Schizophrenia and deliberate self-harm: a systematic review of risk factors

A systematic review of structural and functional magnetic resonance imaging studies on the neurobiology of depressive symptoms in schizophrenia spectrum disorders

Depressive symptoms in Schizophrenia Spectrum Disorders (SSDs) negatively impact suicidality, prognosis, and quality of life. Despite this, efficacious treatments are limited, largely because the neural mechanisms underlying depressive symptoms in SSDs remain poorly understood. We conducted a systematic review to provide an overview of studies that investigated the neural correlates of depressive symptoms in SSDs using neuroimaging techniques. We searched MEDLINE, PsycINFO, EMBASE, Web of Science, and Cochrane Library databases from inception through June 19, 2023. Specifically, we focused on structural and functional magnetic resonance imaging (MRI), encompassing: (1) T1-weighted imaging measuring brain morphology; (2) diffusion-weighted imaging assessing white matter integrity; or (3) T2*-weighted imaging measures of brain function. Our search yielded 33 articles; 14 structural MRI studies, 18 functional (f)MRI studies, and 1 multimodal fMRI/MRI study. Reviewed studies indicate potential commonalities in the neurobiology of depressive symptoms between SSDs and major depressive disorders, particularly in subcortical and frontal brain regions, though confidence in this interpretation is limited. The review underscores a notable knowledge gap in our understanding of the neurobiology of depression in SSDs, marked by inconsistent approaches and few studies examining imaging metrics of depressive symptoms. Inconsistencies across studies' findings emphasize the necessity for more direct and comprehensive research focusing on the neurobiology of depression in SSDs. Future studies should go beyond "total score" depression metrics and adopt more nuanced assessment approaches considering distinct subdomains. This could reveal unique neurobiological profiles and inform investigations of targeted treatments for depression in SSDs.

Prevalence and predictors of admission at the time of presentation in first episode psychosis

BACKGROUND

Individuals presenting with first episode psychosis (FEP) constitute a population with high admission rates. Across psychiatric services, community based treatment is aimed for where appropriate. Therefore, further knowledge on predictors of admission is required.

PURPOSE

The objectives were to: (i) determine the proportion of individuals with FEP admitted at time of presentation (voluntarily and involuntarily) (ii) identify associated demographic and clinical factors.

METHODS

This study included all young people (aged 15-24) who presented with FEP to the Early Psychosis Prevention and Intervention Centre, Melbourne, Australia from 01.01.11 to 31.12.16. Binary logistic regression was used to determine unadjusted and adjusted odds ratios.

RESULTS

Of 1208 participants, 58.6% were male and the median age was 20 years (I.Q.R.17-22). At time of presentation, 50.2% were admitted. On multivariate analysis, the following factors predicted admission: being a migrant (OR = 1.75, 95% CI [1.17, 2.62]), aggression (OR = 1.42, 95% CI [1.02, 1.99]), and more severe psychotic symptoms. Longer duration of untreated psychosis was associated with lower admission rates. 70.1% of admissions were involuntary (33.7% of the cohort). Risk factors for involuntary admission were consistent with any admission, other than aggression, and with the addition of older age and male sex.

CONCLUSION

There remains a high admission rate for FEP, even in an established early intervention service, with severity of psychopathology being the strongest predictive factor. There is an independent association between migrancy and admission. Potential reasons for these findings are discussed, and initiatives to reduce admission rates including (i) interventions to prevent admission and (ii) alternative care pathways.

Impact of Treatment Initiation and Engagement on Deliberate Self-Harm Among Individuals With First-Episode Psychosis

OBJECTIVE

Individuals with psychosis are at increased risk for suicide, with the greatest risk being present during the first few months after diagnosis. The authors aimed to examine whether treatment initiation within 14 days of diagnosis and treatment engagement within 90 days of initiation reduce the risk for deliberate self-harm (DSH) among individuals with first-episode psychosis (FEP).

METHODS

A retrospective longitudinal cohort design was adopted by using Ohio Medicaid claims for 6,349 adolescents and young adults ages 15-24 years with FEP. Logistic regression was used to examine factors associated with treatment initiation and engagement. Cox proportional hazard models were used to estimate the impact of treatment initiation and engagement on DSH. Propensity score weighting was used to control for sociodemographic and clinical covariates.

RESULTS

Approximately 70% of the sample initiated treatment, 55% of whom engaged in treatment. Treatment initiation and engagement were associated with both demographic and clinical variables. Treatment initiation significantly reduced the hazard of DSH (average treatment effect in the entire population: hazard ratio [HR]=0.62, 95% CI=0.47-0.81; average treatment effect among those treated: HR=0.64, 95% CI=0.52-0.80). In contrast, treatment engagement was not significantly associated with DSH.

CONCLUSIONS

These results suggest that the initial treatment contact is essential for reducing DSH among adolescents and young adults with FEP. Additionally, the finding that treatment engagement did not reduce DSH suggests that standard clinical care may not be sufficient for reducing DSH in this population. These findings highlight the need for suicide-specific interventions for individuals with FEP.

Rare Case of Managing and Evaluating Viability after Replantation of a Serial Self-Amputated Bilateral Testis by a Patient with Schizophrenia: A Case Report

Amputation of the testis is very rare in clinical situations; therefore, most surgeons have no experience with an amputated testis. In this case, a 31-year-old male with schizophrenia amputated both testes due to self-mutilation. We performed replantation surgery via microscopy. On postoperative day 1, he removed his right testis by using his hand, even though his hands were restrained. The second attack disrupted the viability of the right testis. However, after proper management, we checked the normal sex hormone level by preserving the replanted left testis. We evaluated the viability of the replanted testis by performing five examinations, namely, intraoperative indocyanine green injection, testicular scan with technetium pertechnetate, contrast-enhanced computerized tomography, Doppler ultrasonography, and serum testosterone level. In this report, we aimed to describe our rare experience about management with replantation of the amputated testes and evaluation of their viability.

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.

Antidepressive Effectiveness of Amisulpride, Aripiprazole, and Olanzapine in Patients With Schizophrenia Spectrum Disorders: A Secondary Outcome Analysis of a Pragmatic, Randomized Trial (BeSt InTro)

BACKGROUND

Depressive symptoms are frequent in schizophrenia and associated with a poorer outcome. Currently, the optimal treatment for depressive symptoms in schizophrenia remains undetermined. Amisulpride, aripiprazole, and olanzapine all have antidepressive pharmacodynamic properties, ranging from serotonergic affinities to limbic dopaminergic selectivity. Consequently, in a 12-month pragmatic, randomized clinical trial, we aimed to investigate differences in antidepressive effectiveness among amisulpride, aripiprazole, and olanzapine as a secondary outcome, measured by change in the Calgary Depression Scale for Schizophrenia sum score in patients within the schizophrenia spectrum.

METHODS

Psychotic patients within the schizophrenia spectrum were included, and effectiveness was analyzed with latent growth curve modeling.

RESULTS

Of the 144 patients, 51 (35%) were women, the mean age was 31.7 (SD 12.7), and 39% were antipsychotic naive. At inclusion, 68 (47%) participants had a Calgary Depression Scale for Schizophrenia sum score >6, indicating severe depressive symptoms. Across the 12-month follow-up, there was a depressive symptom reduction in all medication groups, but no statistically significant differences between the study drugs. Separate analyses of the subcohort with elevated depressive symptoms at inclusion also failed to find differences in depressive symptom reduction between study drugs. The reduction in depressive symptoms mainly occurred within 6 weeks after randomization.

CONCLUSIONS

There was a reduction in depressive symptoms under treatment with amisulpride, aripiprazole, and olanzapine in acutely psychotic patients with schizophrenia spectrum disorder, but no differences between the drugs.

Self-Harm Among Forensic Psychiatric Inpatients With Schizophrenia Spectrum Disorders: An Explorative Analysis

The burden of self-injury among offenders undergoing inpatient treatment in forensic psychiatry is substantial. This exploratory study aims to add to the previously sparse literature on the correlates of self-injury in inpatient forensic patients with schizophrenia spectrum disorders (SSD). Employing a sample of 356 inpatients with SSD treated in a Swiss forensic psychiatry hospital, patient data on 512 potential predictor variables were retrospectively collected via file analysis. The dataset was examined using supervised machine learning to distinguish between patients who had engaged in self-injurious behavior during forensic hospitalization and those who had not. Based on a combination of ten variables, including psychiatric history, criminal history, psychopathology, and pharmacotherapy, the final machine learning model was able to discriminate between self-injury and no self-injury with a balanced accuracy of 68% and a predictive power of AUC = 71%. Results suggest that forensic psychiatric patients with SSD who self-injured were younger both at the time of onset and at the time of first entry into the federal criminal record. They exhibited more severe psychopathological symptoms at the time of admission, including higher levels of depression and anxiety and greater difficulty with abstract reasoning. Of all the predictors identified, symptoms of depression and anxiety may be the most promising treatment targets for the prevention of self-injury in inpatient forensic patients with SSD due to their modifiability and should be further substantiated in future studies.

Self-mutilation in people with psychiatric diagnosis - literature review

Introduction: Self-mutilation is of an auto-aggressive nature. They take many forms. Usually they do not occur as an isolated phenomenon. Self-injuring persons often have a diagnosed mental disorder, and a psychiatric diagnosis is one of the risk factors for the occurrence of self-harm. Material and method: In this study, articles were analyzed that contained information on the occurrence of various mental disorders. These articles searched for information on the occurrence of self-mutilation, its type, origin and causes.  Discussion: Self-mutilation is common in patients with a psychiatric diagnosis. The frequency of such behaviors can range from 33% to 50% in people with autism, up to 22%, and even 49% in people diagnosed with psychotic disorders. Acts of selfharm may affect 50-78% of people diagnosed with border-line personality disorder. In adolescents with eating disorders, 41% of patients report self-harm. In the group of people diagnosed with bipolar disorder, it may be as high as 77.3%. People with depression are also a large self-injuring group. It is reported that it may be up to 71.2% of patients with unipolar disorder. Conclusions: Self-mutilation is a phenomenon that is more and more topical and common not only in the adolescent population. This is a multi-factorial issue. One of the risk factors are mental disorders. Self-mutineers choose various methods, and this choice depends, among others, on from recognition. The size of the phenomenon and its evolution make it necessary to study it in order to increase the level of knowledge, update information and, consequently, the ability to help people at risk of NSSI.  Keywords: self-mutilation, autism spectrum disorder, schizophrenia, bipolar disorder, personality disorders

[Non-suicidal self-injurious behavior in conduct disorders and schizotypal disorder]

OBJECTIVE

To compare the methods and motives of non-suicidal self-injurious behavior (NSIB) in conduct disorders and schizotypal disorder.

MATERIAL AND METHODS

The main group consisted of 91 patients (77.8%), aged 13-24 years, with behavioral disorders and NSIB, who completed questionnaires using the self-harm statements questionnaire. The younger subgroup consisted of 54 patients under the age of 18 with a diagnosis of «Behavior Disorders» (ICD-10 F91), the older subgroup included 37 patients aged 18 years or more with a diagnosis of Emotionally Unstable Personality Disorder (F60.3). The comparison group consisted of 100 patients, aged 13-41 years with a diagnosis of schizotypal disorder (F21) and NSIB. We used clinical-psychopathological, standardized and statistical methods.

RESULTS

Significant differences were revealed in the sexual preference for NSIB (p=0.0001), a number of leading types of NSIB, and the absence of differences in the motives of self-injurious behavior in patients of the compared groups. In the comparison group, cuts and cauterization prevailed as the leading type of NSIB, in patients with behavioral disorders prevailed obstacles to wound healing, which is hypothetically associated with the influence of obsessive psychopathological mechanisms, since pathological excoriation has the same nature as obsessive-compulsive disorder and is included with it in the same DSM-5 category. The impulsive subtype of NSIB observed in this situation usually arises due to an increasing sense of tension and is associated with the motive of intrapersonal self-regulation.

CONCLUSION

The study showed that the difference between the compared nosological groups according to the methods and motives of self-harming actions is determined not so much by intergroup differences as by sex and age patterns within each of the compared groups. This allows us to talk about the proximity of the mechanisms of self-harm in various mental disorders, and the phenomenon of NSIB itself should be considered rather as a nosologically nonspecific psychopathological phenomenon.

Prevalence of suicide ideation, self-harm, and suicide among Chinese patients with schizophrenia: a systematic review and meta-analysis

Aims

Suicide ideation, self-harm, and suicide are common in patients with schizophrenia, but the reported prevalence vary largely across studies. Improved prevalence estimates and identification of moderators of the above self-directed violence are needed to enhance recognition and care, and to guide future management and research. This systematic review aims to estimate the pooled prevalence and identify moderators of suicide ideation, self-harm, and suicide among patients diagnosed with schizophrenia in China.

Methods

Relevant articles published until September 23, 2021, were searched using PubMed, EBSCO, Web of Science, Embase, Science Direct, CNKI, CBM, VIP, and Wanfang databases. Eligible studies published in English or Chinese which reported the prevalence of suicide ideation, self-harm, or suicide among Chinese patients with schizophrenia were collected. All studies passed a quality evaluation. This systematic review was registered with PROSPERO (registration number CRD42020222338). PRISMA guidelines were used in extracting and reporting data. Random-effects meta-analyses were generated using the meta package in R.

Results

A total of 40 studies were identified, 20 of which were evaluated as high-quality studies. Based on these studies, the prevalence of lifetime suicide ideation was 19.22% (95% CI: 7.57-34.50%), prevalence of suicide ideation at the time of investigation was 18.06% (95% CI: 6.49-33.67%), prevalence of lifetime self-harm was 15.77% (95% CI: 12.51-19.33%), and prevalence of suicide was 1.49% (95% CI: 0.00-7.95%). Multivariate meta-regression analysis revealed that age (β = - 0.1517, p = 0.0006) and dependency ratio (β = 0.0113, p < 0.0001) were associated with the lifetime prevalence of self-harm. Study assessment score (β = 0.2668, p < 0.0001) and dependency ratio (β = 0.0050, p = 0.0145) were associated with the lifetime prevalence of suicide ideation. Results of the spatial analysis showed that the prevalence of self-directed violence varied greatly across different provinces.

Conclusion

This systematic review provides estimates of the prevalence of self-directed violence among Chinese patients with schizophrenia and explores its moderators and spatial patterns. Findings also have important implications for allocating prevention and intervention resources to targeted high-risk populations in high prevalence areas.

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

OBJECTIVES

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Psychological Resilience to Suicidal Experiences in People with Non-Affective Psychosis: A Position Paper

It is important to understand the psychological factors which underpin pathways to suicidal experiences. It is equally as important to understand how people develop and maintain resilience to such psychological factors implicated in suicidal experiences. Exploring optimal routes to gaining this understanding of resilience to suicidal thoughts and acts in people with severe mental health problems, specifically non-affective psychosis, was the overarching aim of this position paper. There are five central suggestions: 1. investigating resilience to suicidal experiences has been somewhat over-looked, especially in those with severe mental health problems such as schizophrenia; 2. it appears maximally enlightening to use convergent qualitative, quantitative and mixed research methods to develop a comprehensive understanding of resilience to suicide; 3. relatedly, involving experts-by-experience (consumers) in suicide research in general is vital, and this includes research endeavours with a focus on resilience to suicide; 4. evidence-based models of resilience which hold the most promise appear to be buffering, recovery and maintenance approaches; and 5. there is vast potential for contemporary psychological therapies to develop and scaffold work with clients centred on building and maintaining resilience to suicidal thoughts and acts based on different methodological and analytical approaches which involve both talking and non-talking approaches.

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.

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.

Recommandations de pratique clinique sur la prise en charge du patient adulte à présentation psychiatrique dans les structures d’urgences

De nombreux patients consultant aux urgences souffrent de pathologies psychiatriques préexistantes ou ont une symptomatologie évocatrice d’une pathologie psychiatrique. En effet, les troubles psychiatriques touchent un adulte sur quatre, et 75%des affections psychiatriques débutent avant l’âge de 25 ans. Le parcours de soins d’un patient adulte à présentation psychiatrique dans les structures d’urgences concerne de multiples intervenants. La complexité inhérente à ces patients complexes ainsi qu’à l’interdisciplinarité induite dans la prise en charge impose un cadre de prise en charge clair et consensuel. Des experts de la psychiatrie, de la gérontopsychiatrie et de la médecine d’urgence se sont réunis pour émettre ces recommandations de bonnes pratiques. Le choix de présenter des recommandations de bonnes pratiques et non des recommandations formalisées d’experts a été fait devant l’insuffisance de littérature de fort niveau de preuve dans certaines thématiques et de l’existence de controverses. À travers ces recommandations de bonnes pratiques cliniques, ils se sont attachés à décrire la prise en charge de ses patients aussi bien en préqu’en intrahospitalier. Les objectifs de ces recommandations sont de présenter les éléments indispensables à l’organisation du parcours de soins de ces patients, la gestion de l’agitation ainsi que la prise en charge pharmacologique ou non. Une partie spécifique est consacrée aux aspects réglementaires.

Problematic Drug Use Among Outpatients With Schizophrenia and Related Psychoses

Background: Problematic drug use is common among psychiatric patients and is linked with poorer course and outcomes of illness. The aim of this study is to assess the prevalence of problematic drug use, and to explore its sociodemographic correlates and associations with health behaviors and outcomes among outpatients with schizophrenia and related psychoses in Singapore. Methods: Data from 397 individuals who were aged 21-65 years and were seeking treatment for schizophrenia and related psychoses in the outpatient clinics of a tertiary psychiatric hospital were analyzed. The Drug Abuse Screening Test (DAST-10) was used to assess problematic drug use. Information on sociodemographics, smoking status, alcohol use, symptoms severity and quality of life were collected. Multivariable logistic regressions were conducted to explore correlates and associations of problematic drug use. Results: The prevalence of problematic drug use was 5.8% (n = 23) in the sample, and 10.6% (n = 42) of the participants reported having problematic drug use and/or problematic alcohol use. More males than females reported having problematic drug use (p = 0.021), and also problematic drug and/or alcohol use (p = 0.004). Significant associations were observed between problematic drug use and smokers with nicotine dependence, and with physical health domain of quality of life. Individuals with greater symptom severity were approximately twice as likely to have problematic drug use and/or alcohol use. Conclusion: While the prevalence of problematic drug use in this sample population is relatively lower compared to other countries, there is a considerable number who might be at risk. Routine screening and close monitoring of drug use is recommended as part of psychiatric assessment, particularly among males and patients with nicotine dependence.

Predicting factors for non-suicidal self-injury in patients with schizophrenia spectrum disorders and the role of substance use

Non-suicidal self-injury (NSSI) has been shown as a characteristic feature in many clinical populations in recent years and schizophrenia is one of the most common psychiatric disorders which is associated with NSSI. In this study, we aimed to investigate predictors of NSSI in patients with schizophrenia spectrum disorders (SSD) and the role of lifetime substance use disorder (SUD). A sample of 165 patients with a diagnosis of SSD who were in remission participated in the study. Lifetime NSSI was assessed using the Inventory of Statements About Self-injury (ISAS). Lifetime SUD were evaluated. Logistic regression analysis was conducted to predict NSSI. SUD was found to be related to NSSI in patients with SSD, and it was associated with an approximately fourfold increase in the risk of NSSI. The rates of lifetime SUD in our sample and in the NSSI (+) group were 38.2 % and 55.6 %, respectively. The most commonly abused substances among patients with NSSI were cannabis and synthetic cannabinoids. The prevalence of NSSI was 43.6 % in our sample. 'Self-cutting' was the most common type and 'affect regulation' was the most common function of NSSI. One of the most significant risk factors for NSSI was a previous history of suicide attempts. SUD appears to be a significant predictor of NSSI in patients with SSD. Further investigation of treatable risk factors such as SUD which are related to NSSI is needed. It is also essential to screen SSD patients for NSSI due to the probable relation to high risk of suicide.

The evolution of depression in first-episode psychosis: A naturalistic database study

Depression is commonly seen in the course of schizophrenia and can occur during any of the phases of the psychotic illness. The present study examines the incidence of depression at baseline and de novo depression in first episode of nonaffective psychoses and the course of depression in the 12 months following first-episode psychosis, any predictive significance of baseline depression with recurrence of depression in the subsequent phases of the psychotic illness. The study was conducted with a clinical sample of 460 patients under the care of a first-episode psychosis programme, and data relating to duration of untreated psychosis, sociodemographic data, Positive and Negative Symptom Scale (PANSS), Global Assessment of Functioning (GAF), and Clinical Global Impression (CGI) were collected. Diagnosis was made by at least two psychiatrists using SCID-1, and depression was measured by Patient Health Questionnaire (PHQ-9). Statistical analysis was performed using SAS version 9. We performed multiple logistic regression analyses to identify the sociodemographic and clinical factors that were associated with depression. Statistical significance was set at p value less than 0.05. We found that baseline depression was present in 34.42% patients with a preponderance of females (p = 0.047) and in those with secondary education. A suicide attempt is a strong predictor for depression at baseline. There was lower incidence of depression in those diagnosed with brief psychotic disorder (p = 0.015) and those with lower PANSS positive scores (p = 0.017). De novo depression over 12 months was 9.44%. Depression at 1-year follow-up was significantly predicted by depression at baseline.

Characteristics of the schizophrenia suicide attempts in comparison with the suicide attempts with other diagnosed psychiatric disorders: An Egyptian study

BACKGROUND

There has been much literature on schizophrenia, but little is known about the characteristic features of suicide attempts with schizophrenia in comparison with the suicide attempts with other diagnosed psychiatric disorders.

AIMS

The objective of this study was to clarify the specific characteristics and risk factors among suicide attempters with schizophrenia that differentiate them from other psychiatric disorders.

METHODS

Thirty-three suicide attempters diagnosed with schizophrenia and 87 suicide attempters with other psychiatric disorders were included. Suicide attempts seriousness were appraised by the Beck's Suicide Intent Scale (BSIS). Standardized scales were applied: Suicide Probability Scale (SPS) and Barratt Impulsiveness Scale, Version 11 (BIS-11). The Structured Clinical Interview for DSM-IV Axis I Disorders (SCID-I) and The Structured Clinical Interview for DSM-IV Axis II Disorders (SCID-II) based on the Diagnostic and Statistical Manual of Mental Disorders-IV (DSM-IV) was applied to assess the psychiatric status of individuals. Demographic and clinical characteristics, method of suicide and suicide probability scores and impulsivity were compared among both groups (schizophrenia group and other psychiatric disorders group).

RESULTS

In total, 27.5% of suicide attempts suffered from schizophrenia. The current study found that having more past history of medical diseases, longer duration of illness, using more violent suicidal methods, and having less significant suicidal ideations were the significant factors that differentiated schizophrenia suicide attempts from those diagnosed with other psychiatric disorders. The schizophrenia group did not show more impulsivity or hostility than other psychiatric disorders group.

CONCLUSION

These results indicated that each group shows its unique characteristics. They give us new perspectives to prevent suicides in schizophrenia according to their different characteristics.

Risk assessment scales to predict risk of hospital treated repeat self-harm: A cost-effectiveness modelling analysis

BACKGROUND

Risk scales are used widely for assessing individuals presenting to Emergency Departments (EDs) following self-harm. There is growing evidence that risk scales have limited clinical utility in identifying episodes at highest risk of repeat self-harm. However, their cost-effectiveness in terms of treatment allocation and subsequent repeat self-harm is unknown. We aimed to examine the cost-effectiveness of five risk scales (SAD PERSONS Scale, Modified SAD PERSONS Scale, ReACT Self-Harm Rule, Manchester Self-Harm Rule, Barratt Impulsivity Scale) and single item clinician and patient ratings of risk.

METHOD

Quality-Adjusted Life Years were estimated for each episode. The five risk scales and the patient rating were compared to the clinician rating. Incremental cost-effectiveness ratios (ICERs) were estimated for each scale, using a range of ICER thresholds. Sensitivity analysis explored different model assumptions.

RESULTS

The formal scales were less cost-effective than the clinician and patient ratings across a range of ICER thresholds (£0-£30,000). The five scales were also less cost-effective than the clinician rating in most alternative scenario analyses. However, the clinician rating would be likely to result in unnecessary treatment costs for over half of patients identified as high risk.

LIMITATIONS

Our primary model depended on the assumption that high-intensity care reduced patients' risk of further self-harm.

CONCLUSION

The use of formal assessment tools for managing self-harm presentations to EDs did not appear to be cost-effective. While the judgement of a mental health clinician was found to be slightly more cost-effective, it still resulted in incorrect allocation of costs and missed treatment opportunities.

Association of an Early Intervention Service for Psychosis With Suicide Rate Among Patients With First-Episode Schizophrenia-Spectrum Disorders

IMPORTANCE

Patients with schizophrenia have a substantially higher suicide rate than the general public. Early intervention (EI) services improve short-term outcomes. However, little is known about the association of EI with suicide reduction in the long term.

OBJECTIVE

To examine the association of a 2-year EI service with suicide reduction in patients with first-episode schizophrenia-spectrum (FES) disorders during 12 years and the risk factors for early and late suicide.

DESIGN, SETTING, AND PARTICIPANTS

This historical control study compared 617 consecutive patients with FES who received the 2-year EI service in Hong Kong between July 1, 2001, and June 30, 2003, with 617 patients with FES who received standard care (SC) between July 1, 1998, and June 30, 2001, matched individually. Clinical information was systematically retrieved for the first 3 years of clinical care for both groups. The details of death were collected up to 12 years from presentation to the services. Data analysis was performed from October 30, 2016, to August 18, 2017.

MAIN OUTCOMES AND MEASURES

Suicide rate during 12 years was the primary measure. The association of the EI service with the suicide rates during years 1 through 3 and years 4 through 12 were explored separately.

RESULTS

The main analysis included 1234 patients, with 617 in each group (mean [SD] age at baseline, 21.2 [3.4] years in the EI group and 21.3 [3.4] years in the SC group; 318 male [51.5%] in the EI group and 322 [52.2%] in the SC group). The suicide rates were 7.5% in the SC group and 4.4% in the EI group (McNemar χ2 = 5.55, P = .02). Patients in the EI group had significantly better survival (propensity score-adjusted hazard ratio, 0.57; 95% CI, 0.36-0.91; P = .02), with the maximum association observed in the first 3 years. The number of suicide attempts was an indicator of early suicide (1-3 years). Premorbid occupational impairment, number of relapses, and poor adherence during the initial 3 years were indicators of late suicide (4-12 years).

CONCLUSIONS AND RELEVANCE

This study suggests that the EI service may be associated with reductions in the long-term suicide rate. Suicide at different stages of schizophrenia was associated with unique risk factors, highlighting the importance of a phase-specific service.

Risk factors of compliance with self-harm command hallucinations in individuals with affective and non-affective psychosis

Clinicians are often left with the difficult task of assessing and managing the risk of violent behaviors in individuals having command hallucinations, which may result in substantial rates of false positive or false negative. Moreover, findings on the association between command hallucinations and suicidal behaviors are limited. In an attempt to better understand compliance to this hallucinatory phenomenon, our objective was to identify the risk factors of compliance with self-harm command hallucinations. Secondary analyses from the MacArthur Study were performed on 82 participants with psychosis reporting such commands. Univariate logistic regression was used to examine the classification value of each characteristic associated with compliance with such commands. Seriousness and frequency of childhood physical abuse, a current comorbid substance use disorder, emotional distress, general symptomatology, history of compliance, and belief about compliance in the future were found to be significant risk factors of compliance with self-harm commands in the week preceding psychiatric inpatient. Multivariate analyses revealed that severity of childhood physical abuse, belief about compliance in the future, and a current comorbid substance use disorder were independent risk factors. The final model showed excellent classification accuracy as suggest by the receiver operating characteristic curve (AUC=0.84, 95% CI: 0.75-0.92, p<0.001). Our results suggest considerable clinical implications in regard to the assessment of risk of compliance to self-harm command hallucinations in individuals with psychosis.

Adaptation of the Beck Hopelessness Scale as a suicide risk screening tool among Nigerian patients with schizophrenia

OBJECTIVES

We examined the adaptation of the Beck Hopelessness Scale (BHS) as a subjective suicide risk assessment tool in detecting Nigerian patients with schizophrenia who are at a high risk of suicide.

METHODS

Schizophrenia patients (211) completed the BHS in addition to a sociodemographic questionnaire. They were objectively interviewed with the suicidality module of the Mini International Neuropsychiatric Interview (MINI) as the 'gold standard', against which the criterion validity of the BHS was examined.

RESULTS

The receiver operating characteristics (ROC) curve of the 20-item BHS scale at a total cut-off score of 9 (sensitivity 0.889, specificity 0.916) against the patients' MINI Suicidality Module risk categorisation had an Area Under the Curve (AUC) of 0.96 (95% CI: 0.928-0.987), while, the four-item BHS scale demonstrated a ROC curve with an AUC of 0.92 (95% CI: 0.868-0.966) at a cut-off score of 1 (sensitivity 1.000, specificity 0.832).

CONCLUSIONS

The BHS has proven to be valid in terms of its sensitivity and specificity in the identification of the high suicidal risk Nigerian schizophrenia outpatients.

Repeated self-injury: perspectives from general psychiatry

Patients who repeatedly injure themselves present particular management problems for general psychiatric teams. This article, the first of a series of four, examines the characteristics of those that present to adult mental health services, and the possible underlying background and trigger factors that lead to these anxiety-raising events. Suggestions are made on preventive and assessment procedures, staff reactions and management strategies aimed at helping patients deal with the overwhelming feelings that underlie self-injury.

Suicidal behaviors and their relationship with psychotic-like symptoms in children and adolescents at clinical high risk for psychosis

BACKGROUND

Previous research has demonstrated elevated rates of suicide attempts and ideation in individuals with psychosis. This study investigated rates and severity of suicidal behavior in youth with and at clinical high risk for psychosis, and examined the positive, negative, and disorganized symptoms associated with suicidal behaviors among the clinical high risk group.

METHODS

Eighty-six youth ages 7-18 (n=21 non-clinical controls [NCC], n=40 clinical high risk [CHR], n=25 diagnosed psychotic disorder [PD]) were recruited. CHR and PD participants were identified using the Structured Interview for Prodromal Symptoms (SIPS) and Schedule for Affective Disorders and Schizophrenia for School-Age Children-Present and Lifetime Version (KSADS-PL). All participants completed the Suicide Behaviors Questionnaire-Revised (SBQ-R).

RESULTS

Findings indicated significantly higher levels of suicidal behavior among CHR and PD relative to NCC participants (F=7.64, p=0.001). 17.5% of CHR participants had previously attempted suicide. Dysphoric Mood and Odd Behavior or Appearance were significantly correlated with suicidal behavior severity among CHR youth.

CONCLUSION

Suicidal behavior was observed with greater frequency and severity in the CHR and PD groups than in the NCC group. CHR suicidal behavior severity was correlated most strongly with Dysphoric Mood and Odd Behavior or Appearance, a relationship which warrants further investigation.

Suicidal Ideation in an Egyptian Sample of Hospitalized Patients with Acute Psychosis

BACKGROUND

Suicide mortality is 12 times higher in psychotic patients compared to the general population. Identifying characteristic of suicidal patients among this group might help in preventing such behavior.

AIMS

To assess the predictors of suicidal risk in patients hospitalized due to acute psychosis.

METHODS

One hundred and fifty patients (age 18 - 60 years) admitted with acute psychotic features were recruited. Patients were evaluated clinically by The Arabic version of Mini International Neuropsychiatric Interview (M.I.N.I.). Suicidal ideation was assessed using the Scale for Suicide Ideation (SSI).

RESULTS

Forty four out of 150 patients (29.33%) reported having current and/or previous history of suicidal ideation. Patients with major depression showed the highest suicidal tendencies followed by delusional disorder then bipolar disorder, psychosis related to substance abuse and schizophrenia. The more severe the psychotic symptoms, the more suicidal tendencies shown by patients. Predictors for suicidal ideations included diagnostic category, severity of psychotic features, unemployement and younger age CONCLUSION: Patients with psychosis that require admission to the hospital carry a high risk of suicidal ideation and behavior. Factors like unemployment, young age and psychiatric diagnosis and severity of psychosis could be predicting factors.

[Dyslipidemia and suicidal risk in patients with psychiatric disorders]

The aim of this work is to study the association between dyslipidemia and suicidal risk in patients with psychiatric pathology. Our study has involved 155 patients suffering from major depressive disorder and 124 schizophrenic patients aged 40.58±12.16 and 43.43±10.60 years, respectively. Total cholesterol (TC), triglycerides (TG) and HDL-c were determined by enzymatic methods, LDL-c was calculated by the Friedewald formula. Plasma cholesterol level was significantly lower among suicidal schizophrenic or depressive patients. There were no significant differences in the others lipid levels. The results of our study suggest that total cholesterol values less than 3.59mmol/L could be an indicator of suicide vulnerability in patients with schizophrenia or major depressive disorder.

Burden associated with smoking as a suicidal risk factor in an Australian sample of patients with psychosis

OBJECTIVE

We aim to describe the burden associated with smoking as a risk factor for suicidal behaviors among patients with psychosis.

METHOD

We calculated the Population Attributable Risk (PAR) associated with smoking and other known modifiable risk factors for suicidal behaviors for participants (N=1812) who took part in the Australian Survey of High Impact Psychosis (SHIP). A combined PAR for the seven identified modifiable risk factors was calculated.

RESULTS

Smoking contributed to 21% of the suicidal behaviors in this sample; together, the seven factors contributed to 86% of all attempted suicide in this cohort.

CONCLUSIONS

Smoking may exert a role either directly or indirectly. Evidence indicates that smoking is associated with psychological, biochemical and neurobiological changes that are in turn implicated in smoking. Suicidal behaviors are nevertheless complex behaviors needing multi-faceted approach.

Royal Australian and New Zealand College of Psychiatrists clinical practice guideline for the management of deliberate self-harm

OBJECTIVE

To provide guidance for the organisation and delivery of clinical services and the clinical management of patients who deliberately self-harm, based on scientific evidence supplemented by expert clinical consensus and expressed as recommendations.

METHOD

Articles and information were sourced from search engines including PubMed, EMBASE, MEDLINE and PsycINFO for several systematic reviews, which were supplemented by literature known to the deliberate self-harm working group, and from published systematic reviews and guidelines for deliberate self-harm. Information was reviewed by members of the deliberate self-harm working group, and findings were then formulated into consensus-based recommendations and clinical guidance. The guidelines were subjected to successive consultation and external review involving expert and clinical advisors, the public, key stakeholders, professional bodies and specialist groups with interest and expertise in deliberate self-harm.

RESULTS

The Royal Australian and New Zealand College of Psychiatrists clinical practice guidelines for deliberate self-harm provide up-to-date guidance and advice regarding the management of deliberate self-harm patients, which is informed by evidence and clinical experience. The clinical practice guidelines for deliberate self-harm is intended for clinical use and service development by psychiatrists, psychologists, physicians and others with an interest in mental health care.

CONCLUSION

The clinical practice guidelines for deliberate self-harm address self-harm within specific population sub-groups and provide up-to-date recommendations and guidance within an evidence-based framework, supplemented by expert clinical consensus.

Reducing smoking reduces suicidality among individuals with psychosis: Complementary outcomes from a Healthy Lifestyles intervention study

This study sought to explore the impact of smoking reduction on suicidality (suicide ideation and behaviour) among people with a psychotic disorder (n=235) who participated in a randomized trial of a healthy lifestyle intervention trial. Suicidality, measured by item -4 of the Brief Psychiatric Rating Scale (BPRS) was the main variable of interest. Measures were collected by research assistants blind to treatment allocation at baseline, at 15 weeks (mid-intervention) and 12 months after baseline. Mediation analysis, adjusted for confounders, was used to determine the relationship between smoking reduction and suicidality and to explore whether this was mediated through depression. At 12 months, smoking reduction was found to be significantly associated with suicidality change; an association was also seen between smoking reduction and depression and depression and suicidality. After adjusting for depression, the association between smoking reduction and suicidality was attenuated but remained statistically significant; the proportion of the total effect that was mediated through depression was 30%. There was no significant association between suicidality and treatment group (vs. controls) over time. Our study suggests that smoking interventions may have benefits over and above those for improved physical health, by reducing suicidal ideation in people with psychosis.

Violent typologies among women inpatients with severe mental illness

PURPOSE

Extant severe mental illness (SMI) and physical violence literature focus disproportionately on community-based men samples. To address this empirical imbalance, the current study explored violence towards others and oneself among women inpatients with SMI. As those with SMI are more likely to be victims than perpetrators of violence, victimisation was also an important factor assessed in this study.

METHODS

The study used a quantitative within-subject cross-sectional design. Data were extracted from 5675 inpatient women cases between 2009 and 2013.

RESULTS

Women with a manic disorder (without psychotic features) were 4.5 times, whilst those with psychotic disorders were 2 times, more likely to be physically violent to others compared to those with major mood disorders. Conversely, women with a major mood disorders were 4.8 times and 7.5 times more likely to engage in violence towards oneself (deliberate self-harm), compared to those with psychotic disorder and manic disorders, respectively. The past victimisation increased the likelihood of later physical violence.

CONCLUSION

The data illuminate differential risk factors among women inpatients with SMI that may help predict violence occurring towards others and oneself and allow gender comparisons with the established literature.

Lifetime Physical and Sexual Abuse and Self-Harm in Women With Severe Mental Illness

In a sample of 242 women in treatment for severe mental illness (SMI), we used regression analysis to test the hypothesis that lifetime physical and sexual abuse would correlate with self-harm behaviors (thoughts of self-harm and suicide, self-harming behaviors, and suicide attempts) when controlling for psychiatric symptoms, substance abuse, and negative appraisals of trauma. Lifetime physical abuse and alcohol use were the only significant factors in the model. Women with SMI should be screened regularly for physical abuse, alcohol use, as well as thoughts and behaviors related to self-harming behaviors. Limitations of the study include its cross-sectional design.

Predictors of Suicidality Among Patients with Psychotic Disorders in a Partial Hospital Treatment Program

Individuals with psychotic disorders are at increased risk for suicidality. Demographic and clinical characteristics were compared in individuals with psychotic disorders reporting either high or low suicidality. Among this sample of 259 partial hospital patients, 116 (44.8%) were classified as high risk on the suicidality section of the Mini Neuropsychiatric Interview, and 143 (55.2%) were considered low risk. Bivariate analyses revealed that patients classified as high risk demonstrated greater depression severity, more relationship difficulties, greater emotional lability, and more substance use problems. A logistic regression model indicated that substance use was the most powerful predictor of higher levels of suicidality. Monitoring and intervention for substance use should be targeted as a particularly important aspect of treatment for acutely ill patients diagnosed with psychotic disorders.

Smoking, Suicidality and Psychosis: A Systematic Meta-Analysis

The aim of this study is to systematically review the literature that explored the association between smoking and suicidal risk among those with serious mental illness and to estimate the risk of suicidal behaviors attributable to smoking among this patient group. Multiple databases (CINAHL, PsycINFO, EMBASE, Informit Health Collection and the Cochrane Library databases) were searched from 1 January 1975 through 15 January 2014, along with references from relevant articles for observational studies that ascertained the association between smoking and suicidal behaviors among patients with psychotic disorders conducted in adult patients. Thirteen studies involving 6813 patients with severe mental illness were included. We found that smoking was significantly associated with suicidality in psychosis with an Odds Ratio of 2.12 (95% CI 1.67–2.7). Smoking is associated with suicidal risk amongst individuals with a severe mental illness; however, it is still unclear whether this represents a true risk factor or a confounder or a mediator via mechanisms, hitherto unknown, needs to be studied further.

Escape from Discrepancy: Self-Esteem and Quality of Life as Predictors of Current Suicidal Ideation Among Individuals with Schizophrenia

While suicidal ideation represents an "early warning" sign for suicidal behavior, studies examining suicidal ideation have been limited and largely atheorethical among those with schizophrenia. Informed by the Escape Theory of Suicide, we investigated the relationship between discrepancy factors, in the form of self-esteem and quality of life (QoL), and suicidal ideation. In a sample of 162 individuals with Schizophrenia, hierarchical logistic regression was employed to examine the contribution of (1) demographic (2) clinical and (3) discrepancy factors to suicidal ideation. A mediation analysis was performed to determine if self-esteem mediated the relationship between QoL and suicidal ideation. While QoL (in social relationships) and self-esteem collectively added value to predicting suicidal ideation beyond other factors, only self-esteem remained significant in the final hierarchical model. Self-esteem was found to mediate the relationship between QoL and suicidal ideation. Findings support Escape Theory in schizophrenia, marking self-esteem and QoL as targets for intervention.

Suicide in Recent Onset Psychosis Revisited: Significant Reduction of Suicide Rate over the Last Two Decades - A Replication Study of a Dutch Incidence Cohort

This study aims to compare the suicide risk over the past decade following recent onset psychosis to findings from the eighties and nineties in the same catchment area and to identify predictors of suicide in the context of the Psychosis Recent Onset Groningen-Survey (PROGR-S). A medical file search was carried out to determine the current status of all patients admitted between 2000 and 2009. The suicide rate was compared with a study executed in 1973–1988 in the same catchment area. Predictors of suicide were investigated using Cox regression. The status of 424 of the 614 patients was known in July 2014. Suicide occurred in 2.4% of patients with psychosis disorders (n = 10; mean follow-up 5.6 years); 6 out of 10 suicides took place within two years. Within two decades, the suicide rate dropped from 11% (follow-up 15 years, 8.5% after 5 years) to 2.4%. The Standardized Mortality Rate (SMR) of suicides compared with the general population was 41.6. A higher age was the only significant predictor for suicide. Neuroticism, living situation, disorganized and negative symptoms, and passive coping style all showed a trend for significance. A significant reduction in the suicide rate was found for people with psychosis over the past decades. Given the high SMR, suicide research should be given the highest priority. Identifying predictors may contribute to further reduction of suicide among patients with psychosis.

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.

Are people at risk of psychosis also at risk of suicide and self-harm? A systematic review and meta-analysis

BACKGROUND

Suicide and self-harm are prevalent in individuals diagnosed with psychotic disorders. However, less is known about the level of self-injurious thinking and behaviour in those individuals deemed to be at ultra-high risk (UHR) of developing psychosis, despite growing clinical interest in this population. This review provides a synthesis of the extant literature concerning the prevalence of self-harm and suicidality in the UHR population, and the predictors and correlates associated with these events.

METHOD

A search of electronic databases was undertaken by two independent reviewers. A meta-analysis of prevalence was undertaken for self-harm, suicidal ideation and behaviour. A narrative review was also undertaken of analyses examining predictors and correlates of self-harm and suicidality.

RESULTS

Twenty-one eligible studies were identified. The meta-analyses suggested a high prevalence of recent suicidal ideation (66%), lifetime self-harm (49%) and lifetime suicide attempts (18%). Co-morbid psychiatric problems, mood variability and a family history of psychiatric problems were among the factors associated with self-harm and suicide risk.

CONCLUSIONS

Results suggest that self-harm and suicidality are highly prevalent in the UHR population, with rates similar to those observed in samples with diagnosed psychotic disorders. Appropriate monitoring and managing of suicide risk will be important for services working with the UHR population. Further research in this area is urgently needed considering the high rates identified.

Self-inflicted needle injuries to the eye: a curing pain

There are few reports of severe self-injury to eyes in patients with schizophrenia. We report on a 41-year-old woman, primarily visiting for symptoms of endophthalmitis resulting from self-inflicted needles. Further evaluations established the diagnosis of schizophrenia because of arguing and commenting on auditory hallucinations and negative symptoms including social isolation, decreased self-care, blunt affect, and a monotone voice. The patient had been suffering from auditory hallucinations for several years and found relief in bodily pain caused by needles. The patient received 6 mg of risperidone. Hallucinations were resolved and self-injury behaviour was not repeated.

Meta-analysis of the association between suicidal ideation and later suicide among patients with either a schizophrenia spectrum psychosis or a mood disorder

OBJECTIVE

Recent studies of patients with a mix of psychiatric diagnoses have suggested a modest or weak association between suicidal ideation and later suicide. The aim of this study was to examine the extent to which the association between expressed suicidal ideation and later suicide varies according to psychiatric diagnosis.

METHOD

A systematic meta-analysis of studies that report the association between suicidal ideation and later suicide in patients with 'mood disorders', defined to include major depression, dysthymia and bipolar disorder, or 'schizophrenia spectrum psychosis', defined to include schizophrenia, schizophreniform disorder and delusional disorder.

RESULTS

Suicidal ideation was strongly associated with suicide among patients with schizophrenia spectrum psychosis [14 studies reporting on 567 suicides, OR = 6.49, 95% confidence interval (CI) 3.82-11.02]. The association between suicidal ideation and suicide among patients with mood disorders (11 studies reporting on 860 suicides, OR = 1.49, 95% CI 0.92-2.42) was not significant. Diagnostic group made a significant contribution to between-study heterogeneity (Q-value = 16.2, df = 1, P < 0.001) indicating a significant difference in the strength of the associations between suicidal ideation and suicide between the two diagnostic groups. Meta-regression and multiple meta-regression suggested that methodological issues in the primary research did not explain the findings. Suicidal ideation was weakly but significantly associated with suicide among studies of patients with mood disorders over periods of follow-up of <10 years.

CONCLUSION

Although our findings suggest that the association between suicidal ideation and later suicide is stronger in schizophrenia spectrum psychosis than in mood disorders this result should be interpreted cautiously due to the high degree of between-study heterogeneity and because studies that used stronger methods of reporting had a weaker association between suicidal ideation and suicide.

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.

Prevalence and risk factors for suicidal behavior in young people presenting with first-episode psychosis in Hong Kong: a 3-year follow-up study

PURPOSE

Individuals with first-episode psychosis (FEP) have markedly elevated risk for suicide. Previous research investigating risk factors of suicidal behavior in FEP mainly focused on western populations. This study aimed to examine the prevalence, and pretreatment and early illness predictors of suicidal behavior in Chinese FEP patients.

METHOD

Seven hundred participants aged 15-25 years consecutively enrolled in a territory-wide treatment program for FEP in Hong Kong from July 2001 to August 2003 were studied. Baseline and 3-year follow-up variables were collected via systematic medical file review. Suicidal behavior evaluated in this study comprised suicide attempt and completed suicide.

RESULTS

Seventy-four (10.6%) participants attempted suicide before treatment. Ten percent (n = 70) exhibited suicidal behavior and 1% (n = 7) committed suicide during 3-year follow-up. The majority of post-treatment suicidal behaviors (51.4%) occurred in the first year of follow-up. Jumping from a height was the most common method of committing suicide. Multivariate regression analysis indicated that previous suicide attempt, history of substance abuse and poorer baseline functioning were significantly associated with an increased risk for suicidal behavior after treatment initiation.

CONCLUSION

In a large representative cohort of Chinese young FEP patients, the rates of suicidal behavior before and after treatment and risk factors for post-treatment suicidal behavior were comparable to the findings of previous research on early psychosis conducted in western populations. Close monitoring of high-risk patients with history of attempted suicide or substance abuse, and enhancement of psychosocial functioning may help reduce suicide risk in the early stage of psychotic illness.

Lifetime trauma and suicide attempts in people with severe mental illness

We examined associations among six forms of common lifetime traumatic/adverse events and lifetime suicide attempts while controlling for gender, psychiatric symptoms, self-injury, and substance use in 371 community mental health clients with severe mental illness. Most clients (88.1%) reported at least one traumatic event, and more than half had attempted suicide at least once. Regression revealed that three factors were significantly associated with lifetime suicide attempts: lifetime self-injurious behaviors, lifetime physical abuse, and alcohol use. Having been physically abused appears to be uniquely associated with lifetime suicide attempts when other key risk factors are controlled. Limitations include the cross-sectional design.

The relationships of suicidal ideation with symptoms, neurocognitive function, and psychological factors in patients with first-episode psychosis

BACKGROUND

Individuals with first-episode psychosis (FEP) have markedly elevated risk for suicide. Previous research on suicidality in early psychosis mainly focused on attempted and completed suicide. Data regarding risk factors for suicidal ideation, which is a common antecedent and predictor of suicide attempt, were limited. This study aimed to examine the prevalence of suicidal ideation and its relationships with clinical, neurocognitive and psychological factors in FEP patients.

METHOD

Eighty-nine Chinese patients aged 15 to 25years presenting with FEP to specialized early intervention service were recruited. A comprehensive set of assessments examining pre-treatment illness characteristics, symptom severity, neurocognitive function, and psychological factors were administered. Current suicidal ideation and history of suicide attempt were systematically evaluated.

RESULTS

Approximately 42% of patients expressed suicidal ideation after service entry. Univariate regression analyses found that suicidal ideation was significantly associated with past suicide attempt, depressive symptoms, emotion expressivity, hopelessness, future expectation, attentional impulsiveness, internal and external locus of control, and the likelihood of endorsing fear of social approval and survival and coping beliefs as reasons for living. Final multivariate model showed that previous suicide attempt, depression, less severe diminished expression, greater degree of hopelessness and lower level of internal locus of control independently predicted suicidal ideation.

CONCLUSIONS

Suicidal ideation was prevalent in FEP patients. Our findings implied that close monitoring and prompt intervention of those potentially modifiable risk factors for suicidal ideation including depression, hopelessness and perceived inadequate personal control may reduce suicide risk in the early course of psychotic illness.

The temporal association between self-injurious thoughts and psychotic symptoms: a mobile phone assessment study

The relationship between psychotic symptoms and self-injurious thoughts (SITs) remains unclear. The short-term temporal associations between psychotic symptoms and SITs were explored. A sample of 36 people with a diagnosis of a psychotic disorder or at-risk mental state completed mobile phone-based measures at multiple times each day for 1 week. Clustered regression with time-lagged variables supported a relationship between paranoia and subsequent SITs. Hallucinations did not predict these thoughts when controlling for paranoia. The role of specific psychotic symptoms in triggering SITs is highlighted and the importance of considering these factors in risk management is discussed.

Psychotic symptoms, self-harm and violence in individuals with schizophrenia and substance misuse problems

When schizophrenia is combined with substance misuse, rates are consistently higher. However research findings on the relationship between violence, self-harm and schizophrenia are inconclusive. This study aimed to examine links between specific psychotic symptoms, substance misuse and violence in people dually diagnosed with schizophrenia and substance misuse. Presence and frequency of violence to self and others were examined in relation to the type and severity of psychotic symptoms and level of substance use over a 24 month period in 327 people with schizophrenia and substance misuse problems. 32.3% had an incident of violence to others during the study period and 28.6% had a self-harm/suicide incident. 39 (11.9%) participants reported command hallucinations (CH) and 157 (48.0%) had threat control override symptoms (TCOS). Presence of TCOS and presence of CH were not associated with violence to others but were both associated with self-harm. Different command hallucination sub-types were associated with different types of violence. Delusional and hallucination severity and distress were mainly associated with self-harm. These findings suggest that specific symptoms are related to different outcomes, particularly in relation to self-harm, and these effects remain even after substance use is controlled for. This has important implications for assessment and treatment of this group.