Predictors of suicide-related behaviors during treatment following a first episode of psychosis: The contribution of baseline, past, and recent factors
Introduction
Suicide-related behaviors (suicide attempts and suicides) are common among individuals who receive psychiatric treatment for first-episode psychosis (FEP), and pose a challenge to mental health services due to associated psychosocial and economic sequelae. Approximately 12.0% of patients attempt suicide within 24 months of treatment for FEP (Verdoux et al., 2001, Robinson et al., 2009, Fedyszyn et al., 2011), with over a quarter making multiple attempts (Fedyszyn et al., 2011). Up to 1.5% of first-episode patients die from suicide within 18 months of initial contact with psychiatric services (Verdoux et al., 2001, Nordentoft et al., 2002, Tarrier et al., 2006, Robinson et al., 2009).
Studies have examined a range of variables with a view to assisting in the prediction, and hence prevention, of suicide-related acts during treatment for FEP. The most consistently supported risk factors include: past suicidal ideation and suicide attempts; poorer premorbid functioning; past substance abuse/dependence; past history of depression; and depression, hopelessness, and low levels of life satisfaction at entry to treatment (Verdoux et al., 2001, Nordentoft et al., 2002, Bertelsen et al., 2007, Robinson et al., 2009, Bakst et al., 2010, Melle et al., 2010, Robinson et al., 2010). However, the findings have not yet translated into clinical practice and preventive interventions because these variables have low sensitivity and specificity; that is, they correlate well with suicide-related behaviors, but are poor predictors of short-term risk (Cassells et al., 2005).
Predictive properties of risk factors for suicide-related behaviors in first-episode patients could be enhanced by distinguishing between past and recent factors. This distinction, also known as the distal–proximal dimension of risk factors (Mościcki, 1995, Mościcki, 2001), has been used to study a variety of health events (e.g., Roy, 2003, Roy, 2005, Foley et al., 2006), supporting the validity of clarifying risk factors on the basis of their temporal relationship with the outcome. Specifically, past factors represent an underlying vulnerability to suicide-related behaviors conferred by historical and background characteristics which may be person-related and/or environmental (Mościcki, 1995, Mościcki, 2001). Exposure to past factors is necessary, albeit insufficient in and of itself; the timing of suicide-related behaviors is determined by recent risk factors which also often act as precipitants (Mościcki, 1995, Mościcki, 2001). Thus, without the influence of recent factors, the risk potential conveyed through past variables may never actualize into an event. Likewise, recent risk factors will not result in a suicide-related act unless they augment existing vulnerability conferred by past influences (Mościcki, 1995, Mościcki, 2001).
Previous studies of risk factors for suicide-related behaviors in first-episode patients have mostly examined past and baseline (i.e., assessed at intake) variables. However, currently, little is known about recent risk factors as well as the relative importance of baseline, past, and recent variables to the prediction of suicide-related acts. Furthermore, past variables by definition are not amenable to intervention, whereas recent factors are potentially modifiable. Thus, little progress can be made in the development of effective preventive strategies unless recent variables are better understood.
Accordingly, the present study sought to determine the predictive power of baseline, past, and recent variables. It was hypothesized that recent factors would be stronger predictors of suicide-related acts during initial treatment for FEP, compared to baseline and past variables. The second aim of the study was to identify the most influential recent factors which could become targets of preventive interventions.
Section snippets
Setting
The study was conducted at the Early Psychosis Prevention and Intervention Center (EPPIC; Edwards and McGorry, 2002, McGorry et al., 1996), a specialist service mandated to provide treatment for young people experiencing FEP who live in a catchment area of Melbourne, Australia, of approximately 960,000 (Edwards and McGorry, 2002). EPPIC entry criteria include: presence of delusions, hallucinations, disorganized behavior and/or formal thought disorder; age between 15 and 24 years; no prior
Sample characteristics
Of the sample of 180, just over half the patients were male (101/180; 56.1%) and the mean age was 19.56 years (SD = 2.73). The majority (147/180; 81.67%) were diagnosed with non-affective psychosis (see Table 2). Half the sample (94/180; 52.2%) had at least one comorbid diagnosis, most commonly depression (47/180; 26.1%), anxiety disorders (30/180; 16.7%), and borderline personality disorder or BPD (19/180; 10.6%).
Univariate relationships between suicide-related behaviors and study variables
Table 3 presents descriptive information and OR with 95% confidence intervals (CI)
Discussion
To our knowledge, this study is the first investigation into the relative contribution of baseline, past, and recent variables to the prediction of suicide-related behaviors during treatment for FEP. Discrimination between cases and controls improved significantly when recent factors were considered alongside past and baseline characteristics; the model comprising the three domains accurately classified 75.5% of cases and 89.2% of controls. Predictive power of the model also significantly
Role of funding sources
There were no funding bodies involved in the study. The study was part of a PhD thesis of IF.
Contributors
IF, JR, MH and SP designed the study. IF collected and analyzed the data. All authors contributed to the interpretation of the results. IF wrote the first and subsequent drafts of the manuscript. MH, JR, SP, and SF contributed to manuscript revisions and approved the final version.
Conflict of interest
The authors declare no conflict of interest.
Acknowledgments
The authors would like to acknowledge the support of the Early Psychosis Prevention and Intervention Center (EPPIC), in particular Associate Professor Jane Edwards, for providing access to the medical records of former patients. We also thank Dr. Ben Ong (La Trobe University) for statistical advice, Roy McKenzie (Orygen Youth Health) for assistance with tracing patients' medical records, and the anonymous reviewers for helpful feedback on the previous version of this manuscript.
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