Suicide risk in young people at Ultra-High Risk (UHR) of psychosis: Findings from a 2-year longitudinal study
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)
- et al.
Suicidality in the prodromal phase of schizophrenia
Compr. Psychiatry
(2011) - et al.
Outreach and support in south London (OASIS), 2001–2011: ten years of early diagnosis and treatment for young individuals at clinical risk for psychosis
Eur. Psychiatry.
(2013) - et al.
Assessing suicidal ideation in individuals at clinical high risk for psychosis
Schizophr. Res.
(2015) - et al.
Suicide risk in first episode psychosis: a selective review of the current literature
Schizophr. Res.
(2011) - et al.
Risk of suicide and suicidal ideation in psychosis: results from an Italian multi-modal pilot program on early intervention in psychosis
Schizophr. Res.
(2009) - et al.
The comprehensive assessment of at-risk mental states: from mapping the onset to mapping the structure
Schizophr. Res.
(2011) - et al.
Duration of untreated illness and brain volume changes in early psychosis
Psychiatry Res.
(2017) - et al.
EPA guidance on the early intervention in clinical high risk states of psychoses
Eur. Psychiatry.
(2015) - et al.
Suicidal behaviour in early psychosis
Acta Psychiatr. Scand.
(2004) Diagnostic and Statistical Manual of Mental Disorders, IV Edition, Text Revised (DSM-IV-TR)
(2000)
Suicidal ideation in individuals at ultra-high risk for psychosis and its association with suspiciousness independent of depression
Early Interv. Psychiatry.
Manual for the Beck Scale for Suicidal Ideation
BDI-II: Beck Depression Inventory-II
A Review of Suicide Assessment Measures for Intervention Research With Adults and Older Adults
Risk factor for suicidality in patients with schizophrenia: a systematic review, meta-analysis, and meta-regression of 96 studies
Schizophr. Bull.
Systematic meta-analysis of the risk factors of deliberate self-harm before and after treatment for first-episode psychosis
Acta Psychiatr. Scand.
Quality of life assessment: validation of the Italian version of the WHOQOL-brief
Epidemiol. Psychiatr. Sci.
Disorganization/cognitive and negative symptom dimensions in the at-risk mental state predict subsequent transition to psychosis
Schizophr. Bull.
Cognitive Behavior Therapy for Psychosis
The psychosis high-risk state: a comprehensive state of the art review
JAMA Psychiatry
Comorbid depressive and anxiety disorders in 509 individuals with an at-risk mental state: impact on psychopathology and transition to psychosis
Schizophr. Bull.
A simple sequentially rejective multiple test procedure
Scand. J. Stat.
Prevalence of suicide risk factors in people at ultra-high risk of developing psychosis: a service audit
Early Interv. Psychiatry.
Cited by (26)
Anxious-depressive symptoms after a first episode of schizophrenia: Response to treatment and psychopathological considerations from the 2-year “Parma Early Psychosis” program
2022, Psychiatry ResearchCitation Excerpt :In this respect, meta-analytic results on depressive psychopathology in FES reported a 26% pooled prevalence of depressive disorder diagnosis (Herniman et al., 2019). Depressive symptoms in FES patients may occur in the prodromal stage, during the acute phase of the disorder, or follow the course of positive symptoms in the post-acute period (Pelizza et al., 2020a), significantly contributing to the heavy burden of the disease. Indeed, depressive psychopathology in FES was correlated to low remission rate, increased risk for psychotic relapse, poor functioning and quality of life, longer and more common hospitalization, suicide and self-harm (Conley et al., 2007; Upthegrove et al., 2010; Gardsjord et al., 2016; Chen et al., 2021).
Examining subjective experience of aberrant salience in young individuals at ultra-high risk (UHR) of psychosis: A 1-year longitudinal study
2022, Schizophrenia ResearchCitation Excerpt :Its 21 items (referred to the preceding two weeks) were commonly summed to calculate the BDI-II total score. This questionnaire had good psychometric properties in Italian clinical populations at the psychosis onset (Pelizza et al., 2020c). Finally, the PQ-B (Loewy et al., 2011) is a brief self-report instrument to quickly screen young people for the risk of psychosis.
Demographic and clinical correlates of suicidal ideation in individuals with at-risk mental state (ARMS): A study from Pakistan
2024, Early Intervention in Psychiatry