Strong Clinical Marker for Adolescent Suicide Attempts Identified

JAMA Psychiatry. Published online July 17, 2013.

Psychotic symptoms in adolescents, particularly in individuals with existing psychopathology, appear to be an accurate clinical marker for suicide attempts, new research shows.

In a longitudinal, population-based study, investigators at the Royal College of Surgeons in Ireland, located in Dublin, found that teens who reported psychotic symptoms at baseline had a 10- to 11-fold increased risk for attempted suicide compared with their counterparts who had no psychotic symptoms. The risk was even more pronounced in adolescents with psychotic symptoms and emotional disorder, such as depression and anxiety.

“[T]he presence of psychotic symptoms predicted a very high risk of suicide attempts during the following 12 months. Among adolescents with psychopathology, those who reported psychotic symptoms had a nearly 70-fold increased odds of acute suicide attempts compared with the rest of the population, but this risk was not significantly increased in those who did not report psychotic symptoms,” the authors, led by Ian Kelleher, MD, PhD, write.

Opportunity for Prevention

The World Health Organization estimates that suicide is among the leading causes of death worldwide. The researchers note that about 50% of patients who die by suicide have contact with primary care providers in the month before their death, offering an opportunity for prevention.

However, they point out that suicide assessment is considered to be one of the most difficult areas of clinical practice, adding that “although psychopathology, especially depression, is well established as a major risk factor for suicidal behavior, its high prevalence in the population makes it difficult to identify a meaningful ‘at risk’ group.”

With an estimated prevalence of 7.5%, the investigators note that psychotic symptoms are much more prevalent in the population than full-blown psychotic disorder.

Sometimes such symptoms are “frankly psychotic,” but more often they occur in an “attenuated form,” in which individuals have hallucinations or delusions but their sense of reality remains intact.

Recent research suggests that these symptoms are an “underrecognized marker of risk for suicidal behavior,” but the researchers note that there have been no longitudinal studies examining psychotic symptoms as a predictor of suicidal behavior over time.

The current study, which included 1112 school-based adolescents aged 13 to 16 years, investigated whether the co-occurrence of psychotic symptoms at baseline predicted increased suicide attempts at 3- and 12-month follow-up.

In addition, the researchers looked at whether the co-occurrence of psychotic symptoms with psychopathology “would predict an increased risk of suicide attempt, beyond that predicted by psychopathology alone.”

70-Fold Increased Risk

Study participants were assessed at baseline and at 3 and 12 months for self-reported psychopathology, psychotic symptoms, and suicide attempts using the Strengths and Difficulties Questionnaire, the Adolescent Psychotic Symptoms Screener, and the Paykel Suicide Scale, respectively.

Of the total cohort (1112), 7% (n = 77) reported baseline psychotic symptoms, and of these individuals, 7% (n = 4) reported a suicide attempt at 3-month follow-up compared with 1% (n = 12) of the rest of the sample (odds ratio [OR], 10.01; 95% confidence interval [CI], 2.24 – 45.49).

At 12-month follow-up, 20% (n = 9) of teens with psychotic symptoms reported a suicide attempt vs 2.5% (n = 23) of the rest of the sample (OR, 11.27; 95% CI, 4.44 – 28.62).

Among adolescents with baseline psychopathology who reported psychotic symptoms, 14% reported a suicide attempt by 3 months (OR, 17.91; 95% CI, 3.61 – 88.82), and 34% reported a suicide attempt by 12 months (OR, 32.67; 95% CI, 10.42 – 102.41).

Overall, the investigators found that teens with psychopathology who reported psychotic symptoms had nearly a 70-fold increased risk for acute suicide attempts (OR, 67.50; 95% CI, 11.41 – 399.21).

Potential Mechanisms

The reason psychotic symptoms are such a strong predictor of suicidal behavior is unclear, but researchers speculate that they may be a marker of escalating psychopathology.

It is also possible that individuals who experience psychotic symptoms are more sensitive to stress and may have poorer coping skills, which may increase their risk for suicidal behavior when they are faced with “acute life stressors.”

Other potential mechanisms include possible shared risk factors for suicidal behavior and psychotic symptoms, such as childhood trauma, including physical and sexual abuse.

“Adolescents with psychopathology who report psychotic symptoms are at clinical high risk for suicide attempts. More careful clinical assessment of psychotic symptoms (attenuated or frank) in mental health services and better understanding of their pathological significance are urgently needed,” the investigators conclude.

Full JAMA Article Can Be Found Here:

JAMA Psychiatry. Published online July 17, 2013.

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