Suicide attempt in first-episode psychosis: A 7.4 year follow-up study

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Abstract

Background

Individuals with first-episode psychosis demonstrate high rates of suicide attempt (SA).

Aims

1) To examine the prevalence of, and risk factors for, SA in a first-episode psychosis (FEP) cohort over a 7.4 year follow-up period. 2) To investigate differences between single versus multiple suicide attempters.

Methods

This study reports baseline and follow-up data from a naturalistic, prospective follow-up of 413 FEP patients treated at a specialist early psychosis centre. Assessments were conducted at treatment entry, initial symptom remission or stabilization, and long term follow-up. Binary logistic regression models were used to assess unadjusted and adjusted associations between early illness and sociodemographic characteristics and two outcome measures: any SA during follow-up; and multiple SAs.

Results

Follow-up data were available for 282 participants. Sixty-one (21.6%) made a suicide attempt over the follow-up period, including 12 successful suicides. The following baseline risk factors increased the risk of any SA: history of self-harm (OR = 4.27; p < 0.001), suicidal tendencies (OR = 2.30; p = 0.022), being depressed for > 50% of the initial psychotic episode (OR = 2.49; p = 0.045), and hopelessness (OR = 2.03; p = 0.030). History of problem alcohol use increased the risk of multiple SAs (OR = 4.43; 95% CI (1.05–18.7); p = 0.043).

Discussion

The prevalence of suicide attempt in this study exceeds reports from short-term FEP studies but is comparable to longer term follow-up studies, indicating that risk remains elevated for at least 7 years following commencement of treatment. The key predictor of future suicide attempt was previous self-harm, indicating that interventions for self-harm are required.

Introduction

Individuals with psychotic disorders demonstrate high rates of suicide attempt (SA); up to 40% will attempt suicide during their lifetime (Harkavy-Friedman, 2006). Risk is highest during the early phase of illness (Palmer et al., 2005). Among people with first-episode psychosis (FEP) rates of suicide are estimated at between 1 and 3% over a 4 to 5-year follow-up period (Clarke et al., 2006, Bertelsen et al., 2007). Rates of deliberate self-harm (DSH) and SA are higher; between 10% and 14% of people with FEP report either DSH or a SA prior to presentation for treatment (Robinson et al., 2009, Harvey et al., 2008, Clarke et al., 2006). Rates remain high following the commencement of treatment. One-year prevalence rates of SA range from 2.9% to 11% (Robinson et al., 2009, Addington et al., 2004, Nordentoft et al., 2002). Longer term follow-up studies have reported a 2-year prevalence rate of 11.3% (Verdoux et al., 2001) and a 4-year prevalence rate of 18.2% (Clarke et al., 2006).

Substance use disorder (SUD), the presence of depressive symptoms, younger age, female gender and greater illness insight have been associated with SA; however the strongest predictor of future SA is a previous attempt (Robinson et al., 2009, Bertelsen et al., 2007, Clarke et al., 2006, Crumlish et al., 2005, Verdoux et al., 2001; Power et al., 2003, Roy, 1982). People who make multiple suicide attempts are more likely to demonstrate a more severe psychopathology, alcohol and drug use, greater suicidality and greater social and familial adversity than those who make only one attempt (Forman et al., 2004, Vajda and Steinbeck, 2000), however to our knowledge this has not been examined in FEP.

To date the majority of studies have only looked at outcomes over shorter follow-up period, only one study has reported suicide attempt rates over a period of 5 years or longer (Bertelsen et al., 2008), and none have reported on predictors of SA. The aims of this study were to examine the prevalence of, and risk factors for, suicide attempt among a FEP cohort over a 7.4 year follow-up period, and to investigate differences between single versus multiple suicide attempters.

Section snippets

Participants

Data were collected as part of a prospective follow-up of a cohort of FEP patients (see Henry et al., 2007) treated at the Early Psychosis Prevention and Intervention Centre (EPPIC). The EPPIC program (McGorry and Edwards, 1998, McGorry et al., 1996) is a comprehensive, specialized mental health service for FEP patients originating from a geographically-defined catchment area in metropolitan Melbourne, Australia with a population of approximately 800,000.

The sample for this study comprised 413

Results

The results of analyses examining the representativeness of the study sample of 282 subjects are displayed in Table 1. The only significant finding was that the study sample was approximately half as likely to be depressed for > 50% of the episode compared with the non-completer group. This is likely to have a negligible effect on sample representativeness, particularly as the magnitude of difference is small.

Discussion

The overall rate of SA over the 7.4 year follow-up period was 21.6%, including the completed suicides, or 18.1% (49/270) if these are excluded. The latter figure is comparable to that reported by Clarke et al. (2006) in a 4-year follow-up of FEP patients, but is higher than the 9% at 5-year follow-up reported by Bertelsen et al. (2008) in the OPUS trial. One possibility is that the higher figure in the current study reflects the longer duration of follow-up. Indeed, we noted that 16.3% of

Role of funding source

This study was supported by the Victorian Health Promotion Foundation (grant number 91–0084C), the Australian National Health and Medical Research Council (grant number 350241) and the Colonial Foundation.

Contributors

All authors contributed to the study design and interpretation of results. SH led the statistical analyses. JR, MH and SH drafted the manuscript. All authors participated in critical revision of manuscript drafts and approved the final version.

Conflict of interest

The authors declare no conflicts of interest.

Acknowledgment

There are no further acknowledgments.

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