Suicidality in psychotic disorders; demographical, clinical, and neurocognitive correlates
Appears in the following Collection
- Psykologisk institutt 
AbstractThe overall aim of this thesis was to identify possible demographical, clinical, and neurocognitive risk factors for suicidal behaviour in patients with psychotic disorders.
Suicidal behaviour and neurocognitive impairment are serious and prevalent problems in patients with schizophrenia. Studies indicate that suicidality in patients with schizophrenia may be associated with relatively higher neurocognitive functioning, but the findings are few and inconsistent. Also, behavioural- and personality measures of impulsivity have been linked to increased suicidal behaviour in patients with schizophrenia, but this relationship has not been studied by neuropsychological measures. The first aim of the present thesis was to investigate whether suicide attempters had higher IQ, better executive functioning, or were more impulsive (had poorer inhibitory control) compared to non-attempters in a group of patients with schizophrenia spectrum disorders. The possible confounding effect of current suicidality was taken into account. In a group of 174 patients with schizophrenia spectrum disorders, we found that there were no difference between suicide attempters and non-attempters in IQ, executive function, impulsivity (inhibitory control), or any other neurocognitive domain. The presence of current suicidality did not confound the results. An interesting post hoc finding was that currently suicidal patients were more impulsive (had poorer inhibitory control) than currently non-suicidal patients, but this difference was mediated by positive psychotic symptoms.
The suicide risk in psychotic disorders is highest in the early phases of illness. Studies have typically focused on suicidality from treatment start rather than the actual onset of psychosis. Thus, the second aim of the thesis was to explore the prevalence and characteristics of patients with a first episode of psychosis and suicidality in two different time intervals: 1) prior to study entry and 2) explicitly in the period of untreated psychosis. In a sample of 170 patients with first episode of psychosis, we found that nearly 26% of the patients attempted suicide prior to study entry, and 14% made suicide attempts during the period of untreated psychosis. Of the patients who had been suicidal (i.e. experienced suicidal ideation or attempts), 70% were suicidal during the period of untreated psychosis. Suicide attempts prior to study entry were associated with female gender, more depressive episodes, younger age at psychosis onset, and history of alcohol disorder. Suicide attempts during untreated psychosis were also associated with more depressive episodes and younger age at illness onset, in addition to drug use the last six months and longer duration of untreated psychosis (DUP).
Insight has been found to be associated with increased risk for suicidal behaviour, but not consistently. A possible explanation for this is that insight has different consequences for patients depending on their beliefs about psychosis. The third aim of this thesis was to investigate whether a relationship between insight, negative beliefs about psychosis, and suicidality was mediated by depressive symptoms, and if negative beliefs about psychosis moderated the relationship between insight and suicidality. In a sample of 194 patients with a first episode of psychosis, we found that nearly 46% of the patients were currently suicidal. Depressive symptoms, having a schizophrenia spectrum disorder, insight, and beliefs about negative outcomes for psychosis were independently associated with current suicidality; contradicting a mediating effect of depressive symptoms. Negative beliefs about psychosis did not moderate the effect of insight on current suicidality.
In conclusion, our results suggest that neurocognitive functioning is not essential for engaging in suicidal acts, at least not the neurocognitive domains measured in the present study. Furthermore, the prevalence of suicidality before and in the early phases of first episode psychosis is high, especially during untreated psychosis. As prolonged DUP is associated with suicide attempts during the period of untreated psychosis, reducing the DUP could have the effect of reducing the prevalence of suicide attempts in patients with first episode psychosis. Our findings also indicate that more depressive symptoms, higher insight, and negative beliefs about psychosis increase the risk for suicidality in patients with first episode of psychosis. This finding imply that monitoring insight should be part of assessing the suicide risk in patients with first episode psychosis, and that treating depression and counteracting negative beliefs about psychosis may possibly reduce the risk for suicidality.
List of papers. Papers I-III are removed from the thesis due to copyright restrictions.
Study I: Barrett, E.A, Sundet, K., Simonsen, C., Agartz, I., Lorentzen, S., Mehlum, L., Mork, E., Andreassen O.A., Melle, I.: Neurocognitive functioning and suicidality in schizophrenia spectrum disorders. Comprehensive Psychiatry 2010 - Article in press. doi:10.1016/j.comppsych.2010.06.001
Study II: Barrett, E. A., Sundet, K., Faerden, A., Nesvag, R., Agartz, I., Fosse, R., Mork, E., Steen, N.E., Andreassen, O.A., Melle, I.: Suicidality before and in the early phases of first episode psychosis. Schizophrenia Research 2010;119(1):11-17. doi:10.1016/j.schres.2010.03.022
Study III: Barrett, E. A., Sundet, K., Faerden, A., Agartz, I., Bratlien, U., Romm, K. L., Mork, E., Rossberg, J.I., Steen, N.E., Andreasen, O.A., Melle, I.: Suicidality in first episode psychosis is associated with insight and negative beliefs about psychosis. Schizophrenia Research 2010;123(2):257262 doi:10.1016/j.schres.2010.07.018