Heterogeneity in the course of suicidal ideation and its relation to suicide attempts in first-episode psychosis: a five-year prospective study

doi:10.21203/rs.3.rs-1972884/v2

Download PDF

Research Article

Heterogeneity in the course of suicidal ideation and its relation to suicide attempts in first-episode psychosis: a five-year prospective study

https://doi.org/10.21203/rs.3.rs-1972884/v2

This work is licensed under a CC BY 4.0 License

Journal Publication

published 17 Apr, 2023

Read the published version in The Canadian Journal of Psychiatry →

Version 2

posted

You are reading this latest preprint version

Introduction

: Although the risk of suicide is high in first-episode psychosis (FEP), little is known about the course of suicidal ideation and its relation with suicide attempts. Therefore, we aimed to identify five-year trajectories of suicidal ideation and associated factors in FEP and compare how suicide attempts were distributed across these identified trajectories.

Methods

This five-year prospective study assessed suicidal ideation, suicide attempts and potentially associated factors through research interviews, chart review and coroners’ reports in 382 FEP patients [mean age = 23.53(SD = 3.61)] admitted to two five-year early psychosis services in Montreal, Canada. Trajectories were identified using a semiparametric mixture model, and associated factors with multinomial logistic regression.

Results

Three suicidal ideation trajectories were identified: low and decreasing (85.08%); early decline, then increasing (7.85%), and persistent suicidal ideation (7.07%). Suicidal ideation prior to admission (OR = 2.85,p < 0.05) and cocaine use disorder (OR = 6.78,p < 0.05) were associated with the early decline, then increasing suicidal ideation trajectory. Persons with prior suicide ideation (OR = 4.33,p < 0.05) and attempts (OR = 8.18,p < 0.001) and alcohol use disorder (OR = 3.63, p < 0.05) were more likely to belong to the persistent suicidal ideation trajectory, and to attempt suicide during follow-up.

Conclusion

Our study highlights heterogeneity in the course of suicidal ideation over five years and the importance of ongoing assessment of suicidal risk in FEP patients, particularly during periods of transition to other services and for patients who persistently report suicidal ideation, as they are likelier to engage in suicide attempts. Patients with factors associated with increased or persistent suicidal ideation trajectories should be targeted for suicide prevention interventions.

Psychiatry

first-episode psychosis

suicidal ideation

suicide attempts

trajectories

Persons with psychotic disorders are at high risk of suicide, especially in the early years after psychosis onset (1). Suicide rates in first-episode psychosis (FEP) are up to 18 times higher than in the general population (2). About a third of FEP patients experience suicidal ideation and suicide attempts before entering services (3). The prevalence of suicidal ideation and attempts decreases in the first years following entry into services (3). Nonetheless, suicidal ideation and suicide attempts are major risk factors for death by suicide (4). Some studies have reported little overlap between FEP patients who attempted suicide at service entry and those who did so during follow-up (5-7), suggesting the presence of different subgroups who attempt suicide. Our systematic review concluded that longitudinal studies of suicidal thoughts and behaviours in FEP were limited (3), with only two studies examining the possibility of subgroups having distinct suicidal ideation courses (8, 9). A Danish study (n=521) reported three trajectories of suicidal ideation over a three-year period including the year before entering a two-year program: low-decreasing (61%), frequent-stable (33%), and frequent-increasing (6%) suicidal ideation (8). A Spanish study (n=334) also identified three trajectories over a two-year period: non-suicidal ideation (83%), decreasing suicidal ideation (10%), and increasing suicidal ideation (7%) (9). Being a woman (8), being older, having a longer duration of untreated psychosis (DUP) and reduced sleep at baseline (9) were associated with trajectories of increasing suicidal ideation. In the Danish study, previous suicide attempts and severer hallucinations at baseline were associated with the frequent-stable suicidal ideation trajectory. Patients in the frequent-stable and frequent-increasing subgroups were, respectively, three and six times likelier to have attempted suicide by five years of follow-up.

Studies considering individual variability are essential to understand the evolution of suicidal thoughts and behaviours and their predictors in FEP, and guide the provision of tailored interventions to patients at risk of suicide. While suicide risk appears high in the five years after psychosis onset(3), these two trajectory studies only covered the first two to three years. They did not consider additional factors potentially associated with the evolution of suicidal ideation, such as Cluster B personality traits and specific substance use disorders (3). They did not assess both histories of suicide ideation and attempts nor courses of suicide attempts throughout follow-up, which are a major risk factor for suicide.

Addressing these gaps and building on the Danish (8) and Spanish (9) studies, we aimed to identify trajectories of suicidal ideation and their predictors over the five-year period following entry into early intervention services (EIS) for psychosis, while accounting for sociodemographic, clinical, and functioning factors potentially associated with the course of suicidal ideation. As a secondary objective, we aimed to describe and compare the distribution of suicide attempts over the five-year follow-up across identified suicidal ideation trajectories.

Setting and sample

This five-year prospective study was conducted in two urban EIS for psychosis in Montreal, Canada, affiliated with the University of Montreal: Programme Premiers Épisodes Psychotiques, serving a catchment of 340,000; and Clinique Jeunes Adultes Psychotiques, serving a catchment of 225,000. Both offer a five-year, guidelines-based treatment course (10) to persons with FEP aged 18-30 years. Treatment includes intensive psychiatric follow-up; recovery-oriented case management; needs-informed, developmentally appropriate individual, group and family psychosocial interventions; and supported and planned transition to other services at the end of follow-up.

All patients admitted between 2005 and 2013 were invited to participate when their condition was stabilized, and their written informed consent sought. To be included, patients had to be aged 18 to 30, diagnosed with a psychotic disorder according to DSM-IV-TR criteria (untreated or treated for ≤ one year), and have an adequate understanding of French or English. Patients with moderate to severe intellectual disability were excluded. To ensure that the study sample was representative of the patient population, we obtained approval from the relevant clinical authorities and Research Ethics Boards for conducting retrospective chart reviews for all eligible patients, including those who could not be recruited via informed consent (e.g., inability to consent due illness severity, loss of contact prior to recruitment, etc.).

Assessments

Suicidal ideation and suicide attempts

Upon admission, suicidal ideation and suicide attempts that may have occurred during the psychotic episode that precipitated admission to the EIS were assessed categorically through interviews by a trained and experienced research assistant. Annually for five years, suicidal ideation and attempts within the past year were assessed using the same method. Retrospective chart review was conducted to determine whether suicidal ideation or attempts had been reported. Coroners’ reports were requested for any patient lost to follow-up to ascertain if any fatal suicide attempt had occurred. Suicidal ideation was defined as any passive or active thoughts of suicide. Suicide attempts were defined as deliberate, self-directed, and potentially dangerous behaviours with a clear or ambivalent intent to die therefrom.

Potential vulnerability factors

Along with factors considered by previous trajectory studies (8, 9) (sex, age, occupation, functioning, alcohol use disorder, previous suicide attempts), we included factors that were associated with suicidal thoughts and behaviours in FEP or that had yielded conflicting results in our systematic review (cluster B personality traits; illness severity; cannabis, cocaine and amphetamine use disorder assessed separately; previous suicidal ideation) (3).

Socio-demographic characteristics were collected at admission through patient interviews and chart review. History of suicidal ideation and suicide attempts preceding the psychotic episode that led to entry into EIS was assessed retrospectively through patient interviews and chart review.

At baseline, the best-estimate consensus method(11), involving consensus between two trained psychiatrists (or one psychiatry resident and one psychiatrist) based on all available information, was used to determine the DSM-IV-TR diagnosis of psychotic disorder, presence of Cluster B personality traits, alcohol use disorder diagnosis using the Alcohol Use Scale (12), and cannabis, cocaine or amphetamines use disorder diagnoses using the Drug Use Scale (12); and to score the Social and Occupational Functioning Assessment Scale (13) and the Clinical Global Impression of illness severity (14).

Statistical analyses

Trajectory analyses included persons with no missing data on predictors and with at least three time points with valid data for suicidal ideation.

First, using a semiparametric group-based approach with a SAS-based procedure, PROC TRAJ, individual trajectories for suicidal ideation were identified (15). A binary logit distribution was used to identify distinctive clusters of individual trajectories over five years. To determine the optimal number of groups, one- to four-class models were fitted to the data. Based on clinical utility of the model, the Bayesian information criterion (BIC), and the Akaike information criterion (AIC), the best-fitting model was selected. Lowest BIC and AIC values indicate the best fit. For each trajectory group, the appropriate shape (i.e., linear, quadratic, cubic) was determined based on the same fit estimates.

Second, each person’s most likely trajectory, as determined by the posterior probabilities of membership in each trajectory group generated directly by PROC TRAJ, was extracted and added as a variable to the initial dataset.

Third, we identified factors associated with membership in suicidal ideation trajectories using the Statistical Package for Social Sciences (SPSS, v.27.0.1). We compared trajectory groups on each potential vulnerability factor using chi-square tests or ANOVAs. For significant factors, we performed post hoc analyses with Bonferroni correction to identify which group showed significant difference. To avoid excluding potentially important covariates, we then integrated all factors simultaneously into a multivariate multinomial logistic regression to assess factors associated with trajectory membership. Finally, we compared the frequencies of suicide attempts by trajectory membership using chi-square tests.

Of 567 patients admitted to the two EIS, 382, who had valid data for at least three time points for suicidal ideation and for selected factors, were included in our study (Table S1 shows reasons for missing data). Final sample characteristics are presented in Table 1. The mean age of our sample was 23.53 years; 78.01% were male; 63.52% had a schizophrenia-spectrum disorder; and 26.96% and 8.90% of patients had a history of suicidal ideation and suicide attempts prior to entry, respectively.

Table 1. Baseline characteristics of the study sample and bivariate comparisons by suicidal ideation trajectory membership

	Study sample n=382 (100) n (%) / M (SD)	Trajectory group n (%) / M (SD)			c²	F	p-value	Post hoc^a
	Study sample n=382 (100) n (%) / M (SD)	1. Low decreasing n=325 (85.08)	2. Early decline, then increasing n=30 (7.85)	3. Persistent n=27 (7.07)				1 vs 2	1 vs 3	2 vs 3
Male	298 (78.01)	255 (78.46)	20 (66.67)	23 (85.19)	3.10		.212
Age	23.53 (3.61)	23.64 (2.69)	23.38 (3.10)	22.28 (2.95)		1.79	.168
Working or studying	142 (37.17)	121 (37.23)	14 (46.67)	7 (25.93)	2.62		.270
Cluster B personality traits or disorder	112 (29.32)	95 (29.23)	5 (16.67)	12 (44.44)	5.30		.071
Clinical illness severity-CGI^b	4.86 (0.90)	4.84 (0.90)	5.07 (0.94)	4.85 (0.90)		1.38	.428
Social and Occupational Functioning- SOFAS^c	33.87 (12.68)	34.14 (12.59)	32.17 (14.95)	27 (32.59)		.480	.619
Alcohol use disorder-AUS^d	72 (18.85)	54 (16.62)	7 (23.33)	11 (40.74)	9.91		.007		<.05
Cannabis use disorder-DUS^e	169 (44.24)	145 (44.62)	11 (36.67)	13 (48.15)	.88		.643
Cocaine use disorder-DUS^e	21 (5.50)	17 (5.23)	3 (10.00)	1 (3.70)	1.38		.501
Amphetamine use disorder-DUS^e	50 (13.09)	46 (14.15)	2 (6.67)	2 (7.41)	2.178		.337
History of suicidal thoughts and behaviors					22.30		<.001
Ideation	103 (26.96)	79 (24.31)	12 (40.00)	12 (44.44)
Attempts	34 (8.90)	24 (7.38)	3 (10.00)	7 (25.93)					<.05

^aZ-test and Bonferroni correction for multiple comparisons

^b Clinical Global Impression Scale – illness severity is rated on a scale from 1-7 with 7 indicating the highest level of severity

^c Social and Occupational Functioning Assessment Scale – functioning is rated using a score between 1-100 with 100 indicating excellent functioning

^d Alcohol Use Scale

^e Drug Use Scale

As shown in Table S2, compared with those excluded, included patients were likelier to be unemployed/not studying and have a primary schizophrenia-spectrum disorder diagnosis vs. “other psychoses” and less likely to have a cocaine use disorder at admission.

Seven persons died by suicide during follow-up (see Table S3 for details), five of whom were excluded for having less than three time points with valid suicidal ideation data (n=4) or having missing data on selected factors (n=1). The median time between admission to services and suicide was 11 months.

Suicidal ideation trajectories

Trajectories for suicidal ideation are shown in Fig. 1. The best-fitting model included three different classes. Fit estimates are presented in Table 2. Although the three-class model was associated with slightly higher BIC values than the two-class model, it allowed the detection of the early decline, then increasing suicidal ideation trajectory, which deserves examination for its clinical implications. In contrast, the four-class model only added a trajectory very similar to the low and decreasing one and had higher BIC and AIC values.

Table 2. Fit estimates for one-to-four class solutions of suicidal ideation trajectories

	Fit estimates^a
	BIC (n=2018)	aBIC^b (n=382)	AIC
One class	757.13	753.80	745.91
Two classes	744.10	736.61	718.86
Three classes	752.00	740.64	712.73
Four classes	767.96	752.15	714.67

^aLowest Bayesian information criterion (BIC) and Akaike information criterion (AIC) values indicate the best fit

^b Samples-size-adjusted BIC (aBIC)

The first group, including most patients (n=325, 85.08%), followed a trajectory of low and decreasing probability of presenting suicidal ideation. The second group, (n=30, 7.85%), followed a trajectory of early decline, then increasing suicidal ideation. The probability of presenting suicidal ideation at admission was moderately high for this group (≈30%) followed by an absence of suicidal ideation until the last two years of follow-up, when the probability increased again to ≈45%. The third group (n=27, 7.07%) followed a trajectory of persistent suicidal ideation, wherein the probability of having suicidal ideation at entry into services was moderately high (≈35%) and increased to ≈70% between the first and third year of follow-up and then decreased in the last follow-up year to nearly ≈40%.

Factors associated with trajectory membership

Bivariate analyses

As presented in Table 1, patients in the persistent suicidal ideation trajectory were likelier to have an alcohol use disorder at admission and to have attempted suicide prior to admission than those in the low and decreasing suicidal ideation trajectory.

Multinomial logistic regression

The low and decreasing trajectory group was the reference category. Having a history of suicidal ideation before admission and a baseline cocaine use disorder significantly increased the odds of belonging to the early decline, then increasing suicidal ideation trajectory by 2.85 [95% CI=1.23-6.63] and 6.78 times [95% CI=1.08-42.75], respectively, compared to the low and decreasing group (Table 3). History of suicidal ideation and suicide attempts were the factors most strongly associated with the persistent suicidal ideation compared with the low and decreasing suicidal ideation trajectory. Alcohol use disorder at admission was also associated with belonging to the persistent suicidal ideation trajectory as compared to the low and decreasing suicidal ideation trajectory group.

Table 3. Multinomial logistic regression: factors associated with suicidal ideation trajectory membership

	B	SE	p-value	OR	95% CI
Early decline and increasing suicidal ideation^a
Male	-.712	.453	.116	.491	.202-1.192
Age	-.050	.059	.389	.951	.848-1.066
Working or studying	-.448	.416	.281	1.565	.693-3.533
Cluster B personality traits or disorder	-.892	.553	.107	.410	.139-1.213
Clinical illness severity-CGI^b	.287	.319	.367	1.333	.714-2.489
Social and Occupational Functioning- SOFAS^c	-.004	.023	.858	.996	.952-1.042
Alcohol use disorder-AUS^d	.629	.533	.238	1.876	.660-5.328
Cannabis use disorder-DUS^e	-.170	.478	.722	.844	.330-2.155
Cocaine use disorder-DUS^e	1.914	.939	.042	6.783	1.076-42.753
Amphetamine use disorder-DUS^e	-1.677	1.028	.103	.187	.025-1.402
History of suicidal thoughts and behaviors (reference category= none)
Ideation	1.047	.431	.015	2.849	1.225-6.629
Attempts	.816	.724	.260	2.262	.547-9.349
Persistent suicidal ideation^{a, f}
Male	.196	.624	.753	1.217	.358-4.135
Age	-.109	.065	.096	.897	.789-1.019
Working or studying	-.363	.496	.464	.695	.263-1.840
Cluster B personality traits or disorder	.393	.476	.410	1.481	.582-3.768
Clinical illness severity-CGI^b	-.183	.328	.577	.833	.437-1.585
Social and Occupational Functioning- SOFAS^c	-.009	.024	.706	.991	.944-1.039
Alcohol use disorder-AUS^d	1.289	.487	.008	3.628	1.397-9.424
Cannabis use disorder-DUS^e	-.163	.489	.739	.850	.326-2.218
Cocaine use disorder-DUS^e	.165	1.271	.896	1.180	.098-14.248
Amphetamine use disorder-DUS^e	-1.543	.931	.097	.214	.034-1.326
History of suicidal thoughts and behaviors (reference category= none)
Ideation	1.466	.489	.003	4.332	1.662-11.292
Attempts	2.102	.627	<.001	8.181	2.393-27.973

^aReference category = Low and decreasing suicidal ideation trajectory

^bClinical Global Impression Scale – illness severity is rated on a scale from 1-7 with 7 indicating the highest level of severity

^cSocial and Occupational Functioning Assessment Scale – functioning is rated using a score between 1-100 with 100 indicating excellent functioning

^dAlcohol Use Scale

^eDrug Use Scale

^fThe reference category was changed to compare persons in the early decline, then increasing suicidal ideation trajectory and those in the persistent suicidal ideation trajectory. Except for a tendency that indicates that patients with Cluster B personality traits or disorder were more likely to be in the persistent suicidal ideation trajectory compared to the early decline, then increasing one (OR=3.613 [95% CI=0.927-14.079], p=0.064), no significant differences were detected between these trajectory groups.

The reference category was changed to compare the early decline, then increasing trajectory and the persistent suicidal ideation trajectory groups. No significant differences were identified, although there was a tendency for persons with Cluster B personality traits being likelier to belong to the persistent suicidal ideation trajectory than the early decline, then increasing one (OR=3.613 [95% CI=0.927-14.079], p=0.064).

Frequency of suicide attempts by trajectory membership

Of the 382 included patients, 25 (6.54%) attempted suicide at least once during follow-up, including six (1.57%) who reported at least one suicide attempt in the past year during two of the five yearly assessments, and one person (0.26%) at three assessments.

Except for the fourth year of follow-up, in which no patient attempted suicide, the frequency of suicide attempts differed significantly by trajectory membership in all years of follow-up (Table 4). At admission and for the following three years, a greater proportion of persons attempted suicide in the persistent suicidal ideation trajectory group than those on the other two trajectories.

Table 4. Distribution of suicidal ideation and suicide attempts for each year of follow-up by trajectory membership

Time point	Total sample n=382 (100)	Trajectory group			X²	p-value
Time point	Total sample n=382 (100)	1. Low decreasing n=325 (85.08)	2. Early decline, then increasing n=30 (7.85)	3. Persistent n=27 (7.07)	X²	p-value
Suicidal ideation
Admission	57 (15.24)	39 (12.26)	8 (26.67)	10 (34.86)	16.07	<.001
Year 1	60 (16.30)	42 (13.42)	0 (0)	18 (72.00)	64.58	<.001
Year 2	43 (12.01)	23 (7.54)	0 (0)	20 (83.33)	125.24	<.001
Year 3	36 (10.65)	18 (6.25)	0 (0)	18 (81.82)	126.29	<.001
Year 4	32 (10.19)	0 (0)	22 (75.86)	10 (52.63)	204.23	<.001
Year 5	19 (7.17)	0 (0)	13 (48.15)	6 (37.50)	107.38	<.001
Suicide attempts
Admission	5 (1.32)	1 (0.31)	1 (3.33)	3 (11.54)	24.25	<.001
Year 1	6 (1.63)	2 (0.64)	0 (0)	4 (16.00)	34.60	<.001
Year 2	15 (4.18)	6 (1.96)	0 (0)	9 (37.50)^a	71.58	<.001
Year 3	4 (1.18)	1 (0.35)	0 (0)	3 (14.29)^a	32.90	<.001
Year 4	0 (0)	0 (0)	0 (0)	0 (0)	-	-
Year 5	3 (1.13)	0 (0)	2 (7.41)	1 (6.25)	15.79	<.001

^bOne patient died as a result of their suicide attempt

Towards the end of follow-up, while no patients on the low and decreasing suicidal ideation trajectory attempted suicide, 7.41% and 6.25% of patients on the early decline, then increasing suicidal ideation and the persistent suicidal ideation trajectories, respectively, reported suicide attempts. Two patients died by suicide at two and three years of follow-up, both of whom were in the persistent suicidal ideation trajectory.

Our study identified three distinct trajectories of suicidal ideation over a five-year follow-up of FEP patients ― low and decreasing (85.08%); early decline, then increasing (7.85%); and persistent suicidal ideation (7.07%). While most patients experienced a decrease in suicidal ideation during follow-up, some showed persistent and increasing suicidal ideation.

Our findings are consistent with two other studies (8, 9) of trajectories of suicidal ideation in FEP, both of which identified a trajectory including most patients that is characterized by no or low and decreasing suicidal ideation; another characterized by the persistence of suicidal ideation; and a third with increasing suicidal ideation. In our study, however, increase in the third trajectory was preceded by an early decline in suicidal ideation.

Notably, increasing suicidal ideation has been observed in a subgroup of FEP patients by all three trajectory studies (including ours), regardless of the duration of follow-up. Transitions and lack of continuity in care can be risk factors for suicide (16). Feeling dependent on and not ready to be discharged from EIS could lead to distress (17). We therefore hypothesize that the end of follow-up or the transition from EIS to other services may be difficult for some patients, resulting in an increase in suicidal ideation. The initial decline in suicidal ideation in the early decline, then increasing trajectory group may be explained by patients feeling supported when treatment commences. This feeling may dissipate by the end of follow-up, possibly contributing to suicidal ideation.

Factors associated with the trajectory of increasing suicidal ideation differ between FEP studies. Whereas women (8), older patients, those with longer DUPs, and reduced sleep (9) were likelier to have trajectories of increased suicidal ideation in other studies, we found that persons with prior suicidal ideation and cocaine use disorder at admission were at greater risk for following such trajectories. Except for sex and age, which were assessed by all three studies (Danish, Spanish and ours), no factors were assessed by even two studies, making it impossible to examine whether results diverge or converge. Nevertheless, these factors (i.e., longer DUP, reduced sleep, prior suicidal ideation, cocaine use disorder) have all been associated with poorer symptomatic and functional outcomes in psychosis (18-20). Thus, the increase in suicidal ideation in the early decline, then increasing suicidal ideation trajectory group seems associated with less favourable evolution and possibly less treatment responsiveness.

Substance use disorder has often been studied in association with suicidal thoughts and behaviours in FEP by combining multiple substances (3), making it difficult to compare with our finding that cocaine use disorder is associated with the early decline, then increasing suicidal ideation trajectory. However, a Spanish study found that stimulant abuse, including cocaine and amphetamines, increased risk of suicidal behaviours in FEP (21).

We found that alcohol use disorder was associated with the persistent suicidal ideation trajectory. Studies on the association between alcohol use disorder and suicidal risk in FEP have yielded inconsistent results (3). Alcohol use may not have emerged as a risk factor when considering only the group average and may be pertinent only for FEP patient subgroups with less favourable suicidal courses. Furthermore, the longitudinal association between substance use disorder, including alcohol, and suicidal risk from adolescence to young adulthood is likely bidirectional (22). Alcohol use disorder at admission may increase the risk of suicidal ideation, which in turn increases alcohol use, explaining its observed association with the persistent suicidal ideation trajectory.

Consistent with the Danish study (8), we found that patients with suicidal ideation and suicide attempts before entering services were at higher risk of following the persistent suicidal ideation trajectory. Although personality disorders, particularly borderline personality disorder, have been associated with increased risk of suicidal behaviours (23), this association has rarely been studied in FEP (3). Aligned with our study, one previous study reported that comorbid borderline personality disorder was associated with increased risk of suicidal behaviours in FEP (24).

A greater proportion of persons on the persistent suicidal ideation trajectory attempted suicide during the five-year follow-up, and both persons who died by suicide after one year of follow-up were on the persistent suicidal ideation trajectory. Concomitant with the increase in suicidal ideation, there was an increase in suicide attempts in the early decline, then increasing suicidal ideation trajectory group, although the frequency was small (n=2). These results are nevertheless consistent with literature showing that, as in the general population, suicidal ideation is a risk factor for suicide attempts in FEP patients (3, 8, 25).

Despite the decrease in suicidal ideation for most patients, some presented persistent and increasing suicidal ideation, stressing the need for the ongoing assessment and management of suicide risk in FEP. Our results suggest that patients with a history of suicidal thoughts and behaviours and persistent suicidal ideation may require attention throughout follow-up. They highlight the importance of interventions that target suicidal ideation for this population. Although the evidence for and implementation of such interventions remain limited, suicide-focused psychosocial interventions were associated with decreased suicidal thoughts and behaviours in FEP in a meta-analysis (26). A recent Italian study showed that decrease in suicidal ideation in FEP was predicted by the number of psychotherapy sessions received (27). Persons with cocaine and alcohol use disorder at admission should be targeted early and assessed frequently for suicidal risk. As outlined in EIS guidelines, treatment for these co-morbid disorders should be integrated into services (10). For the patient subgroup at risk for developing suicidal ideation at the end of follow-up, it is essential to provide individualized support and even shared care during transitions from EIS to other services.

This is the first study to identify suicidality trajectories throughout the five-year post-onset critical period in FEP. Considering individual variability allowed us to identify different evolution patterns, which would not have been possible by looking only at group averages. Ours is also the first study to examine whether suicidal ideation trajectories were differentially associated with suicide attempts during follow-up, which EIS seek to prevent. We included a range of potential factors, guided by our systematic review and prior studies.

Our results must be weighed against certain limitations. We excluded persons with less than three time points of valid suicidal ideation data or missing data on potentially associated factors. Included patients were generally similar to those excluded due to missing data. Nonetheless, included patients were likelier to be unemployed/not studying and to have a schizophrenia-spectrum diagnosis, aspects associated with poorer long-term outcomes (28, 29). This potentially suggests an overrepresentation of persons with less favourable outcomes. Included patients were also less likely to have a cocaine use disorder, which was associated with the early decline, then increasing suicidal ideation trajectory. A stronger association may have been observed had more of these patients been included. Also, excluding five of the seven patients who died by suicide resulted in the exclusion of individuals with severe suicidal risk. Nevertheless, our study is fairly representative of suicidal risk in FEP as our sample was drawn from all treated FEP cases in two catchment areas.

Two trajectories included only 7% of participants, which may have limited our power to identify predictors, although the identified predictors had moderate to large effect sizes. The fortunately low number of suicide attempts made it impossible to identify trajectories of suicide attempts or factors associated therewith. However, we went beyond describing trajectories of suicide attempts by comparing the distribution of attempts across the three suicidal ideation trajectories and showing that more patients with persistent suicidal ideation attempted suicide.

We included factors measured at admission, although some of these would have evolved during follow-up (e.g., symptoms). Some important risk factors, like depressive symptoms, impulsivity, and DUP, were not considered either because data were not collected or because there was too much missing data. Relying on annual, binary (yes/no) assessments, our measure of suicidal ideation and attempts did not account for frequency or severity.

To address these limitations, further longitudinal studies should assess most variables at all time points in larger samples and consider time-varying and proximal risk factors for suicidal ideation and suicide attempts. Repeated assessments with a scale assessing suicidal thoughts and behaviours could provide more accurately portray suicidal risk. Future studies should also examine whether different trajectories are associated with subsequent deaths by suicide and whether interventions targeting modifiable factors reduce suicidal risk. Qualitative studies could unpack what underlies persistent or increasing suicidal ideation and suicide attempts and how care transitions may contribute to increases in them.

Our study extends previous trajectory studies of suicidal ideation to a longer period of five years. Our findings underscore the importance of closely monitoring FEP patients who persistently report suicidal ideation, as they are likelier to engage in suicidal behaviours; and of paying attention to the end of follow-up and times of transition to other services, which may represent a greater risk period for some. Further research is needed to better characterize who belongs in each group and develop and study group-specific prevention strategies.

1. Hjorthøj C, Stürup AE, McGrath JJ, Nordentoft M. Years of potential life lost and life expectancy in schizophrenia: A systematic review and meta-analysis. The Lancet Psychiatry. 2017;4(4):295-301.

2. Yuen K, Harrigan SM, Mackinnon AJ, Harris MG, Yuen HP, Henry LP, et al. Long-term follow-up of all-cause and unnatural death in young people with first-episode psychosis. Schizophr Res. 2014;159(1):70-5.

3. Sicotte R, Iyer SN, Kiepura B, Abdel-Baki A. A systematic review of longitudinal studies of suicidal thoughts and behaviors in first-episode psychosis: course and associated factors. Soc Psychiatry Psychiatr Epidemiol. 2021.

4. Turecki G, Brent DA. Suicide and suicidal behaviour. The Lancet. 2016;387(10024):1227-39.

5. Chang WC, Chen ES, Hui CL, Chan SK, Lee EH, Chen EY. Prevalence and risk factors for suicidal behavior in young people presenting with first-episode psychosis in Hong Kong: a 3-year follow-up study. Social psychiatry and psychiatric epidemiology. 2015;50(2):219-26.

6. Clarke M, Whitty P, Browne S, Mc Tigue O, Kinsella A, Waddington JL, et al. Suicidality in first episode psychosis. Schizophr Res. 2006;86(1-3):221-5.

7. Robinson J, Harris MG, Harrigan SM, Henry LP, Farrelly S, Prosser A, et al. Suicide attempt in first-episode psychosis: a 7.4 year follow-up study. Schizophr Res. 2010;116(1):1-8.

8. Madsen T, Karstoft KI, Secher RG, Austin SF, Nordentoft M. Trajectories of suicidal ideation in patients with first-episode psychosis: secondary analysis of data from the OPUS trial. Lancet Psychiatry. 2016;3(5):443-50.

9. Salagre E, Grande I, Jimenez E, Mezquida G, Cuesta MJ, Llorente C, et al. Trajectories of suicidal ideation after first-episode psychosis: a growth mixture modeling approach. Acta Psychiatr Scand. 2021;143(5):418-33.

10. Early Psychosis Guidelines Writing Group and EPPIC National Support Program. Australian Clinical Guidelines for Early Psychosis. Melbourne: Orygen, The National Centre of Excellence in Youth Mental Health; 2016.

11. Roy MA, Lanctôt G, Mérette C, Cliche D, Fournier J-P, Boutin P, et al. Clinical and methodological factors related to reliability of the best-estimate diagnostic procedure. Am J Psychiatry. 1997;154(12).

12. Drake R, Mueser K, McHugo G. Clinician Rating Scales: Alcohol Use Scale (AUS), Drug Use Scale (DUS), and Substance Abuse Treatment Scale (SATS). . In: Sedered L, Dickey B, editors. Outcomes Assessment in Clinical Practice. Baltimore: Williams & Wilkins; 1996. p. 301.

13. Goldman HH, Skodol AE, Lave TR. Revising axis V for DSM-IV: a review of measures of social functioning. Am J Psychiatry. 1992;149(9):1148-56.

14. Padhi A, Fineberg N. Clinical global impression scales. Encyclopedia of Psychopharmacology Heidelberg: Springer Berlin. 2010;303.

15. Nagin DS. Analyzing developmental trajectories: A semiparametric, group-based approach. Psychological Methods. 1999;4(2):139-57.

16. Chaudhary AMD, Memon RI, Dar SK, Bhullar DK, Dar KR, Naveed S. Suicide during Transition of Care: a Review of Targeted Interventions. Psychiatric Quarterly. 2020;91(2):417-50.

17. Loughlin M, Berry K, Brooks J, Bucci S. Moving on from early intervention for psychosis services: Service user perspectives on the facilitators and barriers of transition. Early Interv Psychiatry. 2019;13(6):1396-403.

18. Subramaniam M, Abdin E, Shahwan S, Satghare P, Vaingankar JA, Rama Sendren J, et al. Prevalence, correlates and outcomes of insomnia in patients with first episode psychosis from a tertiary psychiatric institution in Singapore. General Hospital Psychiatry. 2018;51:15-21.

19. Santesteban-Echarri O, Paino M, Rice S, González-Blanch C, McGorry P, Gleeson J, et al. Predictors of functional recovery in first-episode psychosis: A systematic review and meta-analysis of longitudinal studies. Clinical Psychology Review. 2017;58:59-75.

20. Hui CLM, Honer WG, Lee EHM, Chang WC, Chan SKW, Chen ESM, et al. Predicting first-episode psychosis patients who will never relapse over 10 years. Psychol Med. 2019;49(13):2206-14.

21. Gonzalez-Pinto A, Aldama A, Gonzalez C, Mosquera F, Arrasate M, Vieta E. Predictors of suicide in first-episode affective and nonaffective psychotic inpatients: five-year follow-up of patients from a catchment area in Vitoria, Spain. J Clin Psychiatry. 2007;68(2):242-7.

22. Rioux C, Huet A-S, Castellanos-Ryan N, Fortier L, Le Blanc M, Hamaoui S, et al. Substance use disorders and suicidality in youth: A systematic review and meta-analysis with a focus on the direction of the association. PLOS ONE. 2021;16(8):e0255799.

23. Goodman M, Tomas IA, Temes CM, Fitzmaurice GM, Aguirre BA, Zanarini MC. Suicide attempts and self-injurious behaviours in adolescent and adult patients with borderline personality disorder. Personality and Mental Health. 2017;11(3):157-63.

24. Fedyszyn IE, Robinson J, Harris MG, Paxton SJ, Francey S. Predictors of suicide-related behaviors during treatment following a first episode of psychosis: the contribution of baseline, past, and recent factors. Schizophr Res. 2012;140(1-3):17-24.

25. Challis S, Nielssen O, Harris A, Large M. Systematic meta-analysis of the risk factors for deliberate self-harm before and after treatment for first-episode psychosis. Acta Psychiatr Scand. 2013;127(6):442-54.

26. Bornheimer LA, Zhang A, Li J, Hiller M, Tarrier N. Effectiveness of Suicide-Focused Psychosocial Interventions in Psychosis: A Systematic Review and Meta-Analysis. Psychiatr Serv. 2020;71(8):829-38.

27. Pelizza L, Maestri D, Leuci E, Quattrone E, Azzali S, Paulillo G, et al. Individual psychotherapy can reduce suicidal ideation in first episode psychosis: Further findings from the 2-year follow-up of the 'Parma Early Psychosis' programme. Clin Psychol Psychother. 2021.

28. Rubio JM, Schoretsanitis G, John M, Tiihonen J, Taipale H, Guinart D, et al. Psychosis relapse during treatment with long-acting injectable antipsychotics in individuals with schizophrenia-spectrum disorders: an individual participant data meta-analysis. Lancet Psychiatry. 2020;7(9):749-61.

29. Tandberg M, Ueland T, Andreassen OA, Sundet K, Melle I. Factors associated with occupational and academic status in patients with first-episode psychosis with a particular focus on neurocognition. Soc Psychiatry Psychiatr Epidemiol. 2012;47(11):1763-73.

S1fileTrajectoriesSIFEP.docx
Table S1. Reasons for exclusion
S2fileTrajectoriesSIFEP.docx
Table S2. Comparison of study sample and patients excluded because of missing data on suicidal ideation and potential vulnerability factors
S3fileTrajectoriesSIFEP.docx
Table S3. Characteristics of persons who died by suicide during follow-up

Download PDF

Journal Publication

published 17 Apr, 2023

Read the published version in The Canadian Journal of Psychiatry →

Version 2

posted

You are reading this latest preprint version

Heterogeneity in the course of suicidal ideation and its relation to suicide attempts in first-episode psychosis: a five-year prospective study

Status:

Journal Publication

Version 2

Abstract

Introduction

Methods

Results

Conclusion

Figures

Introduction

Materials And Methods

Results

Discussion

Implications

Strength and Limitations

Conclusion

References

Supplementary Files

Status:

Journal Publication

Version 2