The risk of suicide is high in patients with psychosis: 20% to 40% will attempt suicide during their lifetime, and about 8% to 10% will die by suicide.1 The risk is higher among adolescents, especially for those with first episode psychosis (FEP).1-3
In this article, we review information from studies on adolescents with psychosis and discuss the evidence about the risk of suicide and suicidal behavior in this patient population.
Studies have consistently found that adolescents with psychosis are at higher risk for suicide than are adults with psychotic disorders. Also, adolescents with psychotic symptoms are nearly 70 times more likely to attempt suicide than are adolescents in the general population.4 In 1995, a German group monitored adolescents with schizophrenia and suicidal behavior.5 The study is of interest because only adolescents aged 14 to 18 were included. Over 5 to 11 years, 13.1% completed suicide. An Israeli group assessed 48 psychotic adolescents aged 13 to 19.6 They found that schizophrenia-related depression may be similar to that of a major depressive episode, and that the risk of suicidality may be as great. These results are summarized in Table 1.
First episode psychosis and suicide
Important differences have been reported in the rates of suicide attempts (10% to 28%) and suicidal ideation and behavior in patients with FEP. During the first 6 months after the onset of psychotic symptoms regardless of age, patients may be at greatest risk for suicide. Up to 26% of patients with schizophrenia have attempted suicide by the time they are admitted to the psychiatric hospital for the first time. A Norwegian group compiled FEP profiles of 43 adolescents and 189 adults.7 A significantly higher percentage of the adolescents disclosed suicidal plans or behavior (11, or 26%, vs 22, or 12%, of the adults).
In a retrospective study that compared 102 adolescents with FEP with a control group of 98 adolescents with no psychosis admitted to an inpatient child psychiatry unit, the FEP group had twice as many suicide attempts.3 The number of repeated attempts in adolescents with FEP may be higher: in a retrospective sample of adolescents with FEP, the group of patients with suicide attempts was older than the group of adolescents with FEP with no suicide attempts.3
In some patients, the first episode of psychosis can be triggered by substance abuse. Hambrecht and Häfner8 reported the frequency of alcohol abuse in FEP was double that of the general population. Increases in the use of cannabis of up to 70% have also been reported in patients with FEP.9
In a 24-month follow-up study of 110 patients with FEP, investigators reported suicidal behavior and depressive symptoms at admission as the key predictors of suicide by 24 months.1 In this group, 12.4% of patients with psychosis attempted suicide in the first 2 years after the diagnosis: the first year after the diagnosis was the highest-risk period. The severity of the psychotic symptoms was not associated with suicidal behavior in this sample.
Dr Falcone is Assistant Professor in the departments of psychiatry and neurology, Neurological Institute, Cleveland Clinic Foundation; Dr Timmons-Mitchell is Senior Research Associate at the Begun Center for Violence Prevention, Research and Education at the Jack, Joseph and Morton Mandel School of Applied Social Sciences at Case Western Reserve University, Cleveland. They report no conflicts of interest concerning the subject matter of this article.
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13. Early Psychosis Prevention and Intervention Centre. http://eppic.org.au. Accessed October 8, 2013.
14. Assertive Community Treatment Association. http://www.actassociation.org. Accessed October 8, 2013.