Temporal pattern of suicide risk in young individuals with early psychosis☆
Introduction
Suicide is a major cause of premature death in individuals with psychotic disorders, particularly schizophrenia (Brown, 1997). While it is estimated that approximately 5% of schizophrenic patients commit suicide during their lifetime (Palmer et al., 2005), suicide rates near illness onset are three times higher than in the chronic stages of the illness (Mortensen and Juel, 1993, Brown, 1997). Among patients with early psychosis (EP), the rates of other suicidal behaviours are even higher, with 10%–30% attempting suicide prior to the first treatment contact for psychotic symptoms (Nordentoft et al., 2002, Clarke et al., 2006, Melle et al., 2006, Bertelsen et al., 2007). The prevalence of suicide attempts at a 1- or 2-year follow-up falls between 3% and 22% (Nordentoft et al., 2002, Addington et al., 2004, Petersen et al., 2005, Bertelsen et al., 2007), or 11%–18%, respectively (Verdoux et al., 2001, Petersen et al., 2005, Bertelsen et al., 2007). In addition, a large proportion (20%–51%) of EP patients seriously consider suicide while in treatment (Petersen et al., 2005, Bertelsen et al., 2007). Given that suicidal ideation and a history of suicide attempt are significant predictors of future attempts (Tarrier et al., 2004, Shoval et al., 2006) and eventual suicide in psychotic illness (Roy, 1982, Stephens et al., 1999, Sinclair et al., 2004), these figures suggest that management of suicide risk is an important challenge for psychiatric services treating individuals with EP (Nordentoft et al., 2008).
The knowledge of when EP patients are most likely to pose a risk to themselves during treatment is clinical information that would be useful for prediction, intervention and prevention of suicide attempts. Close monitoring of inpatients and more intensive outpatient case management could be provided during these periods of elevated suicide potential even if patients do not appear to be at immediate risk. However, currently little is known about the timing of suicide risk during the early stages of psychotic illness.
Temporal variability in psychopathology is best examined using repeated measures collected longitudinally at regular intervals over the period of interest. Statistical procedures, such as time-series analysis, enable identification of meaningful patterns in the data by separating reliable changes from inherent variability (Morley, 1996). The only published study reporting on the temporal pattern of suicide risk in EP during the first 20 months of treatment (Power et al., 2003) found that the risk was highest in month 1 and 5, and, again, between month 10 and 16. However, the findings of this investigation need to be interpreted with caution due to several methodological limitations: the study used a cross-sectional design; speculations were made entirely on the basis of inspection of descriptive data, and no controls were introduced to account for attrition rates. If the existence of discrete periods of increased risk in this already high risk population can be confirmed in a longitudinal study using statistical methods recommended for this type of data, the findings would have important implications for clinical practice.
The present study examined the course of suicide risk in EP patients whose level of suicidality was repeatedly evaluated throughout treatment as part of routine assessment protocols. The aim of the study was twofold: firstly, to investigate the temporal pattern of suicide risk over the 24-month follow-up and, secondly, to determine whether there are discrete periods of significantly elevated suicide risk using time-series analysis.
Section snippets
Setting
The study was conducted at the Early Psychosis Prevention and Intervention Centre (EPPIC) in Melbourne, Australia (Edwards et al., 1994), a comprehensive specialist treatment program for youth experiencing their first episode of psychosis (FEP), serving an urban catchment area of approximately 960,000 inhabitants. EPPIC entry criteria are as follows: i) the presence of delusions, hallucinations, disorganized behaviour, and/or formal thought disorder; ii) age between 15 and 24 years; iii) no
Results
Of the 647 patients who commenced treatment at EPPIC between December 2002 and December 2005, and whose suicidality was assessed using the BPRS, 16.4% (106) were identified as high risk on the basis of their rating during the 24-month follow-up; 12.2% (79) were at risk in the first year of treatment and 6.8% (44) in the second year. There was one suicide from a drug overdose which occurred after 14 months of treatment. Half (53) of the high risk patients made at least one suicide attempt during
Discussion
The results of the present study indicate that, among EP patients who remain engaged with a specialist service, suicide risk tends to decrease over the course of treatment. The finding that the first month since admission was the time of greatest risk is in line with the results reported by Tarrier et al. (2006), who observed that the proportion of EP patients who were at risk of suicide was greatest at baseline, compared with follow-up assessments at 6 weeks, 3 months and 18 months. The
Acknowledgements
The authors acknowledge the contribution of the former and current TREAT co-ordinators, Antonia Merritt and Diana Maud; Kirsty Irving, who retrieved information from the mental health patient information system and the incident database; and Leah Brooke, who provided assistance with medical records. We also thank the anonymous reviewers for their feedback on the earlier version of the manuscript.
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2021, Schizophrenia ResearchCitation Excerpt :Only one study evaluated ideation and found that 48% of their sample experienced suicidal thoughts (DeVylder et al., 2020). The values for attempted suicide were 12.4% (Sanchez-Gistau et al., 2013; Fedyszyn et al., 2011), 25% (Jarbin and von Knorring, 2004), 31% (Falcone et al., 2010), 53% (Fedyszyn et al., 2010), and 72% (Lincoln et al., 2017). Rates of completed suicide ranged from 2.73% - 4.5% (Fedyszyn et al., 2011; Jarbin and von Knorring, 2003).
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2019, Journal of Affective DisordersCitation Excerpt :Several other studies have reported that the first year after FEP was the period with the highest rates of suicidal behaviour (Dutta et al., 2010). Moreover, it has been suggested that the six months following the onset of the disorder is a sensitive suicidal period, with an important decrease in suicide rates after that (Fedyszyn et al., 2010). Fedyszyn et al. (2011), in a study carried out in a sample of early psychosis patients, showed that multiple suicide attempters made their first attempts significantly earlier than single suicide attempters (Fedyszyn et al., 2011).
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2016, Comprehensive PsychiatryCitation Excerpt :The highest rates of suicidal behavior have been identified as occurring during the months previous and following FEP [37,38]. Fedyszyn et al. (2010) showed that the period of highest risk of SA occurred in the months following the first contact with mental health services, decreasing rapidly over the next six months [9]. The same temporal pattern was found in our sample of fSA after FEP.
Suicidal behaviour in first-episode non-affective psychosis: Specific risk periods and stage-related factors
2015, European NeuropsychopharmacologyCitation Excerpt :It should be pointed out that such a history may influence clinicians in the decision to admit and hence this is observation is somewhat circular. To our knowledge, little is known about this period of extreme risk because studies that specifically investigated suicidality surrounding admission are limited (Fedyszyn et al., 2010; Melle et al., 2006). The highest suicide risk period in FEP patients remains unclear, as do possible changes to the contributors to suicide risk over the early stages of the psychotic illness.
Are structural brain abnormalities associated with suicidal behavior inpatients with psychotic disorders?
2013, Journal of Psychiatric Research
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Presented in part at 6th International Conference on Early Psychosis, Melbourne, Australia, October, 2008.