Elsevier

Schizophrenia Research

Volume 220, June 2020, Pages 98-105
Schizophrenia Research

Suicide risk in young people at Ultra-High Risk (UHR) of psychosis: Findings from a 2-year longitudinal study

https://doi.org/10.1016/j.schres.2020.03.051Get rights and content

Abstract

Background

Suicide risk is high in first episode schizophrenia. Little data are available in young individuals at Ultra-High Risk (UHR) of psychosis. Purposes of the study were: (1) to assess prevalence and incidence rates of suicide attempts, suicidal ideation, and completed suicide in UHR individuals compared with First Episode Psychosis (FEP) and non-FEP/UHR help-seeking peers at baseline and over a 24-month follow-up time, and (2) to explore any association of suicidal ideation with other psychopathological parameters at baseline.

Methods

273 young people (13–35 years) were evaluated with the Comprehensive Assessment of At-Risk Mental States (CAARMS), the Beck Depression Inventory – II Edition (BDI), and the World Health Organization Quality Of Life scale – Brief version (WHOQOL-BREF). The BDI item 9 cut-off score of ≥1 dichotomized the presence/absence of suicidal ideation.

Results

UHR individuals showed more severe suicidal ideation and a higher percentage of individuals with a history of attempted suicide than FEP and non-UHR/FEP samples, and a higher 2-year incidence rate of suicide attempts than non-UHR/FEP subjects. No inter-group differences in incidence rates of completed suicide were found. In the UHR group, suicidal ideation was associated with BDI-II and CAARMS “Anhedonia” scores, and showed a negative correlation with all WHOQOL-BREF scores.

Conclusions

Suicidal ideation is frequent in UHR subjects, supporting the routine monitoring of suicide risk in people at risk of psychosis. Suicide risk is correlated with severity of depression and anhedonia, and with a poorer quality of life.

Introduction

In the last two decades, there has been an increasing clinical interest on early intervention in young people at Ultra-High Risk (UHR) of psychosis (Fusar-Poli et al., 2013a). In the context of the clinical staging model of psychotic disorders, McGorry et al. (2006) developed specific criteria to identify three different subgroups of UHR mental states: (a) Genetic Risk and Functioning Deterioration Syndrome (GRFD), a trait/state risk condition in which the individual has a family history of psychosis (in first-degree relatives) or manifests schizotypal personality disorder along with low functioning maintained for ≤1 month; (b) Brief Limited Intermittent Psychotic Symptoms (BLIPS), i.e. transient positive symptoms that spontaneously disappear within 1 week; and (c) Attenuated Psychotic Symptoms (APS), i.e. sub-threshold positive symptoms (Yung et al., 2005).

Assessing suicidal ideation in this clinical sample is important because suicide risk has been shown to be high at the onset of a First Episode Psychosis (FEP) (Pompili et al., 2011; Cassidy et al., 2018). Indeed, about 5% of new onset or first admission patients with schizophrenia die committing suicide (Palmer et al., 2005). Moreover, 2–11% of schizophrenic patients make a suicide attempt in the first year of intervention (Addington et al., 2004). Thus, the early detection of FEP and UHR mental states, aimed even only at encouraging adherence to therapy, may also reduce suicide risk (Preti et al., 2009).

A meaningful meta-analysis showed a high prevalence of suicidal ideation in UHR subjects (specifically, a recent [2-week] prevalence of 66.08% and a lifetime prevalence of 48.61%), comparable to FEP patients (Taylor et al., 2015). Moreover, in the same study, the meta-analysis of lifetime suicide attempts in UHR people indicated a prevalence of 11.64%. Only two researches prospectively examined suicide attempts in UHR population, showing prevalence rates of 5.26% over 1 year and 3.70% over 2 years of follow-up (Preti et al., 2009; Welsh and Tiffin, 2014). Little available data concerned completed suicide in UHR subjects. In this regards, four UHR individuals died by suicide (n = 4/320; 1.25%) during a follow-up period ranging from 2 to 15 years (Nelson et al., 2013) and a further completed suicide (n = 1/182; 0.55%) was reported in a 1-year of follow-up in a European study (Velthorst et al., 2010).

Overall, these findings support the idea that UHR subjects are not only at risk of psychosis, but also that they need attention for their concomitant high risk of suicide (Pelizza et al., 2019a). However, although focus on transition risk to psychosis in UHR people has been appropriately placed, nowadays there is no exhaustive picture regarding their risk of suicide (Taylor et al., 2015). Adequately recognizing the real dimension size of the problem concerning suicide risk in this young population (even compared to FEP patients) is crucial because an heightened risk of suicide might be more urgent than the psychosis risk at first psychiatric contact (Hutton et al., 2011; Bang et al., 2019).

Considering this background, purpose of the present study was four-fold:

  • 1)

    to assess baseline prevalence of suicide attempts and suicidal ideation in adolescents and young people at UHR of psychosis compared with FEP patients and non-UHR help-seekers;

  • 2)

    to evaluate and compare cumulative incidence rates of attempted and completed suicide among the three subgroups after 12- and 24-month follow-up periods;

  • 3)

    to monitor the longitudinal stability of suicidal ideation after 12- and 24-months of follow-up in the UHR subgroup;

  • 4)

    to explore any relevant association of suicidal ideation with quality of life, functioning, sociodemographic and psychopathological parameters within the total UHR group.

Overall, we assumed that UHR participants would show high levels of suicidal thinking and behaviors both at baseline and during the 2 years of follow-up, at least comparable to FEP patients. Moreover, we speculated significant associations of baseline suicidal ideation with functioning, quality of life and specific psychopathological features (in particular, depression, positive and negative symptoms).

Section snippets

Participants

Participants (n = 273) were help-seeking young adults and adolescents, aged 13–35 years, recruited through the “Reggio Emilia At-Risk Mental States” (ReARMS) project from September 2012 to October 2017. The ReARMS project (Raballo et al., 2014) is an early intervention infrastructure implemented under the aegis of the “Regional Project on Early Intervention in Psychosis” in all of adult and child/adolescent mental health services of the Reggio Emilia Department of Mental Health, in the northern

Results

During the course of this study, 273 participants (mean age = 21.24 ± 5.85 years; 117 females and 156 males) consecutively entered the ReARMS protocol. Mean ratings of the Duration of Untreated Illness (DUI, defined as the time interval [in weeks] between the onset of a relevant psychiatric symptom and the initiation of the first psychological/pharmacological therapy) (Rapp et al., 2017) and socio-demographic variables of the three groups (i.e. UHR−, UHR+, and FEP) are reported in Table 1.

Discussion

The first aim of the current research was to examine suicidal profile in UHR young individuals compared with FEP patients and non-UHR help-seeking peers. Overall, our findings suggest that suicidal ideation is highly frequent in the UHR+ group at baseline assessment. Indeed, 60% of our UHR+ participants showed at least mild, recent (2-week) suicidal thinking (as measured on BDI-II item 9) at point of entry to the ReARMS protocol. This percentage is in line with recently reported (66.08%) in a

Conclusions

Our results suggest a relevant prevalence of suicidal ideation in the UHR population and indicate the routine monitoring of risk of suicidal thinking and behavior by professionals working with UHR individuals. Moreover, it is crucial in clinical practice to offer more targeted treatment strategies for suicide prevention in this at-risk population (e.g. CBT and/or family psychoeducation modules centered around safety planning, self-reflection, identification of thoughts and feelings, strengths

Funding sources

This research received no specific grant from funding agencies in the public, commercial or not-for-profit sectors. ReARMS project is partly financed through a special regional fund: “Progetto Esordi Psicotici della Regione Emilia Romagna”.

Contributors

Authors LP, MiP, and AR designed the study and wrote the protocol. Authors LP and SP managed the literature searches and analyses. Authors LP, SA, FP, SG, IS, and LRC collected data. Authors LP, MiP, and AR undertook the statistical analysis. Authors LP, MiP, MaP, and AR wrote the first draft of the manuscript. All authors contributed to and have approved the final manuscript.

Declaration of competing interest

None.

Acknowledgements

Our warmest thank to all the participants.

Ethical standards

The authors assert that all procedures contributing to this work comply with the ethical standards of the relevant national and institutional committees on human experimentation and with the Helsinki Declaration of 1975, as revised in 2008.

References (46)

  • M. Bang et al.

    Suicidal ideation in individuals at ultra-high risk for psychosis and its association with suspiciousness independent of depression

    Early Interv. Psychiatry.

    (2019)
  • A.T. Beck et al.

    Manual for the Beck Scale for Suicidal Ideation

    (1991)
  • A.T. Beck et al.

    BDI-II: Beck Depression Inventory-II

    (2006)
  • G.K. Brown

    A Review of Suicide Assessment Measures for Intervention Research With Adults and Older Adults

    (2000)
  • R.M. Cassidy et al.

    Risk factor for suicidality in patients with schizophrenia: a systematic review, meta-analysis, and meta-regression of 96 studies

    Schizophr. Bull.

    (2018)
  • S. Challis et al.

    Systematic meta-analysis of the risk factors of deliberate self-harm before and after treatment for first-episode psychosis

    Acta Psychiatr. Scand.

    (2013)
  • G. De Girolamo et al.

    Quality of life assessment: validation of the Italian version of the WHOQOL-brief

    Epidemiol. Psychiatr. Sci.

    (2000)
  • A. Demjaha et al.

    Disorganization/cognitive and negative symptom dimensions in the at-risk mental state predict subsequent transition to psychosis

    Schizophr. Bull.

    (2012)
  • D. Fowler et al.

    Cognitive Behavior Therapy for Psychosis

    (1995)
  • P. Fusar-Poli et al.

    The psychosis high-risk state: a comprehensive state of the art review

    JAMA Psychiatry

    (2013)
  • P. Fusar-Poli et al.

    Comorbid depressive and anxiety disorders in 509 individuals with an at-risk mental state: impact on psychopathology and transition to psychosis

    Schizophr. Bull.

    (2014)
  • S. Holm

    A simple sequentially rejective multiple test procedure

    Scand. J. Stat.

    (1979)
  • P. Hutton et al.

    Prevalence of suicide risk factors in people at ultra-high risk of developing psychosis: a service audit

    Early Interv. Psychiatry.

    (2011)
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