REVIEW ARTICLE
Suicidal Behavior and Mortality in First-Episode Psychosis Merete Nordentoft, DrMSc,*†‡ Trine Madsen, PhD,‡ and Izabela Fedyszyn, PhD‡ Abstract: Suicide is a serious public health problem, with more than 800,000 deaths taking place worldwide each year. Mental disorders are associated with increased risk of suicide. In schizophrenia and other psychotic disorders, the lifetime risk of suicide death is estimated to be 5.6%. The risk is particularly high during the first year of the initial contact with mental health services, being almost twice as high as in the later course of the illness. The most consistently reported risk factor for suicide among people with psychotic disorders is a history of attempted suicide and depression. Suicide risk in psychosis in Denmark decreased over time, most likely because of improved quality of inpatient and outpatient services. There is a high proportion of young people with first-episode psychosis who attempted suicide before their first contact with mental health services. This finding suggests that the mortality rates associated with psychotic disorders may be underreported because of suicide deaths taking place before first treatment contact. However, currently, no data exist to confirm or refute this hypothesis. Attempted suicide can be an early warning sign of later psychotic disorder. Data from different studies indicate that the risk of suicide attempt during the first year of treatment is as high as 10%. The most important risk factors for attempted suicide after the first contact are young age, female sex, suicidal plans, and a history of suicide attempt. Early intervention services are helpful in first-episode psychosis, and staff members should, in collaboration with the patients, monitor the risk of suicide and develop and revise crisis plans. Key Words: Suicide, risk factors, first episode psychosis, schizophrenia (J Nerv Ment Dis 2015;203: 387–392)
that all countries develop and implement comprehensive national strategies for the prevention of suicide, with special attention given to groups who have been identified at increased risk of suicide (Target 74). A global target was set to reduce the rate of suicide in all countries by 10% before the year 2020 (global target 3.2). After the Mental Health Action Plan was introduced in 2013, a specific action plan was launched for suicide prevention, called “Preventing Suicide—A Global Imperative.” The latter also recommends a greater focus on suicide among individuals with mental illness, especially in the early phases of the disorders (World Health Organization, 2014). People with mental disorders are a large risk group (Pedersen et al., 2014) for suicide, and they have the highest relative risk for suicide. Translated into population attributable risk, it has been estimated that if suicide mortality among individuals with mental disorders were reduced to the level found in the general population, the overall suicide risk could be reduced by almost 50% (Mortensen et al., 2000). The risk of suicide appears to be particularly elevated in schizophrenia and other psychotic disorders, with numerous studies demonstrating up to 20-fold increase in relative risk for suicide in this diagnostic group compared with the general population (Dutta et al., 2010; Harris and Barraclough, 1997; Mortensen et al., 2000; Qin and Nordentoft, 2005). The aim of this paper is to describe the risk of suicide and attempted suicide in schizophrenia and related disorders with special focus on early phases of the illness. Moreover, risk factors will be identified, and preventive measures will be reviewed.
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Suicide Risk in Schizophrenia and Related Disorders
*Institute of Clinical Medicine, Faculty of Health Sciences, University of Copenhagen; †iPSYCH—The Lundbeck Foundation Initiative for Psychiatric Research; and ‡Mental Health Services in the Capital Region of Denmark, Mental Health Center Copenhagen, Denmark. Send reprint requests to Merete Nordentoft, DrMSc, Mental Health Center Copenhagen, Mental Health Services in the Capital Region of Denmark, Bispebjerg Bakke 23, 2400 Copenhagen, Denmark. E-mail: [email protected]. Copyright © 2015 Wolters Kluwer Health, Inc. All rights reserved. ISSN: 0022-3018/15/20305–0387 DOI: 10.1097/NMD.0000000000000296
The absolute risk of dying by suicide is often referred to as the lifetime risk of suicide after an onset of a mental disorder. Although to date no study has actually conducted a lifetime follow-up, the lifetime risk is often mentioned in scientific papers, as it can be estimated in terms of the percentage of a cohort expected to die by suicide before all members of the cohort have died, emigrated, or have been lost to follow-up. Among the most widely cited publications is a review by Miles (1977), estimating that 10% of individuals with schizophrenia would die by suicide. However, the review was based on relatively small studies of selected samples with short follow-ups. Subsequent metaanalyses, which used sophisticated statistical methods and included large long-term follow-up studies, found lower figures (Inskip et al. 1998; Palmer et al. 2005). Specifically, the lifetime suicide risk in schizophrenia was estimated to be 5.6%. In a long-term follow-up study of a large cohort of individuals with FEP (n = 2132), the absolute risk of suicide was 3.23% for patients 20 years after the initial diagnosis of a psychotic disorder (Dutta et al., 2010). In this study from United Kingdom, men were found to be 3 times more likely to die by suicide than women. In a study of a Danish national cohort of 176,347 individuals followed from their first psychiatric contact and up to 36 years later, the absolute risk of suicide in schizophrenia was 6.55% (95% CI: 5.85–7.34) among men, and 4.91% (95% CI: 4.03–5.98) among women (Nordentoft et al., 2011). Thus, even though the long-term suicide risk in schizophrenia and other psychotic disorders is not as high as the original estimate, the excess mortality is a significant problem, impacting not only the patients but also their families and clinicians.
uicide is a serious public health problem, with more than 800,000 lives lost worldwide each year. In 2012, suicide was among the top 20 causes of mortality; in the United States; 1.3% of deaths were due to suicide, with the suicide mortality rate of 8.9 per 100,000 inhabitants, whereas in Europe, the figures were 1.4% and 13.8 per 100,000, respectively. These estimates are likely to be underreported because suicide remains a sensitive, and often stigmatized, issue (http://www.who. int/healthinfo/global_burden_disease/estimates/en/index1.html). Despite the scope of the problem, suicide mortality is yet to reach a priority on the national and international agendas. To this aim, the World Health Organization has launched the World Mental Health Action Plan, wherein it is mentioned that early identification and management of mental disorders as well as of suicidal behaviors can be effective (Mental Health Action Plan target 72). It is also specifically mentioned that children and adolescents with mental disorders should be provided with early intervention through evidence-based psychosocial and other nonpharmacological interventions based in the community, avoiding institutionalization and medicalization (Target 69) (World Health Organization, 2013). Furthermore, it is recommended
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Suicide Risk in First-Episode Psychosis Many studies have indicated that the risk of suicide is highest within the first year of the initial hospital contact. Although this is true for all mental illnesses, suicide risk appears to be especially elevated among individuals who had been diagnosed with a bipolar disorder and with disorders in the schizophrenia spectrum (Large et al., 2009; Nordentoft et al., 2004; Nordentoft et al., 2011; Nordentoft et al., 2013b). In the analyses of the Danish register data, the excess mortality from suicide in the first year of the initial hospital contact was 1.6 times greater compared with the later phases of the illness (Nordentoft et al., 2004). Recent studies based on the register data from several Nordic countries confirmed that the excess risk for death from external causes, including suicide, is twofold higher during the first year of the initial hospital contact compared with the next 3 years (Nordentoft et al., 2013b). The illness process of schizophrenia and related disorders is most active in the period shortly after the first contact with mental health services, most likely reflecting that worsening of the condition has led to contact to mental health services. Clearly, the difficulties associated with these early phases of psychosis are major challenges for the individuals affected by the disorder and their families. The global recognition of the importance of early intervention is reflected by the fact that timely identification and management of mental disorders were set as areas of high priority in the Mental Health Action Plan 2013–2020 (World Health Organization, 2013).
Risk Factors for Suicide in Schizophrenia Risk factors for suicide in schizophrenia and related disorders have been the subject of several studies, including case-control and prospective investigations. Although suicide risk is elevated in this treatment population, death from suicide is a relatively rare event even in these high-risk patients. To identify risk factors for suicide in schizophrenia and related disorders, prospective studies would therefore require large sample sizes and long follow-ups. For this reason, case-control studies might be more powerful in addressing this research question. In a review of studies investigating the risk of suicide in schizophrenia, Caldwell and Gottesman (1990) retrieved a long list of studies of first-episode and mixed samples. They reported the following variables as risk factors: young age, male sex, white race, social isolation, depressed mood, past history of suicide attempt, family history of suicide, being unmarried, unemployed, having experienced deteriorating health, recent loss, limited external support, family stress or instability, chronic illness with numerous exacerbations, high level of psychopathology and functional impairment, fear of deterioration, and loss of faith in treatment. In a later systematic review of risk factors for suicide in schizophrenia, Hawton et al. (2005) identified 29 eligible studies and found robust evidence of increased risk being conferred by depressive disorders, previous suicide attempts, drug misuse, agitation and motor restlessness, fear of mental disintegration, poor adherence to treatment, and recent loss. Some of the studies included in the above-mentioned reviews were based solely on the information retrieved from the registers. In these investigations, clinical characteristics could only be included if they had been reported as a comorbid diagnosis (e.g., depression or substance abuse). The four large Danish register-based studies of suicide risk in patients with schizophrenia indicated that a history of suicide attempt, male sex, young age, short duration of illness, multiple admissions during the past year, current inpatient admission, short time since psychiatric hospital discharge, and comorbid depression were independent risk factors (Mortensen and Juel, 1993; Nordentoft et al., 2011; Rossau and Mortensen, 1997). The information extracted from the clinical studies included in the above-mentioned reviews supplies the register-based studies with the following variables as the most important and frequently observed predictors of suicide in schizophrenia: previous suicide attempt, comorbid depression, drug misuse, poor compliance with medication, poor 388
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adherence to treatment, high IQ, and suicidal ideation. Although these investigations contributed a greater level of detail to the clinical data, they tended to be smaller studies, as the practical work involved in clinical assessments had been substantial. Previous suicide attempt was taken into consideration in almost all clinical studies. However, apart from that, different studies evaluated different risk factors, thus it cannot be concluded that not mentioning a risk factor in a specific study excludes this variable from being a significant predictor. Consequently, some risk factors might not have reached statistical significance because of the insufficient power to detect a “true” effect. The analyses of psychotic symptoms as risk factors for suicide in schizophrenia and other psychotic disorders yielded contradictory findings. In the previously mentioned meta-analysis, the pooled odds ratio for suicide for positive symptoms was not significant. However, when individual symptoms were examined, both hallucinations and delusions seemed to exert a protective effect (delusions: OR = 0.53 (95% CI 0.28– 1.01); hallucinations: OR = 0.5 (95% CI 0.35–0.71)), but there was a nonsignificant tendency that command hallucinations were associated with higher suicide risk (Hawton et al., 2005). It should be noted that a recent randomized clinical trial showed effectiveness of cognitive behavioral therapy in reducing compliance with command hallucinations by challenging the omniscience and omnipotence of the commanding voices (Birchwood et al., 2014). Several studies reported that negative symptoms may have a protective function, but these were not significant in the meta-analysis (Hawton et al., 2005). More recently, patients with first-episode schizophrenia who received disability pension had lower risk of suicide, compared with those in full-time employment (Agerbo, 2007). Madsen et al. (2012) found that the suicide risk increased with higher educational level among inpatients, but also that attempted suicide was a strong risk factor for suicide. In the previously mentioned long-term study after the initial psychiatric contact, the co-occurrence of deliberate self-harm increased the risk of suicide death approximately twofold (Nordentoft et al., 2011). In addition, hanging as a method for suicide attempt was reported to constitute a strong predictor for later suicide in schizophrenia (Runeson et al., 2010). Although studies have examined a range of variables as potential risk factors for suicide, a history of previous suicide attempt and depression are the two most robust factors.
The Timing of Suicide in Psychiatric Inpatients With Schizophrenia and Related Disorders Psychiatric inpatients are regarded as a high-risk group for suicide, and many patients are admitted to the hospital to avoid suicidal acts; thus, it is common practice to evaluate patients’ suicide risk. Even if not all inpatient suicide events are foreseeable and preventable, an inpatient stay is still expected to be protective against suicide. Prevention of suicidal behavior (fatal as well as nonfatal) is prioritized in mental health services; first of all to help the suicidal patient who is in emotional distress, but also because suicidal behavior causes immense distress for family, friends and clinical staff caring for the patient. Actions taken to reduce risk of suicidal behavior during inpatient stay includes thorough assessment of risk of suicide and reducing access to dangerous means for suicide such as medication, sharp objects, and ligature points. However, even though prevention of inpatient suicides has a high priority and admission to psychiatric hospital in many cases may be protective, a high risk of suicide during inpatient stay has been found in studies in different countries (Dong et al., 2005; Kapur et al., 2006; Neuner et al., 2008; Qin and Nordentoft, 2005; Taiminen and Kujari, 1994). Many studies have confirmed that the risk of suicide is also very high shortly after discharge (Appleby et al., 1999; Goldacre et al., 1993; Kan et al., 2007; Kapur et al., 2013; Lawrence et al., 1999; Mortensen and Juel, 1993; Rossau and Mortensen, 1997). In a large Danish register-based study, it was found that patients with schizophrenia and other psychotic disorders had two sharp peaks © 2015 Wolters Kluwer Health, Inc. All rights reserved.
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in suicide risk: the first peak occurred immediately after admission (adjusted risk ratio around 80, compared with individuals with no history of psychiatric admission), and the second peak was shortly after discharge (adjusted risk ratio around 110, compared with persons with no history of admission) (Qin and Nordentoft, 2005). Approximately one third of suicides in schizophrenia took place during admission, or in the first week after discharge, and accounted for almost 3% of all suicides in Denmark. This finding indicates the two important risk periods that may need to become targets of preventive interventions. Among individuals who died by suicide, 37% of men and 57% of women had a history of admission to psychiatric hospitals (Qin and Nordentoft, 2005). This indicates that men at risk for suicide are less likely to seek or receive psychiatric treatment.
Time Trends in Suicide in Schizophrenia In 1980, the suicide rate in Denmark peaked and reached a level that was among the highest in the world, with 34 suicides per 100,000 inhabitants. After 1980, the number of suicides decreased each year, and in 1997, the rate was 15 per 100,000 inhabitants, which is a 56% reduction in the suicide rate during the period from 1980 to 1997. In Denmark, approximately half of the persons who die by suicide have previously been admitted to psychiatric departments, and more than one fourth have been admitted during the last year (Mortensen et al., 2000; Qin et al. 2003). In the period from 1981 to 1997, the suicide rate among patients with schizophrenia and related disorders in Denmark declined to less than half. The change in the suicide rate among these patients was the same as the change among never-admitted persons in the general population (Nordentoft et al., 2004). Later studies of the Danish population have shown that the risk of suicide during psychiatric inpatient admission and after discharge has decreased in the period from 1998 to 2005 (Madsen and Nordentoft, 2013). Importantly, a significant decline was found in the postdischarge suicide rates among individuals who had been hospitalized with a diagnosis of schizophrenia. Also, studies in UK have confirmed that risk of suicide has decreased during recent years, but the same study identified an increase in postdischarge suicides (Kapur et al., 2013). In a registerbased study from Finland, Denmark, and Sweden, Wahlbeck et al. (2011) found a small reduction in suicide rates in the period from 1987 to 2005 among people who at least once had been inpatients at a psychiatric ward.
Suicide Attempts During Untreated Psychosis It is very likely that the risk of suicide is even higher before the first contact to mental health services, but at that time, people will not appear in the psychiatric case register, and they would not yet have been included in clinical studies. During the phases of untreated psychosis before the first hospital contact, there are many nonfatal suicidal acts that can be recorded retrospectively. Based on an audit of medical records, Nielssen and Large (2009) investigated the proportion of survivors of violent suicide attempts (jumping, stabbing, and gunshot) during psychotic illness who had not previously received treatment with antipsychotic medication. They concluded that there was a higher risk of violent suicide attempts during the first episode of psychosis than later in the illness. Many studies have demonstrated that the duration of untreated psychosis (DUP) varies considerably in patients with first-episode psychosis. Staying psychotic for months or years is likely to negatively influence one’s social, occupational, and interpersonal functioning. Internationally, efforts have been made to shorten DUP, and the DanishNorwegian TIPS (Early Treatment and Intervention in Psychosis) study is the best-documented initiative to date. The findings from the TIPS study indicated that an intensive early detection program was effective and significantly shortened the DUP to a median of five weeks in an
Suicidal Behavior in Psychosis
early detection area, compared with two control areas in which the median DUP was 16 weeks. Moreover, it was shown that the early detection program recruited patients into treatment before some of the complications of untreated illness, including suicidal plans and acts, had developed (Melle et al., 2004, 2006).
Suicide Attempts Before the First Treatment Contact for First-Episode Psychosis Several studies have examined the proportion of young individuals who had attempted suicide before their initial contact with mental health services because of first-episode psychosis. In the Danish OPUS I trial, which included 547 patients with first-episode psychosis, 28.2% had attempted suicide previously, and 18.3% had done so in the year before their inclusion in the trial (Bertelsen et al., 2007). In OPUS II trial, which included 400 patients with first-episode psychosis, the rate of attempted suicide was higher, at 40% (Melau, 2013). An Australian case-control study indicated that 36.4% of individuals who attempted suicide during the treatment (cases) had reported a suicide attempt history at assessment at the entry to the youth mental health service. This figure was significantly higher than the rate of 19.0% found among the first-episode patients who did not attempt suicide during treatment (controls) (Fedyszyn et al., 2012). There was also a significant difference between cases and controls in the proportion of patients who engaged in nonsuicidal self-injurious behaviors before the commencement of treatment, with 54.3% of cases and 23.4% of controls, respectively (Fedyszyn et al., 2012). Recently, Challis et al. (2013) published a systematic review and meta-analysis of controlled studies of factors associated with deliberate self-harm in first-episode psychosis and found the pooled proportion of patients who had reported deliberate self-harm before treatment to be 18.4%, whereas 11.4% of patients reported deliberate self-harm during periods of follow up, spanning over 1 and 7 years. Interestingly, in a nested case-control study based on the Danish nationwide registers, Jepsen et al. (2005) found a fourfold increase in the risk of schizophrenia after hospitalization with paracetamol selfpoisoning. There was also an increase in the risk of other disorders, especially affective disorders. Psychiatric diagnosis was most frequently made shortly after self-poisoning. In some cases, this result might indicate that the psychiatric disorder had already been present but was only brought to attention at the hospital contact because of self-poisoning. Self-poisoning should therefore be considered as a risk marker for psychiatric disorders, and it might constitute a marker for a later first-episode psychosis.
Risk Factors for Attempted Suicide in Schizophrenia and Related Disorders Haw et al. (2005) conducted a systematic review of schizophrenia and deliberate self-harm, and identified the following variables as risk factors: past or recent suicidal ideation, previous deliberate self-harm, past depressive episode, drug abuse or dependence, and a high number of psychiatric admissions. Challis et al., (2013) found that risk factors for deliberate self-harm after first contact with mental health services included a history of deliberate self-harm, with a fourfold increased risk, expressed suicidal ideation (OR = 2.34), greater insight (OR = 1.64), alcohol abuse (OR = 1.68), and substance use (OR = 1.46). Continuous variables associated with an increased risk of deliberate self-harm were younger age of onset, younger age at first treatment, depressed mood, and the duration of untreated psychosis. The authors concluded that earlier treatment of first-episode psychosis and successful treatment of depression as well as substance use could prevent some episodes of deliberate self-harm and might reduce suicide mortality in early psychosis. In the previously mentioned Danish OPUS trial, the risk factors for attempting suicide during the first year of treatment for first-episode psychosis were female sex, young age, and suicidal plans at baseline
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(Bertelsen et al., 2007). The Australian study of first-episode patients considered as potential predictors of suicide attempts during treatment baseline, past, and recent socio-demographic and clinical variables. The results indicated that the only significant multivariate predictors were recent nonsuicidal self-injurious behavior (AOR = 73.0) and a greater number of recent negative life events (AOR = 1.9) (Fedyszyn et al., 2012). Some studies have indicated that significantly more women than men attempt suicide during the first years after first contact (Barrett et al., 2010; Fedyszyn et al., 2012; Melle et al., 2010), but other studies have not found support the differential effect of sex (Bakst et al., 2010; Barrett et al., 2010; Robinson et al., 2010). Harvey et al. (2008) found that men were more likely than women to have attempted suicide before first contact to psychiatric services. The evidence base regarding transitions from being “not suicidal” to developing “suicidal ideations,” and “suicidal behavior” in the critical period of first-episode psychosis is so far rather weak. To date such transitions between suicidal stages have only been examined in the Danish OPUS trial. A third of the patients who reported no suicidal ideation at time of treatment initiation developed suicidal ideation, or engaged in suicidal behaviors, during the first year of treatment. Furthermore, only a small proportion of first episode psychosis patients with suicidal thoughts, plans, or attempts in the year before treatment commencement reported no suicidal tendencies during the first year of treatment, which indicates that suicidal problems are not fleeting. Importantly, it was found that the risk of attempting suicide during the first year of treatment did not differ in patients who before treatment had suicidal thoughts, plans, or suicide attempts, respectively. These results suggest that it is important for the psychiatric staff to be aware that transitions between suicidal stages occur frequently during this high-risk phase, and consequently, it is important to address suicidality with patients regularly (Madsen and Nordentoft, 2012).
The Organizational Framework of Specialized Assertive Early Intervention Services The organizational framework and structure of specialized assertive early intervention services vary, but most services apply some of the methods modified from the original Assertive Community Treatment model, developed in Madison, WI, by Leonard Stein and MaryAnn Test (Stein and Santos, 1998). The core of early intervention services is most often multidisciplinary teams, who organize themselves with each staff member being responsible for a caseload varying from less than 10 and up to 20. According to the Index of Fidelity of Assertive Community Treatment (IFACT) fidelity scale (McGrew et al., 1994), the teams should include psychiatrists and psychiatric nurses, but to ensure a truly multidisciplinary approach, social workers, occupational therapists, psychologists, and staff members with expertise in treatment of substance abuse should be employed as well. It is stressed that team meetings should facilitate collaboration between staff members and provision of mutual support in work with individual patients. Team members should collaborate with the patients about a wide range of issues, not restricted to psychopathology and medication, but also including everyday life problems, financial problems, interpersonal problems, vocational and educational involvement, substance abuse, and suicidal ideation. The venue for contact can be an office, community settings, or the patients’ home. In most models, it is stressed that the teams should be flexible with regard to time and space for the patient contact. Psychoeducation is considered to be an important part of early intervention services, and it can be provided individually or in a group format. Involving the family and other significant others is also considered to be a crucial part of early intervention services. Some services additionally offer cognitive behavioral treatment, social skills training, and vocational training. In a study based on a Delphi process among early intervention experts, Marshall et al. (2004) concluded that early intervention services should adopt a need-based model of support, 390
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produce a care plan quickly after referral, operate in a catchment area of about 150,000 inhabitants in inner city areas, and encourage direct referrals from educational and other relevant institutions.
Studies of the Effect of Specialized Assertive Early Intervention Services on the Risk of Suicide Attempt and Suicide in First-Episode Psychosis The low base rate of suicide indicates that very large randomized trials are needed if suicide is chosen as the primary outcome measure. Even in a high-risk group like patients with schizophrenia, a thousand patients in each intervention group would be needed to detect a reduction from 6% to 3% (Pocock, 1996). Therefore, in some studies, deliberate self-harm has been chosen as outcome measure. Among patients with schizophrenia, there have been no large studies investigating the effect on suicide of psychosocial interventions. The Danish OPUS trial examined if the risk of suicide and suicide attempts could be reduced by offering intensive treatment to patients who first contact mental health services because of disorders in the schizophrenia spectrum. Among the patients who received the intensive treatment, 1 of 275 died by suicide during the first 2 years of treatment, whereas 4 of 272 patients in standard treatment died by suicide. To prove a fourfold difference in suicide rate, 1600 patients should be included in each treatment condition (Petersen et al., 2005). The intensive treatment was not associated with reduced risk of suicide attempt (Nordentoft et al., 2002).
Risk Assessment and Crisis Plans at Specialized Assertive Early Intervention Services Scales for identifying risk of suicide have been developed, but because of the low base rate of suicide, the predictive value is low. Many of the scales focus on the long-term risk of suicide, which may not be most relevant in acute situations. Risk assessment needs to focus on immediate risk, and given the low base rate of suicide, we need to focus on risk of suicidal acts, being well aware that risk factors for fatal and nonfatal suicidal acts are not entirely the same. In a recent study based on 32 hospital services in England, it was found that hospitals that used scales for identifying suicide risk had a slightly lower median rate of repeat self-harm within 6 months, possibly reflecting a higher quality of risk assessment and aftercare in such hospitals (Quinlivan et al., 2014). Implementation of mandatory assessment of risk seems to be associated with declining suicide risk, but it is worth mentioning that there is a potential risk of false reassurance if scales are implemented mechanically. An important part of the work in early intervention services is the development of a crisis plan. Currently, evidence supports the feasibility of crisis plans prepared collaboratively with the patients, but the evidence demonstrating the efficacy of such plans is still lacking (Borschmann et al., 2013). The crisis plan typically includes three different elements: 1) actions and thoughts which the young person can activate to overcome suicidal thoughts and impulses; 2) a list of people in the personal network from whom the young person can get help and consolation; and 3) a list of help lines, professionals, or institutions from where the young person can get help. It is very important that crisis plans are revised, and with modern technology, it is relevant to have them stored on mobile telephones. Crisis plans can be combined with nice voice messages, pictures of loved ones, and favorite music. This can be implemented in Apps on mobile telephones. An example of a crisis plan (Nordentoft et al., 2009) is shown in Figure 1.
CONCLUSIONS AND RECOMMENDATIONS The steepest increase in suicide risk occurs during the first years after the first contact to mental health services, and this calls for early intensive intervention initiatives. By establishing closer contact with the patient and closer monitoring of symptoms, such initiatives can © 2015 Wolters Kluwer Health, Inc. All rights reserved.
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The Journal of Nervous and Mental Disease • Volume 203, Number 5, May 2015
Suicidal Behavior in Psychosis
FIGURE 1. An example of a crisis plan.
help reduce suicide risk in this high-risk period and thereby positively influence the long-term risk of suicide. Specialized early intervention services can offer comprehensive treatment to young persons with first episode psychosis and their families, and include adequate assessment and management of risk of suicide. The falling risk of suicide among patients with mental disorders in Denmark has been steepest among patients with schizophrenia and related disorders (Madsen and Nordentoft, 2013), probably reflecting improvements in services especially for this group of patients (Nordentoft et al., 2015). In the Danish Action Plan for Prevention of Suicide and Suicide Attempts, it was recommended that outpatient care immediately after discharge should be intensified and that it should be set as a standard that all patients should have an outpatient appointment within 1 week after discharge. The importance of this intervention is underlined by the finding that one third of all suicides in schizophrenia occur during admission or shortly after discharge. In the Danish National quality development project (National Indicator Project, schizophrenia), the standard is that all patients discharged from psychiatric department with a diagnosis of schizophrenia should be carefully interviewed and assessed with regard to risk of suicide. The British Action Plan contains similar elements. Such initiatives could be disseminated to other countries. ACKNOWLEDGMENT No specific funding for this article. DISCLOSURES The authors declare no conflict of interest.
Barrett EA, Sundet K, Faerden A, Nesvag R, Agartz I, Fosse R, Mork E, Steen NE, Andreassen OA, Melle I (2010) Suicidality before and in the early phases of first episode psychosis. Schizophr Res. 119:11–17. Bertelsen M, Jeppesen P, Petersen L, Thorup A, Øhlenschlæger J, le Quack P, Christensen TØ, Krarup G, Jørgensen P, Nordentoft M (2007) Suicidal behaviour and mortality in first-episode psychosis: the OPUS trial. Br J Psychiatry Suppl. 191:s140–s146. Birchwood M, Mihail M, Meaden A, Tarrier N, Lewis S, Wykes T, Davies L, Dunn G, Peters E (2014) Cognitive behaviour therapy to prevent harmful compliance with command hallucinations (COMMAND): a randomised controlled trial. Lancet Psychiatry. 1:23–33. Borschmann R, Barrett B, Hellier JM, Byford S, Henderson C, Rose D, Slade M, Sutherby K, Szmukler G, Thornicroft G, Hogg J, Moran P (2013) Joint crisis plans for people with borderline personality disorder: feasibility and outcomes in a randomised controlled trial. Br J Psychiatry. 202:357–364. Caldwell CB, Gottesman II (1990) Schizophrenics kill themselves too: a review of risk factors for suicide. Schizophr Bull. 16:571–589. Challis S, Nielssen O, Harris A, Large M (2013) Systematic meta-analysis of the risk factors for deliberate self-harm before and after treatment for first-episode psychosis. Acta Psychiatr Scand. 127:442–454. Dong JY, Ho TP, Kan CK (2005) A case–control study of 92 cases of in-patient suicides. J Affect Disord. 87:91–99. Dutta R, Murray RM, Hotopf M, Allardyce J, Jones PB, Boydell J (2010) Reassessing the long-term risk of suicide after a first episode of psychosis. Arch Gen Psychiatry. 67:1230–1237.
REFERENCES
Fedyszyn IE, Robinson J, Harris MG, Paxton SJ, Francey S (2012) Predictors of suicide-related behaviors during treatment following a first episode of psychosis: the contribution of baseline, past, and recent factors. Schizophr Res. 140:17–24.
Agerbo E (2007) High income, employment, postgraduate education, and marriage: a suicidal cocktail among psychiatric patients. Arch Gen Psychiatry. 64:1377–1384.
Goldacre M, Seagroatt V, Hawton K (1993) Suicide after discharge from psychiatric inpatient care [see comments]. Lancet. 342:283–286.
Appleby L, Shaw J, Amos T, McDonnell R, Harris C, McCann K, Kiernan K, Davies S, Bickley H, Parsons R (1999) Suicide within 12 months of contact with mental health services: national clinical survey [see comments]. BMJ. 318:1235–1239.
Harris EC, Barraclough B (1997) Suicide as an outcome for mental disorders. A metaanalysis. Br J Psychiatry. 170:205–228.
Bakst S, Rabinowitz J, Bromet EJ (2010) Antecedents and patterns of suicide behavior in first-admission psychosis. Schizophr Bull. 36:880–889.
Harvey SB, Dean K, Morgan C, Walsh E, Demjaha A, Dazzan P, Morgan K, Lloyd T, Fearon P, Jones PB, Murray RM (2008) Self-harm in first-episode psychosis. Br J Psychiatry. 192:178–184.
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Haw C, Hawton K, Sutton L, Sinclair J, Deeks J (2005) Schizophrenia and deliberate self-harm: a systematic review of risk factors. Suicide Life Threat Behav. 35:50–62. Hawton K, Sutton L, Haw C, Sinclair J, Deeks JJ (2005) Schizophrenia and suicide: systematic review of risk factors. Br J Psychiatry. 187:9–20. Inskip HM, Harris EC, Barraclough B (1998) Lifetime risk of suicide for affective disorder, alcoholism and schizophrenia. Br J Psychiatry. 172:35–37. Jepsen P, Qin P, Norgard B, Agerbo E, Mortensen PB, Vilstrup H, Sorensen HT (2005) The association between admission for poisoning with paracetamol or other weak analgesics and subsequent admission for psychiatric disorder: a Danish nationwide case–control study. Aliment Pharmacol Ther. 22:645–651. Kan CK, Ho TP, Dong JY, Dunn EL (2007) Risk factors for suicide in the immediate post-discharge period. Soc Psychiatry Psychiatr Epidemiol. 42:208–214. Kapur N, Hunt IM, Webb R, Bickley H, Windfuhr K, Shaw J, Appleby L (2006) Suicide in psychiatric in-patients in England, 1997 to 2003. Psychol Med. 36:1485–1492. Kapur N, Hunt IM, Windfuhr K, Rodway C, Webb R, Rahman MS, Shaw J, Appleby L (2013) Psychiatric in-patient care and suicide in England, 1997 to 2008: a longitudinal study. Psychol Med. 43:61–71. Large M, Babidge N, Andrews D, Storey P, Nielssen O (2009) Major self-mutilation in the first episode of psychosis. Schizophr Bull. 35:1012–1021.
Nordentoft M, Jeppesen P, Abel M, Kassow P, Petersen L, Thorup A, Krarup G, Hemmingsen R, Jorgensen P (2002) OPUS study: suicidal behaviour, suicidal ideation and hopelessness among patients with first-episode psychosis. One-year follow-up of a randomised controlled trial. Br J Psychiatry Suppl. 43:s98–s106. Nordentoft M, Laursen TM, Agerbo E, Qin P, Hoyer EH, Mortensen PB (2004) Change in suicide rates for patients with schizophrenia in Denmark, 1981–97: nested case–control study. BMJ. 329:261–266. Nordentoft M, Melau M, Iversen T, Kjær S (2009) Psykose hos unge symptomer, behandling og fremtid. Erfaringer fra OPUS, 1 ed. København, Psykiatrifondens Forlag. Nordentoft M, Melau M, Iversen T, Petersen L, Jeppesen P, Thorup A, Bertelsen M, Hjorthøj CR, Hastrup LH, Jørgensen P (2015) From research to practice: how OPUS treatment was accepted and implemented throughout Denmark. Early Interv Psychiatry. 9:156–162. Nordentoft M, Mortensen PB, Pedersen CB (2011) Absolute risk of suicide after first hospital contact in mental disorder. Arch Gen Psychiatry. 68:1058–1064. Nordentoft M, Wahlbeck K, Hallgren J, Westman J, Osby U, Alinaghizadeh H, Gissler M, Laursen TM (2013b) Excess mortality, causes of death and life expectancy in 270,770 patients with recent onset of mental disorders in Denmark, Finland and Sweden. PLoS One. 8:e55176.
Lawrence DM, Holman CD, Jablensky AV, Fuller SA (1999) Suicide rates in psychiatric in-patients: an application of record linkage to mental health research. Aust N Z J Public Health. 23:468–470.
Palmer BA, Pankratz VS, Bostwick JM (2005) The lifetime risk of suicide in schizophrenia: a reexamination. Arch Gen Psychiatry. 62:247–253.
Madsen T, Agerbo E, Mortensen PB, Nordentoft M (2012) Predictors of psychiatric inpatient suicide: a national prospective register-based study. J Clin Psychiatry. 73:144–151.
Pedersen CB, Mors O, Bertelsen A, Waltoft BL, Agerbo E, McGrath JJ, Mortensen PB, Eaton WW (2014) A comprehensive nationwide study of the incidence rate and lifetime risk for treated mental disorders 1. JAMA Psychiatry. 71:573–581.
Madsen T, Nordentoft M (2012) Suicidal changes in patients with first episode psychosis: clinical predictors of increasing suicidal tendency in the early treatment phase. Early Interv Psychiatry. 6:292–299.
Petersen L, Jeppesen P, Thorup A, Abel MB, Ohlenschlaeger J, Christensen TO, Krarup G, Jorgensen P, Nordentoft M (2005) A randomised multicentre trial of integrated versus standard treatment for patients with a first episode of psychotic illness. BMJ. 331:602.
Madsen T, Nordentoft M (2013) Changes in inpatient and postdischarge suicide rates in a nationwide cohort of Danish psychiatric inpatients, 1998–2005. J Clin Psychiatry. 74:e1190–e1194. Marshall M, Lockwood A, Lewis S, Fiander M (2004) Essential elements of an early intervention service for psychosis: the opinions of expert clinicians. BMC Psychiatry. 4:17. McGrew JH, Bond GR, Dietzen L, Salyers M (1994) Measuring the fidelity of implementation of a mental health program model. J Consult Clin Psychol. 62:670–678. Melau M (2013) Baseline Characteristics, Working Alliance and Patients' Perspectives — A cross-sectional and qualitative study in a cohort of patients with a first episode psychosis treated eighteen months in specialized early intervention services. Copenhagen, Denmark; PhD-thesis University of Copenhagen.
Pocock SJ (1996) Clinical Trials. A Practical Approach. Chichester New York Brisbane Toronto Singapore: John Wiley & Sons. Qin P, Agerbo E, Mortensen PB (2003) Suicide risk in relation to socioeconomic, demographic, psychiatric, and familial factors: a national register-based study of all suicides in Denmark, 1981–1997. Am J Psychiatry. 160:765–772. Qin P, Nordentoft M (2005) Suicide risk in relation to psychiatric hospitalization: evidence based on longitudinal registers. Arch Gen Psychiatry. 62:427–432. Quinlivan L, Cooper J, Steeg S, Davies L, Hawton K, Gunnell D, Kapur N (2014) Scales for predicting risk following self-harm: an observational study in 32 hospitals in England. BMJ Open. 4:e004732.
Melle I, Johannesen JO, Friis S, Haahr U, Joa I, Larsen TK, Opjordsmoen S, Rund BR, Simonsen E, Vaglum P, McGlashan T (2006) Early detection of the first episode of schizophrenia and suicidal behavior. Am. J Psychiatry. 163:800–804.
Robinson J, Harris MG, Harrigan SM, Henry LP, Farrelly S, Prosser A, Schwartz O, Jackson H, McGorry PD (2010) Suicide attempt in first-episode psychosis: a 7.4 year follow-up study. Schizophr Res. 116:1–8.
Melle I, Johannessen JO, Friis S, Haahr U, Joa I, Larsen TK, Opjordsmoen S, Rund BR, Simonsen E, Vaglum P, McGlashan T (2010) Course and predictors of suicidality over the first two years of treatment in first-episode schizophrenia spectrum psychosis. Arch Suicide Res. 14:158–170.
Rossau CD, Mortensen PB (1997) Risk factors for suicide in patients with schizophrenia: nested case–control study. Br J Psychiatry. 171:355–359.
Melle I, Larsen TK, Haahr U, Friis S, Johannessen JO, Opjordsmoen S, Simonsen E, Rund BR, Vaglum P, McGlashan T (2004) Reducing the duration of untreated firstepisode psychosis: effects on clinical presentation. Arch Gen Psychiatry. 61:143–150. Miles CP (1977) Conditions predisposing to suicide: a review. J Nerv Ment Dis. 164: 231–246. Mortensen PB, Agerbo E, Erikson T, Qin P, Westergaard-Nielsen N (2000) Psychiatric illness and risk factors for suicide in Denmark. Lancet. 355:9–12.
Runeson B, Tidemalm D, Dahlin M, Lichtenstein P, Langstrom N (2010) Method of attempted suicide as predictor of subsequent successful suicide: national long term cohort study. BMJ. 341:c3222. Stein LI, Santos AB (1998) Assertive community treatment of persons with severe mental illness. New York London: W.W. Norton & Company, INC. Taiminen TJ, Kujari H (1994) Antipsychotic medication and suicide risk among schizophrenic and paranoid inpatients. A controlled retrospective study. Acta Psychiatr Scand. 90:247–251.
Mortensen PB, Juel K (1993) Mortality and causes of death in first admitted schizophrenic patients. Br J Psychiatry. 163:183–189.
Wahlbeck K, Westman J, Nordentoft M, Gissler M, Laursen TM (2011) Outcomes of Nordic mental health systems: Life expectancy of patients with mental disorders. Br J Psychiatry. 199:453–458.
Neuner T, Schmid R, Wolfersdorf M, Spiessl H (2008) Predicting inpatient suicides and suicide attempts by using clinical routine data? Gen Hosp Psychiatry. 30:324–330.
World Health Organization (2013) Mental Health Action Plan 2013–2020. Geneva, Switzerland: World Health Organization.
Nielssen OB, Large MM (2009) Untreated psychotic illness in the survivors of violent suicide attempts. Early Interv Psychiatry. 3:116–122.
World Health Organization (2014) Preventing suicide - A global imperative. Geneva: World Health Organization.
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Suicidal Behavior and Mortality in First-Episode Psychosis Merete Nordentoft, DrMSc,*†‡ Trine Madsen, PhD,‡ and Izabela Fedyszyn, PhD‡ Abstract: Suicide is a serious public health problem, with more than 800,000 deaths taking place worldwide each year. Mental disorders are associated with increased risk of suicide. In schizophrenia and other psychotic disorders, the lifetime risk of suicide death is estimated to be 5.6%. The risk is particularly high during the first year of the initial contact with mental health services, being almost twice as high as in the later course of the illness. The most consistently reported risk factor for suicide among people with psychotic disorders is a history of attempted suicide and depression. Suicide risk in psychosis in Denmark decreased over time, most likely because of improved quality of inpatient and outpatient services. There is a high proportion of young people with first-episode psychosis who attempted suicide before their first contact with mental health services. This finding suggests that the mortality rates associated with psychotic disorders may be underreported because of suicide deaths taking place before first treatment contact. However, currently, no data exist to confirm or refute this hypothesis. Attempted suicide can be an early warning sign of later psychotic disorder. Data from different studies indicate that the risk of suicide attempt during the first year of treatment is as high as 10%. The most important risk factors for attempted suicide after the first contact are young age, female sex, suicidal plans, and a history of suicide attempt. Early intervention services are helpful in first-episode psychosis, and staff members should, in collaboration with the patients, monitor the risk of suicide and develop and revise crisis plans. Key Words: Suicide, risk factors, first episode psychosis, schizophrenia (J Nerv Ment Dis 2015;203: 387–392)
that all countries develop and implement comprehensive national strategies for the prevention of suicide, with special attention given to groups who have been identified at increased risk of suicide (Target 74). A global target was set to reduce the rate of suicide in all countries by 10% before the year 2020 (global target 3.2). After the Mental Health Action Plan was introduced in 2013, a specific action plan was launched for suicide prevention, called “Preventing Suicide—A Global Imperative.” The latter also recommends a greater focus on suicide among individuals with mental illness, especially in the early phases of the disorders (World Health Organization, 2014). People with mental disorders are a large risk group (Pedersen et al., 2014) for suicide, and they have the highest relative risk for suicide. Translated into population attributable risk, it has been estimated that if suicide mortality among individuals with mental disorders were reduced to the level found in the general population, the overall suicide risk could be reduced by almost 50% (Mortensen et al., 2000). The risk of suicide appears to be particularly elevated in schizophrenia and other psychotic disorders, with numerous studies demonstrating up to 20-fold increase in relative risk for suicide in this diagnostic group compared with the general population (Dutta et al., 2010; Harris and Barraclough, 1997; Mortensen et al., 2000; Qin and Nordentoft, 2005). The aim of this paper is to describe the risk of suicide and attempted suicide in schizophrenia and related disorders with special focus on early phases of the illness. Moreover, risk factors will be identified, and preventive measures will be reviewed.
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Suicide Risk in Schizophrenia and Related Disorders
*Institute of Clinical Medicine, Faculty of Health Sciences, University of Copenhagen; †iPSYCH—The Lundbeck Foundation Initiative for Psychiatric Research; and ‡Mental Health Services in the Capital Region of Denmark, Mental Health Center Copenhagen, Denmark. Send reprint requests to Merete Nordentoft, DrMSc, Mental Health Center Copenhagen, Mental Health Services in the Capital Region of Denmark, Bispebjerg Bakke 23, 2400 Copenhagen, Denmark. E-mail: [email protected]. Copyright © 2015 Wolters Kluwer Health, Inc. All rights reserved. ISSN: 0022-3018/15/20305–0387 DOI: 10.1097/NMD.0000000000000296
The absolute risk of dying by suicide is often referred to as the lifetime risk of suicide after an onset of a mental disorder. Although to date no study has actually conducted a lifetime follow-up, the lifetime risk is often mentioned in scientific papers, as it can be estimated in terms of the percentage of a cohort expected to die by suicide before all members of the cohort have died, emigrated, or have been lost to follow-up. Among the most widely cited publications is a review by Miles (1977), estimating that 10% of individuals with schizophrenia would die by suicide. However, the review was based on relatively small studies of selected samples with short follow-ups. Subsequent metaanalyses, which used sophisticated statistical methods and included large long-term follow-up studies, found lower figures (Inskip et al. 1998; Palmer et al. 2005). Specifically, the lifetime suicide risk in schizophrenia was estimated to be 5.6%. In a long-term follow-up study of a large cohort of individuals with FEP (n = 2132), the absolute risk of suicide was 3.23% for patients 20 years after the initial diagnosis of a psychotic disorder (Dutta et al., 2010). In this study from United Kingdom, men were found to be 3 times more likely to die by suicide than women. In a study of a Danish national cohort of 176,347 individuals followed from their first psychiatric contact and up to 36 years later, the absolute risk of suicide in schizophrenia was 6.55% (95% CI: 5.85–7.34) among men, and 4.91% (95% CI: 4.03–5.98) among women (Nordentoft et al., 2011). Thus, even though the long-term suicide risk in schizophrenia and other psychotic disorders is not as high as the original estimate, the excess mortality is a significant problem, impacting not only the patients but also their families and clinicians.
uicide is a serious public health problem, with more than 800,000 lives lost worldwide each year. In 2012, suicide was among the top 20 causes of mortality; in the United States; 1.3% of deaths were due to suicide, with the suicide mortality rate of 8.9 per 100,000 inhabitants, whereas in Europe, the figures were 1.4% and 13.8 per 100,000, respectively. These estimates are likely to be underreported because suicide remains a sensitive, and often stigmatized, issue (http://www.who. int/healthinfo/global_burden_disease/estimates/en/index1.html). Despite the scope of the problem, suicide mortality is yet to reach a priority on the national and international agendas. To this aim, the World Health Organization has launched the World Mental Health Action Plan, wherein it is mentioned that early identification and management of mental disorders as well as of suicidal behaviors can be effective (Mental Health Action Plan target 72). It is also specifically mentioned that children and adolescents with mental disorders should be provided with early intervention through evidence-based psychosocial and other nonpharmacological interventions based in the community, avoiding institutionalization and medicalization (Target 69) (World Health Organization, 2013). Furthermore, it is recommended
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Suicide Risk in First-Episode Psychosis Many studies have indicated that the risk of suicide is highest within the first year of the initial hospital contact. Although this is true for all mental illnesses, suicide risk appears to be especially elevated among individuals who had been diagnosed with a bipolar disorder and with disorders in the schizophrenia spectrum (Large et al., 2009; Nordentoft et al., 2004; Nordentoft et al., 2011; Nordentoft et al., 2013b). In the analyses of the Danish register data, the excess mortality from suicide in the first year of the initial hospital contact was 1.6 times greater compared with the later phases of the illness (Nordentoft et al., 2004). Recent studies based on the register data from several Nordic countries confirmed that the excess risk for death from external causes, including suicide, is twofold higher during the first year of the initial hospital contact compared with the next 3 years (Nordentoft et al., 2013b). The illness process of schizophrenia and related disorders is most active in the period shortly after the first contact with mental health services, most likely reflecting that worsening of the condition has led to contact to mental health services. Clearly, the difficulties associated with these early phases of psychosis are major challenges for the individuals affected by the disorder and their families. The global recognition of the importance of early intervention is reflected by the fact that timely identification and management of mental disorders were set as areas of high priority in the Mental Health Action Plan 2013–2020 (World Health Organization, 2013).
Risk Factors for Suicide in Schizophrenia Risk factors for suicide in schizophrenia and related disorders have been the subject of several studies, including case-control and prospective investigations. Although suicide risk is elevated in this treatment population, death from suicide is a relatively rare event even in these high-risk patients. To identify risk factors for suicide in schizophrenia and related disorders, prospective studies would therefore require large sample sizes and long follow-ups. For this reason, case-control studies might be more powerful in addressing this research question. In a review of studies investigating the risk of suicide in schizophrenia, Caldwell and Gottesman (1990) retrieved a long list of studies of first-episode and mixed samples. They reported the following variables as risk factors: young age, male sex, white race, social isolation, depressed mood, past history of suicide attempt, family history of suicide, being unmarried, unemployed, having experienced deteriorating health, recent loss, limited external support, family stress or instability, chronic illness with numerous exacerbations, high level of psychopathology and functional impairment, fear of deterioration, and loss of faith in treatment. In a later systematic review of risk factors for suicide in schizophrenia, Hawton et al. (2005) identified 29 eligible studies and found robust evidence of increased risk being conferred by depressive disorders, previous suicide attempts, drug misuse, agitation and motor restlessness, fear of mental disintegration, poor adherence to treatment, and recent loss. Some of the studies included in the above-mentioned reviews were based solely on the information retrieved from the registers. In these investigations, clinical characteristics could only be included if they had been reported as a comorbid diagnosis (e.g., depression or substance abuse). The four large Danish register-based studies of suicide risk in patients with schizophrenia indicated that a history of suicide attempt, male sex, young age, short duration of illness, multiple admissions during the past year, current inpatient admission, short time since psychiatric hospital discharge, and comorbid depression were independent risk factors (Mortensen and Juel, 1993; Nordentoft et al., 2011; Rossau and Mortensen, 1997). The information extracted from the clinical studies included in the above-mentioned reviews supplies the register-based studies with the following variables as the most important and frequently observed predictors of suicide in schizophrenia: previous suicide attempt, comorbid depression, drug misuse, poor compliance with medication, poor 388
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adherence to treatment, high IQ, and suicidal ideation. Although these investigations contributed a greater level of detail to the clinical data, they tended to be smaller studies, as the practical work involved in clinical assessments had been substantial. Previous suicide attempt was taken into consideration in almost all clinical studies. However, apart from that, different studies evaluated different risk factors, thus it cannot be concluded that not mentioning a risk factor in a specific study excludes this variable from being a significant predictor. Consequently, some risk factors might not have reached statistical significance because of the insufficient power to detect a “true” effect. The analyses of psychotic symptoms as risk factors for suicide in schizophrenia and other psychotic disorders yielded contradictory findings. In the previously mentioned meta-analysis, the pooled odds ratio for suicide for positive symptoms was not significant. However, when individual symptoms were examined, both hallucinations and delusions seemed to exert a protective effect (delusions: OR = 0.53 (95% CI 0.28– 1.01); hallucinations: OR = 0.5 (95% CI 0.35–0.71)), but there was a nonsignificant tendency that command hallucinations were associated with higher suicide risk (Hawton et al., 2005). It should be noted that a recent randomized clinical trial showed effectiveness of cognitive behavioral therapy in reducing compliance with command hallucinations by challenging the omniscience and omnipotence of the commanding voices (Birchwood et al., 2014). Several studies reported that negative symptoms may have a protective function, but these were not significant in the meta-analysis (Hawton et al., 2005). More recently, patients with first-episode schizophrenia who received disability pension had lower risk of suicide, compared with those in full-time employment (Agerbo, 2007). Madsen et al. (2012) found that the suicide risk increased with higher educational level among inpatients, but also that attempted suicide was a strong risk factor for suicide. In the previously mentioned long-term study after the initial psychiatric contact, the co-occurrence of deliberate self-harm increased the risk of suicide death approximately twofold (Nordentoft et al., 2011). In addition, hanging as a method for suicide attempt was reported to constitute a strong predictor for later suicide in schizophrenia (Runeson et al., 2010). Although studies have examined a range of variables as potential risk factors for suicide, a history of previous suicide attempt and depression are the two most robust factors.
The Timing of Suicide in Psychiatric Inpatients With Schizophrenia and Related Disorders Psychiatric inpatients are regarded as a high-risk group for suicide, and many patients are admitted to the hospital to avoid suicidal acts; thus, it is common practice to evaluate patients’ suicide risk. Even if not all inpatient suicide events are foreseeable and preventable, an inpatient stay is still expected to be protective against suicide. Prevention of suicidal behavior (fatal as well as nonfatal) is prioritized in mental health services; first of all to help the suicidal patient who is in emotional distress, but also because suicidal behavior causes immense distress for family, friends and clinical staff caring for the patient. Actions taken to reduce risk of suicidal behavior during inpatient stay includes thorough assessment of risk of suicide and reducing access to dangerous means for suicide such as medication, sharp objects, and ligature points. However, even though prevention of inpatient suicides has a high priority and admission to psychiatric hospital in many cases may be protective, a high risk of suicide during inpatient stay has been found in studies in different countries (Dong et al., 2005; Kapur et al., 2006; Neuner et al., 2008; Qin and Nordentoft, 2005; Taiminen and Kujari, 1994). Many studies have confirmed that the risk of suicide is also very high shortly after discharge (Appleby et al., 1999; Goldacre et al., 1993; Kan et al., 2007; Kapur et al., 2013; Lawrence et al., 1999; Mortensen and Juel, 1993; Rossau and Mortensen, 1997). In a large Danish register-based study, it was found that patients with schizophrenia and other psychotic disorders had two sharp peaks © 2015 Wolters Kluwer Health, Inc. All rights reserved.
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in suicide risk: the first peak occurred immediately after admission (adjusted risk ratio around 80, compared with individuals with no history of psychiatric admission), and the second peak was shortly after discharge (adjusted risk ratio around 110, compared with persons with no history of admission) (Qin and Nordentoft, 2005). Approximately one third of suicides in schizophrenia took place during admission, or in the first week after discharge, and accounted for almost 3% of all suicides in Denmark. This finding indicates the two important risk periods that may need to become targets of preventive interventions. Among individuals who died by suicide, 37% of men and 57% of women had a history of admission to psychiatric hospitals (Qin and Nordentoft, 2005). This indicates that men at risk for suicide are less likely to seek or receive psychiatric treatment.
Time Trends in Suicide in Schizophrenia In 1980, the suicide rate in Denmark peaked and reached a level that was among the highest in the world, with 34 suicides per 100,000 inhabitants. After 1980, the number of suicides decreased each year, and in 1997, the rate was 15 per 100,000 inhabitants, which is a 56% reduction in the suicide rate during the period from 1980 to 1997. In Denmark, approximately half of the persons who die by suicide have previously been admitted to psychiatric departments, and more than one fourth have been admitted during the last year (Mortensen et al., 2000; Qin et al. 2003). In the period from 1981 to 1997, the suicide rate among patients with schizophrenia and related disorders in Denmark declined to less than half. The change in the suicide rate among these patients was the same as the change among never-admitted persons in the general population (Nordentoft et al., 2004). Later studies of the Danish population have shown that the risk of suicide during psychiatric inpatient admission and after discharge has decreased in the period from 1998 to 2005 (Madsen and Nordentoft, 2013). Importantly, a significant decline was found in the postdischarge suicide rates among individuals who had been hospitalized with a diagnosis of schizophrenia. Also, studies in UK have confirmed that risk of suicide has decreased during recent years, but the same study identified an increase in postdischarge suicides (Kapur et al., 2013). In a registerbased study from Finland, Denmark, and Sweden, Wahlbeck et al. (2011) found a small reduction in suicide rates in the period from 1987 to 2005 among people who at least once had been inpatients at a psychiatric ward.
Suicide Attempts During Untreated Psychosis It is very likely that the risk of suicide is even higher before the first contact to mental health services, but at that time, people will not appear in the psychiatric case register, and they would not yet have been included in clinical studies. During the phases of untreated psychosis before the first hospital contact, there are many nonfatal suicidal acts that can be recorded retrospectively. Based on an audit of medical records, Nielssen and Large (2009) investigated the proportion of survivors of violent suicide attempts (jumping, stabbing, and gunshot) during psychotic illness who had not previously received treatment with antipsychotic medication. They concluded that there was a higher risk of violent suicide attempts during the first episode of psychosis than later in the illness. Many studies have demonstrated that the duration of untreated psychosis (DUP) varies considerably in patients with first-episode psychosis. Staying psychotic for months or years is likely to negatively influence one’s social, occupational, and interpersonal functioning. Internationally, efforts have been made to shorten DUP, and the DanishNorwegian TIPS (Early Treatment and Intervention in Psychosis) study is the best-documented initiative to date. The findings from the TIPS study indicated that an intensive early detection program was effective and significantly shortened the DUP to a median of five weeks in an
Suicidal Behavior in Psychosis
early detection area, compared with two control areas in which the median DUP was 16 weeks. Moreover, it was shown that the early detection program recruited patients into treatment before some of the complications of untreated illness, including suicidal plans and acts, had developed (Melle et al., 2004, 2006).
Suicide Attempts Before the First Treatment Contact for First-Episode Psychosis Several studies have examined the proportion of young individuals who had attempted suicide before their initial contact with mental health services because of first-episode psychosis. In the Danish OPUS I trial, which included 547 patients with first-episode psychosis, 28.2% had attempted suicide previously, and 18.3% had done so in the year before their inclusion in the trial (Bertelsen et al., 2007). In OPUS II trial, which included 400 patients with first-episode psychosis, the rate of attempted suicide was higher, at 40% (Melau, 2013). An Australian case-control study indicated that 36.4% of individuals who attempted suicide during the treatment (cases) had reported a suicide attempt history at assessment at the entry to the youth mental health service. This figure was significantly higher than the rate of 19.0% found among the first-episode patients who did not attempt suicide during treatment (controls) (Fedyszyn et al., 2012). There was also a significant difference between cases and controls in the proportion of patients who engaged in nonsuicidal self-injurious behaviors before the commencement of treatment, with 54.3% of cases and 23.4% of controls, respectively (Fedyszyn et al., 2012). Recently, Challis et al. (2013) published a systematic review and meta-analysis of controlled studies of factors associated with deliberate self-harm in first-episode psychosis and found the pooled proportion of patients who had reported deliberate self-harm before treatment to be 18.4%, whereas 11.4% of patients reported deliberate self-harm during periods of follow up, spanning over 1 and 7 years. Interestingly, in a nested case-control study based on the Danish nationwide registers, Jepsen et al. (2005) found a fourfold increase in the risk of schizophrenia after hospitalization with paracetamol selfpoisoning. There was also an increase in the risk of other disorders, especially affective disorders. Psychiatric diagnosis was most frequently made shortly after self-poisoning. In some cases, this result might indicate that the psychiatric disorder had already been present but was only brought to attention at the hospital contact because of self-poisoning. Self-poisoning should therefore be considered as a risk marker for psychiatric disorders, and it might constitute a marker for a later first-episode psychosis.
Risk Factors for Attempted Suicide in Schizophrenia and Related Disorders Haw et al. (2005) conducted a systematic review of schizophrenia and deliberate self-harm, and identified the following variables as risk factors: past or recent suicidal ideation, previous deliberate self-harm, past depressive episode, drug abuse or dependence, and a high number of psychiatric admissions. Challis et al., (2013) found that risk factors for deliberate self-harm after first contact with mental health services included a history of deliberate self-harm, with a fourfold increased risk, expressed suicidal ideation (OR = 2.34), greater insight (OR = 1.64), alcohol abuse (OR = 1.68), and substance use (OR = 1.46). Continuous variables associated with an increased risk of deliberate self-harm were younger age of onset, younger age at first treatment, depressed mood, and the duration of untreated psychosis. The authors concluded that earlier treatment of first-episode psychosis and successful treatment of depression as well as substance use could prevent some episodes of deliberate self-harm and might reduce suicide mortality in early psychosis. In the previously mentioned Danish OPUS trial, the risk factors for attempting suicide during the first year of treatment for first-episode psychosis were female sex, young age, and suicidal plans at baseline
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(Bertelsen et al., 2007). The Australian study of first-episode patients considered as potential predictors of suicide attempts during treatment baseline, past, and recent socio-demographic and clinical variables. The results indicated that the only significant multivariate predictors were recent nonsuicidal self-injurious behavior (AOR = 73.0) and a greater number of recent negative life events (AOR = 1.9) (Fedyszyn et al., 2012). Some studies have indicated that significantly more women than men attempt suicide during the first years after first contact (Barrett et al., 2010; Fedyszyn et al., 2012; Melle et al., 2010), but other studies have not found support the differential effect of sex (Bakst et al., 2010; Barrett et al., 2010; Robinson et al., 2010). Harvey et al. (2008) found that men were more likely than women to have attempted suicide before first contact to psychiatric services. The evidence base regarding transitions from being “not suicidal” to developing “suicidal ideations,” and “suicidal behavior” in the critical period of first-episode psychosis is so far rather weak. To date such transitions between suicidal stages have only been examined in the Danish OPUS trial. A third of the patients who reported no suicidal ideation at time of treatment initiation developed suicidal ideation, or engaged in suicidal behaviors, during the first year of treatment. Furthermore, only a small proportion of first episode psychosis patients with suicidal thoughts, plans, or attempts in the year before treatment commencement reported no suicidal tendencies during the first year of treatment, which indicates that suicidal problems are not fleeting. Importantly, it was found that the risk of attempting suicide during the first year of treatment did not differ in patients who before treatment had suicidal thoughts, plans, or suicide attempts, respectively. These results suggest that it is important for the psychiatric staff to be aware that transitions between suicidal stages occur frequently during this high-risk phase, and consequently, it is important to address suicidality with patients regularly (Madsen and Nordentoft, 2012).
The Organizational Framework of Specialized Assertive Early Intervention Services The organizational framework and structure of specialized assertive early intervention services vary, but most services apply some of the methods modified from the original Assertive Community Treatment model, developed in Madison, WI, by Leonard Stein and MaryAnn Test (Stein and Santos, 1998). The core of early intervention services is most often multidisciplinary teams, who organize themselves with each staff member being responsible for a caseload varying from less than 10 and up to 20. According to the Index of Fidelity of Assertive Community Treatment (IFACT) fidelity scale (McGrew et al., 1994), the teams should include psychiatrists and psychiatric nurses, but to ensure a truly multidisciplinary approach, social workers, occupational therapists, psychologists, and staff members with expertise in treatment of substance abuse should be employed as well. It is stressed that team meetings should facilitate collaboration between staff members and provision of mutual support in work with individual patients. Team members should collaborate with the patients about a wide range of issues, not restricted to psychopathology and medication, but also including everyday life problems, financial problems, interpersonal problems, vocational and educational involvement, substance abuse, and suicidal ideation. The venue for contact can be an office, community settings, or the patients’ home. In most models, it is stressed that the teams should be flexible with regard to time and space for the patient contact. Psychoeducation is considered to be an important part of early intervention services, and it can be provided individually or in a group format. Involving the family and other significant others is also considered to be a crucial part of early intervention services. Some services additionally offer cognitive behavioral treatment, social skills training, and vocational training. In a study based on a Delphi process among early intervention experts, Marshall et al. (2004) concluded that early intervention services should adopt a need-based model of support, 390
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produce a care plan quickly after referral, operate in a catchment area of about 150,000 inhabitants in inner city areas, and encourage direct referrals from educational and other relevant institutions.
Studies of the Effect of Specialized Assertive Early Intervention Services on the Risk of Suicide Attempt and Suicide in First-Episode Psychosis The low base rate of suicide indicates that very large randomized trials are needed if suicide is chosen as the primary outcome measure. Even in a high-risk group like patients with schizophrenia, a thousand patients in each intervention group would be needed to detect a reduction from 6% to 3% (Pocock, 1996). Therefore, in some studies, deliberate self-harm has been chosen as outcome measure. Among patients with schizophrenia, there have been no large studies investigating the effect on suicide of psychosocial interventions. The Danish OPUS trial examined if the risk of suicide and suicide attempts could be reduced by offering intensive treatment to patients who first contact mental health services because of disorders in the schizophrenia spectrum. Among the patients who received the intensive treatment, 1 of 275 died by suicide during the first 2 years of treatment, whereas 4 of 272 patients in standard treatment died by suicide. To prove a fourfold difference in suicide rate, 1600 patients should be included in each treatment condition (Petersen et al., 2005). The intensive treatment was not associated with reduced risk of suicide attempt (Nordentoft et al., 2002).
Risk Assessment and Crisis Plans at Specialized Assertive Early Intervention Services Scales for identifying risk of suicide have been developed, but because of the low base rate of suicide, the predictive value is low. Many of the scales focus on the long-term risk of suicide, which may not be most relevant in acute situations. Risk assessment needs to focus on immediate risk, and given the low base rate of suicide, we need to focus on risk of suicidal acts, being well aware that risk factors for fatal and nonfatal suicidal acts are not entirely the same. In a recent study based on 32 hospital services in England, it was found that hospitals that used scales for identifying suicide risk had a slightly lower median rate of repeat self-harm within 6 months, possibly reflecting a higher quality of risk assessment and aftercare in such hospitals (Quinlivan et al., 2014). Implementation of mandatory assessment of risk seems to be associated with declining suicide risk, but it is worth mentioning that there is a potential risk of false reassurance if scales are implemented mechanically. An important part of the work in early intervention services is the development of a crisis plan. Currently, evidence supports the feasibility of crisis plans prepared collaboratively with the patients, but the evidence demonstrating the efficacy of such plans is still lacking (Borschmann et al., 2013). The crisis plan typically includes three different elements: 1) actions and thoughts which the young person can activate to overcome suicidal thoughts and impulses; 2) a list of people in the personal network from whom the young person can get help and consolation; and 3) a list of help lines, professionals, or institutions from where the young person can get help. It is very important that crisis plans are revised, and with modern technology, it is relevant to have them stored on mobile telephones. Crisis plans can be combined with nice voice messages, pictures of loved ones, and favorite music. This can be implemented in Apps on mobile telephones. An example of a crisis plan (Nordentoft et al., 2009) is shown in Figure 1.
CONCLUSIONS AND RECOMMENDATIONS The steepest increase in suicide risk occurs during the first years after the first contact to mental health services, and this calls for early intensive intervention initiatives. By establishing closer contact with the patient and closer monitoring of symptoms, such initiatives can © 2015 Wolters Kluwer Health, Inc. All rights reserved.
Copyright © 2015 Wolters Kluwer Health, Inc. All rights reserved.
The Journal of Nervous and Mental Disease • Volume 203, Number 5, May 2015
Suicidal Behavior in Psychosis
FIGURE 1. An example of a crisis plan.
help reduce suicide risk in this high-risk period and thereby positively influence the long-term risk of suicide. Specialized early intervention services can offer comprehensive treatment to young persons with first episode psychosis and their families, and include adequate assessment and management of risk of suicide. The falling risk of suicide among patients with mental disorders in Denmark has been steepest among patients with schizophrenia and related disorders (Madsen and Nordentoft, 2013), probably reflecting improvements in services especially for this group of patients (Nordentoft et al., 2015). In the Danish Action Plan for Prevention of Suicide and Suicide Attempts, it was recommended that outpatient care immediately after discharge should be intensified and that it should be set as a standard that all patients should have an outpatient appointment within 1 week after discharge. The importance of this intervention is underlined by the finding that one third of all suicides in schizophrenia occur during admission or shortly after discharge. In the Danish National quality development project (National Indicator Project, schizophrenia), the standard is that all patients discharged from psychiatric department with a diagnosis of schizophrenia should be carefully interviewed and assessed with regard to risk of suicide. The British Action Plan contains similar elements. Such initiatives could be disseminated to other countries. ACKNOWLEDGMENT No specific funding for this article. DISCLOSURES The authors declare no conflict of interest.
Barrett EA, Sundet K, Faerden A, Nesvag R, Agartz I, Fosse R, Mork E, Steen NE, Andreassen OA, Melle I (2010) Suicidality before and in the early phases of first episode psychosis. Schizophr Res. 119:11–17. Bertelsen M, Jeppesen P, Petersen L, Thorup A, Øhlenschlæger J, le Quack P, Christensen TØ, Krarup G, Jørgensen P, Nordentoft M (2007) Suicidal behaviour and mortality in first-episode psychosis: the OPUS trial. Br J Psychiatry Suppl. 191:s140–s146. Birchwood M, Mihail M, Meaden A, Tarrier N, Lewis S, Wykes T, Davies L, Dunn G, Peters E (2014) Cognitive behaviour therapy to prevent harmful compliance with command hallucinations (COMMAND): a randomised controlled trial. Lancet Psychiatry. 1:23–33. Borschmann R, Barrett B, Hellier JM, Byford S, Henderson C, Rose D, Slade M, Sutherby K, Szmukler G, Thornicroft G, Hogg J, Moran P (2013) Joint crisis plans for people with borderline personality disorder: feasibility and outcomes in a randomised controlled trial. Br J Psychiatry. 202:357–364. Caldwell CB, Gottesman II (1990) Schizophrenics kill themselves too: a review of risk factors for suicide. Schizophr Bull. 16:571–589. Challis S, Nielssen O, Harris A, Large M (2013) Systematic meta-analysis of the risk factors for deliberate self-harm before and after treatment for first-episode psychosis. Acta Psychiatr Scand. 127:442–454. Dong JY, Ho TP, Kan CK (2005) A case–control study of 92 cases of in-patient suicides. J Affect Disord. 87:91–99. Dutta R, Murray RM, Hotopf M, Allardyce J, Jones PB, Boydell J (2010) Reassessing the long-term risk of suicide after a first episode of psychosis. Arch Gen Psychiatry. 67:1230–1237.
REFERENCES
Fedyszyn IE, Robinson J, Harris MG, Paxton SJ, Francey S (2012) Predictors of suicide-related behaviors during treatment following a first episode of psychosis: the contribution of baseline, past, and recent factors. Schizophr Res. 140:17–24.
Agerbo E (2007) High income, employment, postgraduate education, and marriage: a suicidal cocktail among psychiatric patients. Arch Gen Psychiatry. 64:1377–1384.
Goldacre M, Seagroatt V, Hawton K (1993) Suicide after discharge from psychiatric inpatient care [see comments]. Lancet. 342:283–286.
Appleby L, Shaw J, Amos T, McDonnell R, Harris C, McCann K, Kiernan K, Davies S, Bickley H, Parsons R (1999) Suicide within 12 months of contact with mental health services: national clinical survey [see comments]. BMJ. 318:1235–1239.
Harris EC, Barraclough B (1997) Suicide as an outcome for mental disorders. A metaanalysis. Br J Psychiatry. 170:205–228.
Bakst S, Rabinowitz J, Bromet EJ (2010) Antecedents and patterns of suicide behavior in first-admission psychosis. Schizophr Bull. 36:880–889.
Harvey SB, Dean K, Morgan C, Walsh E, Demjaha A, Dazzan P, Morgan K, Lloyd T, Fearon P, Jones PB, Murray RM (2008) Self-harm in first-episode psychosis. Br J Psychiatry. 192:178–184.
© 2015 Wolters Kluwer Health, Inc. All rights reserved. Copyright © 2015 Wolters Kluwer Health, Inc. All rights reserved.
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391
Nordentoft et al.
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Haw C, Hawton K, Sutton L, Sinclair J, Deeks J (2005) Schizophrenia and deliberate self-harm: a systematic review of risk factors. Suicide Life Threat Behav. 35:50–62. Hawton K, Sutton L, Haw C, Sinclair J, Deeks JJ (2005) Schizophrenia and suicide: systematic review of risk factors. Br J Psychiatry. 187:9–20. Inskip HM, Harris EC, Barraclough B (1998) Lifetime risk of suicide for affective disorder, alcoholism and schizophrenia. Br J Psychiatry. 172:35–37. Jepsen P, Qin P, Norgard B, Agerbo E, Mortensen PB, Vilstrup H, Sorensen HT (2005) The association between admission for poisoning with paracetamol or other weak analgesics and subsequent admission for psychiatric disorder: a Danish nationwide case–control study. Aliment Pharmacol Ther. 22:645–651. Kan CK, Ho TP, Dong JY, Dunn EL (2007) Risk factors for suicide in the immediate post-discharge period. Soc Psychiatry Psychiatr Epidemiol. 42:208–214. Kapur N, Hunt IM, Webb R, Bickley H, Windfuhr K, Shaw J, Appleby L (2006) Suicide in psychiatric in-patients in England, 1997 to 2003. Psychol Med. 36:1485–1492. Kapur N, Hunt IM, Windfuhr K, Rodway C, Webb R, Rahman MS, Shaw J, Appleby L (2013) Psychiatric in-patient care and suicide in England, 1997 to 2008: a longitudinal study. Psychol Med. 43:61–71. Large M, Babidge N, Andrews D, Storey P, Nielssen O (2009) Major self-mutilation in the first episode of psychosis. Schizophr Bull. 35:1012–1021.
Nordentoft M, Jeppesen P, Abel M, Kassow P, Petersen L, Thorup A, Krarup G, Hemmingsen R, Jorgensen P (2002) OPUS study: suicidal behaviour, suicidal ideation and hopelessness among patients with first-episode psychosis. One-year follow-up of a randomised controlled trial. Br J Psychiatry Suppl. 43:s98–s106. Nordentoft M, Laursen TM, Agerbo E, Qin P, Hoyer EH, Mortensen PB (2004) Change in suicide rates for patients with schizophrenia in Denmark, 1981–97: nested case–control study. BMJ. 329:261–266. Nordentoft M, Melau M, Iversen T, Kjær S (2009) Psykose hos unge symptomer, behandling og fremtid. Erfaringer fra OPUS, 1 ed. København, Psykiatrifondens Forlag. Nordentoft M, Melau M, Iversen T, Petersen L, Jeppesen P, Thorup A, Bertelsen M, Hjorthøj CR, Hastrup LH, Jørgensen P (2015) From research to practice: how OPUS treatment was accepted and implemented throughout Denmark. Early Interv Psychiatry. 9:156–162. Nordentoft M, Mortensen PB, Pedersen CB (2011) Absolute risk of suicide after first hospital contact in mental disorder. Arch Gen Psychiatry. 68:1058–1064. Nordentoft M, Wahlbeck K, Hallgren J, Westman J, Osby U, Alinaghizadeh H, Gissler M, Laursen TM (2013b) Excess mortality, causes of death and life expectancy in 270,770 patients with recent onset of mental disorders in Denmark, Finland and Sweden. PLoS One. 8:e55176.
Lawrence DM, Holman CD, Jablensky AV, Fuller SA (1999) Suicide rates in psychiatric in-patients: an application of record linkage to mental health research. Aust N Z J Public Health. 23:468–470.
Palmer BA, Pankratz VS, Bostwick JM (2005) The lifetime risk of suicide in schizophrenia: a reexamination. Arch Gen Psychiatry. 62:247–253.
Madsen T, Agerbo E, Mortensen PB, Nordentoft M (2012) Predictors of psychiatric inpatient suicide: a national prospective register-based study. J Clin Psychiatry. 73:144–151.
Pedersen CB, Mors O, Bertelsen A, Waltoft BL, Agerbo E, McGrath JJ, Mortensen PB, Eaton WW (2014) A comprehensive nationwide study of the incidence rate and lifetime risk for treated mental disorders 1. JAMA Psychiatry. 71:573–581.
Madsen T, Nordentoft M (2012) Suicidal changes in patients with first episode psychosis: clinical predictors of increasing suicidal tendency in the early treatment phase. Early Interv Psychiatry. 6:292–299.
Petersen L, Jeppesen P, Thorup A, Abel MB, Ohlenschlaeger J, Christensen TO, Krarup G, Jorgensen P, Nordentoft M (2005) A randomised multicentre trial of integrated versus standard treatment for patients with a first episode of psychotic illness. BMJ. 331:602.
Madsen T, Nordentoft M (2013) Changes in inpatient and postdischarge suicide rates in a nationwide cohort of Danish psychiatric inpatients, 1998–2005. J Clin Psychiatry. 74:e1190–e1194. Marshall M, Lockwood A, Lewis S, Fiander M (2004) Essential elements of an early intervention service for psychosis: the opinions of expert clinicians. BMC Psychiatry. 4:17. McGrew JH, Bond GR, Dietzen L, Salyers M (1994) Measuring the fidelity of implementation of a mental health program model. J Consult Clin Psychol. 62:670–678. Melau M (2013) Baseline Characteristics, Working Alliance and Patients' Perspectives — A cross-sectional and qualitative study in a cohort of patients with a first episode psychosis treated eighteen months in specialized early intervention services. Copenhagen, Denmark; PhD-thesis University of Copenhagen.
Pocock SJ (1996) Clinical Trials. A Practical Approach. Chichester New York Brisbane Toronto Singapore: John Wiley & Sons. Qin P, Agerbo E, Mortensen PB (2003) Suicide risk in relation to socioeconomic, demographic, psychiatric, and familial factors: a national register-based study of all suicides in Denmark, 1981–1997. Am J Psychiatry. 160:765–772. Qin P, Nordentoft M (2005) Suicide risk in relation to psychiatric hospitalization: evidence based on longitudinal registers. Arch Gen Psychiatry. 62:427–432. Quinlivan L, Cooper J, Steeg S, Davies L, Hawton K, Gunnell D, Kapur N (2014) Scales for predicting risk following self-harm: an observational study in 32 hospitals in England. BMJ Open. 4:e004732.
Melle I, Johannesen JO, Friis S, Haahr U, Joa I, Larsen TK, Opjordsmoen S, Rund BR, Simonsen E, Vaglum P, McGlashan T (2006) Early detection of the first episode of schizophrenia and suicidal behavior. Am. J Psychiatry. 163:800–804.
Robinson J, Harris MG, Harrigan SM, Henry LP, Farrelly S, Prosser A, Schwartz O, Jackson H, McGorry PD (2010) Suicide attempt in first-episode psychosis: a 7.4 year follow-up study. Schizophr Res. 116:1–8.
Melle I, Johannessen JO, Friis S, Haahr U, Joa I, Larsen TK, Opjordsmoen S, Rund BR, Simonsen E, Vaglum P, McGlashan T (2010) Course and predictors of suicidality over the first two years of treatment in first-episode schizophrenia spectrum psychosis. Arch Suicide Res. 14:158–170.
Rossau CD, Mortensen PB (1997) Risk factors for suicide in patients with schizophrenia: nested case–control study. Br J Psychiatry. 171:355–359.
Melle I, Larsen TK, Haahr U, Friis S, Johannessen JO, Opjordsmoen S, Simonsen E, Rund BR, Vaglum P, McGlashan T (2004) Reducing the duration of untreated firstepisode psychosis: effects on clinical presentation. Arch Gen Psychiatry. 61:143–150. Miles CP (1977) Conditions predisposing to suicide: a review. J Nerv Ment Dis. 164: 231–246. Mortensen PB, Agerbo E, Erikson T, Qin P, Westergaard-Nielsen N (2000) Psychiatric illness and risk factors for suicide in Denmark. Lancet. 355:9–12.
Runeson B, Tidemalm D, Dahlin M, Lichtenstein P, Langstrom N (2010) Method of attempted suicide as predictor of subsequent successful suicide: national long term cohort study. BMJ. 341:c3222. Stein LI, Santos AB (1998) Assertive community treatment of persons with severe mental illness. New York London: W.W. Norton & Company, INC. Taiminen TJ, Kujari H (1994) Antipsychotic medication and suicide risk among schizophrenic and paranoid inpatients. A controlled retrospective study. Acta Psychiatr Scand. 90:247–251.
Mortensen PB, Juel K (1993) Mortality and causes of death in first admitted schizophrenic patients. Br J Psychiatry. 163:183–189.
Wahlbeck K, Westman J, Nordentoft M, Gissler M, Laursen TM (2011) Outcomes of Nordic mental health systems: Life expectancy of patients with mental disorders. Br J Psychiatry. 199:453–458.
Neuner T, Schmid R, Wolfersdorf M, Spiessl H (2008) Predicting inpatient suicides and suicide attempts by using clinical routine data? Gen Hosp Psychiatry. 30:324–330.
World Health Organization (2013) Mental Health Action Plan 2013–2020. Geneva, Switzerland: World Health Organization.
Nielssen OB, Large MM (2009) Untreated psychotic illness in the survivors of violent suicide attempts. Early Interv Psychiatry. 3:116–122.
World Health Organization (2014) Preventing suicide - A global imperative. Geneva: World Health Organization.
392
www.jonmd.com
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