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High rates of suicide attempt in early-onset psychosis are associated with depression, anxiety and previous self-harm
  1. Olav Nielssen1,
  2. Matthew Large2
  1. 1St Vincent's Hospital/University of New South Wales, Sydney, New South Wales, Australia;
  2. 2Prince of Wales Hospital/University of New South Wales, Sydney, New South Wales, Australia
  1. Correspondence to Olav Nielssen, olavn{at}

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What is already known on this topic?

Suicide is a major cause of death among people who develop psychotic illness.1 The period between the onset of symptoms and adequate treatment is known to be a period with a greatly increased incidence of self-harm and violence to others.2 A recent meta-analysis found that 18.4% of first-episode patients had self-harmed or attempted suicide prior to initial treatment, while the proportion of patients who committed acts of self-harm in the period after initial treatment was 11.4%.3 Risk factors associated with self-harm in early psychosis established by meta-analysis include a prior history of self-harm, younger age at onset and initial treatment, depressed mood and a longer duration of untreated psychosis.2

What this paper adds?

  • The rate of attempted suicide after initiation of treatment for first episode psychosis is similar to the rate among older patients.

  • The strength of the associations between severe depression and previous suicide attempts and deliberate self-harm (DSH) might be stronger than among adult patients.

  • Anxiety symptoms might be an important but under-recognised risk factor for DSH in younger people.

  • Clinical impression might be a useful marker of suicide risk in young first-episode patients.


  • The study may have missed some significant associations (false negatives) because of the small sample size.

  • The study examined 30 potential risk factors, raising the likelihood that some associations were significant by chance (false positives).

  • The proportion of patients with substance-use disorders was low meaning the results might not be as relevant to young patients with substance-use disorders.

What next in research?

A randomised controlled trial, with one arm providing intensive treatment to patients identified as high-risk and less intensive treatment to low-risk patients, while patients in the other arm are not risk-assessed and receive treatment as usual. Such a study could test the generally held assumption that risk assessment is a rational basis for allocating treatment resources.

Do these results change my practice and why?

The results change our practice by increasing our awareness of suicide risk in early psychosis and the need to identify and treat depression in this group.



ABSTRACT FROM: Sanchez-Gistau V, Baeza I, Arango C, et al. Predictors of suicide attempt in early-onset, first-episode psychoses: a longitudinal 24-month follow-up study. J Clin Psychiatry 2013;74:59–66.

Patients/participants One hundred and ten young people (age 9–17 years) in their first episode of psychosis, defined as the presence of positive psychotic symptoms of less than 6 months duration. At 2-year follow-up, 84 participants remained in the study (no significant difference was found between completers and non-completers), at which time 41 were diagnosed with schizophrenia (DSM-IV), 7 with schizoaffective disorder, 19 with bipolar disorder, 4 with depressive disorder and 5 with unspecified psychoses, while the remaining 6 participants had no present diagnosis of psychosis.

Setting Six child and adolescent psychiatry departments in Spain; enrolment March 2003 to November 2005.

Prognostic factors Suicidal behaviour at baseline was assessed through Clinical Global Impression for Severity of Suicidality (CGI-SS), and item 3 of the Hamilton Depression Rating Scale (HDRS); participants were classified as being at high, low or no risk of suicide. Other potential prognostic factors measured were age, gender, socioeconomic status (Hollingshead-Redlich Scale), family history of psychiatric disorders or completed suicide, psychotic, manic and depressive symptomatology (PANSS, Youth Mania Rating Scale (YMRS) and HDRS scores, respectively), duration of untreated psychosis and insight into psychosis, past or current DSM-IV Axis I disorders IQ and drug treatment.

Control Participants not attempting suicide during follow-up; participants classified as having low or no risk of suicide at baseline.

Follow-up period Two years.


Prevalence of attempted suicide During the first 12 months, 11.7% (11/94) participants attempted suicide; during the second 12 months, 2.5% (2/81) of participants made a suicide attempt. The 24-month prevalence of suicide attempters was 12.4% (10/82), of whom half had also attempted suicide prior to first admission. Four participants attempted suicide once, two people twice, one person five times, two people seven times and one person eight times; one suicide attempt was fatal.

Prediction of suicide attempts Being at high risk of suicide predicted suicide attempts (adjusted OR (AOR)=81.67, 95% CI 11.61 to 574.35).

Factors associated with being classified as high-suicide risk Participants were significantly more likely to be classified as being at high-suicide risk if they had a history of suicide attempts prior to the current psychotic episode (AOR=20.13, 95% CI 1.83 to 220.55), severe depressive symptoms (AOR=8.78, 95% CI 1.15 to 67.11) and to be taking antidepressants (AOR=15.56, 95% CI 2.66 to 90.86). Suicide attempters and non-attempters did not differ in terms of diagnostic subtype (affective or non-affective psychosis) or in positive and negative PANSS scores.


  • Competing interests ON is a member of a Lundbeck Advisory Board. ON and ML have received speaker's fees from Astra Zeneca in the past 5 years.