Self-harm in first-episode psychosis

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.

Systematic meta-analysis of the risk factors for deliberate self-harm before and after treatment for first-episode psychosis

OBJECTIVE

Attempted suicide and deliberate self-injury can occur before or after presentation with a first-episode of psychosis. The aim of the study is to identify the factors associated with suicide attempts or deliberate self-injury before and after treatment for first-episode psychosis.

METHOD

A systematic review and meta-analysis of controlled studies of factors associated with either suicide attempts or deliberate self-injury, referred to here as deliberate self-harm (DSH).

RESULTS

The pooled proportion of patients who reported DSH prior to treatment for first-episode psychosis was 18.4% (95% Confidence Interval (CI) 14.4-23.3, N = 18 studies, I(2) = 93.8). The pooled proportion of patients with DSH during the period of untreated psychosis was 9.8%, (95% CI 6.7-14.2, N = 5 studies, I(2) = 58.9). The pooled proportion of patients committing DSH during periods of follow up of between 1 and 7 years was 11.4%, (95% CI, 8.3-15.5, N = 13 studies, I(2) = 89.2). Categorical factors associated with an increased risk of DSH were a prior history of DSH (OR = 3.94), expressed suicide ideation (OR = 2.34), greater insight (OR = 1.64), alcohol abuse (OR = 1.68) and substance use (OR = 1.46). Continuous variables associated with an increased risk of DSH were younger age of onset (Standardized Mean Difference (SMD) = -0.28), younger age at first treatment (SMD = -0.18), depressed mood (SMD = 0.49) and the duration of untreated psychosis (SMD = 0.20). Depressed mood and substance use were associated with DSH both before and after treatment, negative symptoms were associated with DSH after treatment but not before treatment. Positive symptoms and social and global functioning were not associated with DSH. Younger age and the duration of untreated psychosis were associated with DSH before treatment but not after treatment.

CONCLUSION

Earlier treatment of first-episode psychosis and successful treatment of depression and substance use could prevent some episodes of DSH and might reduce suicide mortality in early psychosis.

Predicting the likelihood of suicide attempts for rural outpatients with schizophrenia

AIMS AND OBJECTIVES

To explore suicide predictors in rural outpatients with schizophrenia. Background.  Suicide is a major cause of mortality in patients with schizophrenia. Evidence indicates that patients in rural areas are at high risk for inadequate health care services. However, information is limited on suicide risk in outpatients with schizophrenia in rural areas.

DESIGN

Cross-sectional survey.

METHODS

Data were collected on individuals enrolled in the 2007 Taiwan National Health Insurance program as diagnosed with schizophrenia, ≥ 18 years, and living in a rural county. Eligible individuals (n=1655) were assessed by 12 community-based nurses at 12 public health centres. Participants' personal information was retrieved from National Health Insurance records using a personal data sheet, and treatment experiences were obtained by interviewing patients with a 10-item risk-assessment inventory. Data were collected over 18 months (2007-2008) and analysed by descriptive statistics and regression analyses.

RESULTS

Risk of suicide attempt in the previous year had four significant predictors: number of self-harm incidents during the previous year, violent incidents towards others during the previous year, number of follow-ups by mental health clinics and number of involuntary hospitalisations during the previous year (R(2) = 0.337, adjusted R(2) = 0.334, F=133.19, p=0.000).

CONCLUSION

Health care providers should assess rural outpatients with schizophrenia for suicidal thoughts by asking simple questions to evaluate for a history of self-harm and violence and by comparing this information with health system data on follow-ups by mental health clinics and involuntary hospitalisations.

RELEVANCE TO CLINICAL PRACTICE

Community-based health providers may use these results to prioritise assessments when they have a high case load of patients with schizophrenia. Community-based nurses need to be trained to recognise these four predictors to increase their sensitivity to suicidality among patients with schizophrenia.