptimal, and that these patients face a considerable burden in terms of hospitalization, other HRU, and healthcare costs.

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.

First-episode psychosis in the Ferrara Mental Health Department: Incidence and clinical course within the first 2 years

AIM

To examine the incidence of with first-episode psychosis (FEP) in the Integrated Department of Mental Health and Pathological Addictions in Ferrara, Italy, and to examine the association between the Duration of Untreated Psychosis (DUP) and the clinical course.

METHODS

Participants recruited in 2013-2019 were assessed with the Health of the Nation Outcome Scale (HoNOS) every 6 months for 24 months. Hierarchical growth models analysed changes of global severity (HoNOS total scores) and symptom dimensions. Regression modelled factors associated with remission (HoNOS < 8) and clinical improvement (<12).

RESULTS

The incidence of FEP was 21.5 (95%CI: 21.2-21.9) cases per 100 000 person year. Among participants (n = 86, mean age 23, 76% males), baseline HoNOS scores were higher for those with a longer DUP. More than half subjects reached clinical remission (61.6%) or improvement (82.6%), while very few (2.3%) were re-hospitalized. HoNOS total scores decayed with a mixed linear/quadratic trend, with a slower decay among migrants. A longer DUP was associated with reduced improvements of positive symptoms and lower likelihood of clinical improvement (OR: 0.84; 95%CI: 0.73-0.96).

CONCLUSIONS

Patients from the FEP program of Ferrara reached good clinical outcomes. Nonetheless, individuals with a longer DUP may need additional clinical attention. Systematic monitoring of clinical outcomes may be an optimal strategy to improve the outcomes of FEP in the real world.

Psychotic Depression: Diagnosis, Differential Diagnosis, and Treatment

Psychotic depression was initially considered to be at one end of a continuum of severity of major depression. Subsequent experience demonstrated that psychosis is an independent trait that may accompany mood disorders of varying severity. While much has been learned about the impact of severe mood congruent delusions and hallucinations on the course and treatment response of depression, less is known about fleeting or mild psychosis, mood incongruent features, or psychotic symptoms that reflect traumatic experiences. Acute treatment of psychotic unipolar depression generally involves the combination of an antidepressant and an antipsychotic drug or electroconvulsive therapy. There is inadequate information about maintenance treatment of unipolar psychotic depression and acute and chronic treatment of psychotic bipolar disorder. Decision-making therefore still must rely in part on clinical experience.

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.

Perceived burdensomeness, thwarted belongingness and suicidal ideation among individuals with first-episode psychosis

Individuals with first-episode psychosis (FEP) are at elevated risk for suicide. The current study explored the applicability of the Interpersonal-Psychological Theory of Suicide (IPTS) as a model for understanding suicide in FEP. Thirty-nine individuals with FEP completed measures of thwarted belongingness, perceived burdensomeness, acquired capability for suicide, and suicidal ideation. Results indicate that participants with recent suicidal ideation have greater levels of perceived burdensomeness and thwarted belongingness than those without recent suicidal ideation. In contrast, the interaction of IPTS variables did not predict the severity of suicidal ideation across the entire sample. These findings suggest that burdensomeness and belongingness differentiate between individuals with and without suicidal ideation, although these constructs might be less useful in predicting the severity of suicidal ideation among individuals with psychosis. Further research is needed to understand both transdiagnostic and unique risk factors that contribute to the high rates of suicide in this population.

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.

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.

Suicidal ideation in first-episode psychosis: Considerations for depression, positive symptoms, clinical insight, and cognition

BACKGROUND

Suicide is a leading cause of death for individuals with psychosis. Although factors influencing suicide risk have been studied in schizophrenia, far less is known about factors that protect against or trigger increased risk during early-stage and first episode of psychosis. This study examined whether depression, psychotic symptoms, clinical insight, and cognition were associated with suicide ideation among individuals with first-episode psychosis.

METHODS

Data were obtained from the Recovery After an Initial Schizophrenia Episode (RAISE) project. Participants (n = 404) included adults between ages 15 and 40 in a first episode of psychosis. Measurement included the Positive and Negative Syndrome Scale, Brief Assessment of Cognition in Schizophrenia, and Calgary Depression Scale for Schizophrenia. A logistic regression model evaluated clinical and cognitive variables as predictors of suicidal ideation.

RESULTS

Greater positive symptoms (OR = 1.085, p < .01) and depression (OR = 1.258, p < .001) were associated with increased likelihood of experiencing suicidal ideation during the RAISE project. Meanwhile, stronger working memory (OR = 0.922, p < .05) and impaired clinical insight (OR = 0.734, p < .05) were associated with a decreased likelihood of experiencing suicidal ideation.

CONCLUSION

The likelihood of experiencing suicidal ideation was significantly increased when positive and depressive symptoms were present, and significantly decreased when clinical insight was poorer and working memory stronger. These findings have important implications for the role of cognition and insight in risk for suicide ideation in early-stage psychosis, which may aid in improving the prediction of suicide behaviors and inform clinical decision-making over the course of the illness.

Suicide Reduction in Schizophrenia via Exercise (SUnRISE): study protocol for a multi-site, single-blind, randomized clinical trial of aerobic exercise for suicide risk reduction in individuals with schizophrenia

BACKGROUND

Suicide risk among individuals with schizophrenia (SZ) is intractably high, with over 40% of individuals attempting to take their own lives during their lifetime and an estimated 5-10% completing suicide. At present, available pharmacological and psychotherapeutic treatments offer limited risk reduction benefits, and thus, there remains an urgent need to explore novel interventions that will ameliorate this risk. Aerobic exercise (AE) has been shown to improve a number of predictors of suicide risk (e.g., depressed mood, sleeping difficulties). As individuals with SZ display a highly sedentary lifestyle, AE may reduce suicide risk.

METHODS

Employing a multi-site, single-blind, randomized clinical trial design, we will examine the impact of AE on risk for suicide and related variables in individuals with SZ. Participants will be randomized to one of two 12-week exercise interventions: AE or a stretching and toning (ST) control intervention. Primary outcome measures will include suicide risk (Columbia Suicide Severity Rating Scale, C-SSRS) and aerobic fitness (VO2max), along with additional measures of suicide risk, mood, emotion regulation, sleep, cognition, and physical activity, with assessments completed at baseline and after 6 and 12 weeks of interventions.

DISCUSSION

It is hypothesized that AE will reduce suicide risk among individuals with SZ. This study may offer support for a more efficacious treatment method for this population in addition to the pre-existing pharmacological and psychotherapeutic treatment regimens.

TRIAL REGISTRATION

Clinicaltrials.gov, NCT03270098 . Registered on September 1, 2017.

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

OBJECTIVE

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Depression moderates the relationships between hallucinations, delusions, and suicidal ideation: The cumulative effect of experiencing both hallucinations and delusions

Suicide is a leading cause of preventable death in the United States and worldwide, with symptoms of depression and psychosis relating to increases in risk for ideation, attempt, and completion. This study examined moderating effects of depression in the relationships between three categories of psychotic symptoms (experiencing only hallucinations, only delusions, and both hallucinations and delusions) and suicidal ideation. Data (n = 12,195) were obtained from the cross-sectional Collaborative Psychiatric Epidemiology Surveys data which include large general population-based samples of households in the United States. Data were examined using Structural Equation Modeling (SEM) in Mplus 8. Approximately 19% of the sample met criteria for major depression and 13% reported having the experience of suicidal ideation. Only 16% of the sample reported having a diagnosis of schizophrenia and/or a psychotic disorder. Depression functioned as a moderator and among those who experienced depression, increases in all psychotic symptom categories significantly related to increased likelihood of experiencing suicidal ideation. Among those who were not depressed, increases in two psychotic symptom categories (only hallucinations and both hallucinations and delusions) were significantly related to greater likelihood of experiencing suicidal ideation. Findings emphasize the high-risk for ideation among individuals who experience hallucinations or delusions, with the cumulative effect of experiencing both hallucinations and delusions being most harmful in relation to the likelihood of experiencing suicidal ideation; particularly so among those who were depressed. Assessment of risk factors for suicidal ideation is imperative given its relationship to the potential of suicide attempt and/or completion.

Effects of Aerobic Exercise on Metabolic Syndrome, Cardiorespiratory Fitness, and Symptoms in Schizophrenia Include Decreased Mortality

Schizophrenia is a severe psychiatric disorder with a lifetime prevalence of about 1%. People with schizophrenia have a 4-fold higher prevalence of metabolic syndrome than the general population, mainly because of antipsychotic treatment but perhaps also because of decreased physical activity. Metabolic syndrome is a risk factor for cardiovascular diseases, and the risk of these diseases is 2- to 3-fold higher in schizophrenia patients than in the general population. The suicide risk is also higher in schizophrenia, partly as a result of depression, positive, and cognitive symptoms of the disease. The higher suicide rate and higher rate of cardiac mortality, a consequence of the increased prevalance of cardiovascular diseases, contribute to the reduced life expectancy, which is up to 20 years lower than in the general population. Regular physical activity, especially in combination with psychosocial and dietary interventions, can improve parameters of the metabolic syndrome and cardiorespiratory fitness. Furthermore, aerobic exercise has been shown to improve cognitive deficits; total symptom severity, including positive and negative symptoms; depression; quality of life; and global functioning. High-intensity interval endurance training is a feasible and effective way to improve cardiorespiratory fitness and metabolic parameters and has been established as such in somatic disorders. It may have more beneficial effects on the metabolic state than more moderate and continuous endurance training methods, but to date it has not been investigated in schizophrenia patients in controlled, randomized trials. This review discusses physical training methods to improve cardiorespiratory fitness and reduce metabolic syndrome risk factors and symptoms in schizophrenia patients. The results of studies and future high-quality clinical trials are expected to lead to the development of an evidence-based physical training program for patients that includes practical recommendations, such as the optimal length and type of aerobic exercise programs and the ideal combination of exercise, psychoeducation, and individual weight management sessions.