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PSYCHOTIC EXPERIENCES AS A PREDICTOR OF THE NATURAL COURSE OF, SUICIDAL IDEATION: A SWEDISH COHORT STUDY
Abstracts of the 4th Biennial Schizophrenia International Research Conference / Schizophrenia Research 153, Supplement 1 (2014) S1–S384
suicide-related behaviour in young people and the to examine in more detail the evidence for a range of interventions designed to reduce risk that could inform both clinical practice and government policy. Methods: Three systematic reviews, and one narrative review, were conducted in order to examine the range, and effectiveness, of interventions designed to reduce suicide risk among young people, in clinical, schoolbased and online settings. For each of the reviews conducted suicide-related behaviour had to be a primary outcome of interest. Results: Suicide prevention in clinical settings: Fifteen published trails were included. Of them two targeted young people with mood disorders, one targeted young people with borderline personality disorder and one study targeted young people with a psychotic disorder. Interventions included (but are not restricted to): medication, a family-based intervention, dialectical behavioural therapy, problem-solving therapy, cognitive behavioural therapy and group therapy. No differences were found between treatment and control groups except in one study that found a difference in rates of suicidal ideation between individual cognitive behavioural therapy and treatment as usual. Suicide prevention in school settings: Forty-three studies were included here, of which 15 reported on universal education or awareness programs, 23 reported on selective interventions (e.g. gatekeeper training and screening programs), 3 reported on targeted interventions, and 2 examined a postvention response in schools. Of these studies the most promising appeared to be gatekeeper training and screening programs, although more research is necessary. Suicide prevention in online settings: These reviews found that, despite the number, and potential effectiveness of, online programs for young people with depression and/or anxiety disorders, there are currently no published studies reporting on the effects of online therapy for suicidal youth. Similarly a number of studies have been found that discuss the relationship between suicide and social media, however despite the popularity and the potential reach of social media, no actual interventions studies were identified. Discussion: Overall it is concluded that whilst we know much about the epidemiology of suicide among youth, there is a dearth of well-conducted studies that provide adequate evidence regarding what works in youth suicide prevention. This has implications both clinically and at a policy level. A greater emphasis on intervention studies – including novel interventions – would lead to better practice in terms of detecting and supporting suicidal young people, and could also contribute to a better informed, and more evidence-based, policy agenda around the world.
PSYCHOTIC EXPERIENCES AS A PREDICTOR OF THE NATURAL COURSE OF SUICIDAL IDEATION: A SWEDISH COHORT STUDY Ian Kelleher 1 , Martin Cederlöf 2 , Paul Lichtenstein 2 Royal College of Surgeons in Ireland, Karolinska Institutet, Stockholm, Sweden; 2 Karolinska Institutet, Department of Medical Epidemiology and Biostatistics, Nobels vag 12A, 17177 Stockholm, Sweden 1
Background: Psychotic experiences are far more prevalent in the population than psychotic disorders and are associated with a wide range of depressive, anxiety and behavioral disorders, as well as increased risk for psychotic disorder. Recently, psychotic experiences have been highlighted as a potentially valuable clinical marker of risk for suicidal behavior. There have been few studies to date, however, to assess psychotic experiences as a predictor of suicidality over time. Method: We wished to assess whether young persons with suicidal ideation at baseline assessment who reported psychotic experiences were at higher risk for persistence of suicidal ideation at follow up than young persons who also reported suicidal ideation at baseline but who did not report co-occurring psychotic experiences. A total of 2,263 Swedish adolescents were assessed at ages 13 to 14 years for psychotic experiences, suicidal ideation and internalizing and externalizing psychopathology. Participants were re-assessed at ages 16 to 17 years and 19 to 20 years. Results: Among 13- to 14-year olds with suicidal ideation, co-occurring psychotic experiences did not predict an increased odds of persistence of suicidal ideation to 16 to 17 years (OR=0.94, 95%CI=0.19-4.78). Among 16to 17-year olds with suicidal ideation, however, co-occurring psychotic experiences predicted a 6-fold increased odds of persistence of suicidal ideation to ages 19 to 20 years (OR=5.53, 95%CI=1.33-23.00). This finding was not explained by internalizing or externalizing psychopathology or by cannabis use.
S11
Discussion: Although most suicidal ideation is transient and does not require close clinical attention, for some individuals, suicidal ideation becomes persistent, causing long-term morbidity, mental distress and ultimately increasing the risk of attempted and completed suicide. Identification of individuals whose suicidal ideation is likely to become persistent, then, is an important, if complex, challenge in clinical psychiatry. Our results show that psychotic experiences are an important, but under-recognized, marker of risk for persistence of suicidal ideation, in particular from midadolescence. An increased emphasis on the clinical assessment of psychotic experiences in mental health services should be a priority
DEPRESSION AND SUICIDALITY IN FIRST EPISODE PSYCHOSIS: SUBORDINATION AND SHAME Rachel Upthegrove 1,2 , Jonathan Ives 3 , Amrita Sandhu 3 , Lisa Jones 3 , Kerry Ross 4 , Katerine Brunet 4 1 University of Birmingham; 2 Early Intervention Service; 3 School of Clinical and Experimental Medicine, University of Birmingham; 4 Early Intervention Service, Birmingham and Solihull Mental Helath Trust Suicidal behaviour in early psychosis is linked to depression and hopelessness, however the meaning and mechanisms of this association is understudied. We may accept a depressive dimension in psychosis, in keeping with a dimensional rather than categorical approach, however our concepts of this depression here has been transported wholesale from unipolar affective disorders. It is not clear that this is a valid approach. We will present a series of short papers exploring the development and phenomenology of depression and suicidal thinking in early psychosis. We aimed initially to have a clearer understanding of the ebb and flow of depression and suicidal thinking in the early phase of psychosis, whether these events are predictable and how they relate to the early course of psychotic symptoms. Ninety-two patients with first episode psychosis (FEP) completed measures of self harm, hopelessness, depression, and duration of untreated psychosis. Follow-up took place over 12 months. A combination of depression and suicidal thinking was present in 63%. Depression in the prodromal phase was the most significant predictor of future depression and acts of self-harm and thus may be key to the development of future depression and suicidal thinking. Exploring the relationship between early psychotic symptoms and suicidal ideation in detail, we examined the relationship of depression and suicidal thinking with appraisal of illness, voices and persecutors. Prospective data was gathered on 72 patients with acute FEP on depression, severity and experience of positive symptoms, insight and appraisals of illness using validated interviews over12 months. Malevolent voices, use of safety behaviours and subordination to persecutors was associated with depression and suicidal behaviour in acute FEP. Loss, shame, low level continuing positive symptoms and longer duration of untreated psychosis were associated with post psychotic depression. Negative appraisals remained stable despite recovery in other symptom domains. Thus depression in early psychosis may be propagated by the personal significance and content of positive symptoms experienced in FEP. In recovery, low level symptoms, longer period of illness and negative appraisals are significant factors. Using novel qualitative methodology, we went on to explore the subjective experience and phenomenological features of post-psychotic depression using photo-elicitation and unstructured interviews. The psychotic episode was a traumatic event followed by subjective doubt, shame and embarrassment. Common biological symptoms of depression did not feature. Participants rather felt that the psychotic episode had destroyed their personality and identity, leading to a loss of role, status and suicidal ideation; “It’s a feeling of worthlessness, feeling of no hope, feeling of you’re useless to anything, anyone . . . you got nothing to look forward to, it’s all taken away from you.” Efforts to predict and reduce suicide in psychosis may need to target the early phase of illness to reduce later risk. Understanding this dimension of psychosis in and of itself has the potential to improve and aid development of more effective and appropriately targeted interventions.
suicide-related behaviour in young people and the to examine in more detail the evidence for a range of interventions designed to reduce risk that could inform both clinical practice and government policy. Methods: Three systematic reviews, and one narrative review, were conducted in order to examine the range, and effectiveness, of interventions designed to reduce suicide risk among young people, in clinical, schoolbased and online settings. For each of the reviews conducted suicide-related behaviour had to be a primary outcome of interest. Results: Suicide prevention in clinical settings: Fifteen published trails were included. Of them two targeted young people with mood disorders, one targeted young people with borderline personality disorder and one study targeted young people with a psychotic disorder. Interventions included (but are not restricted to): medication, a family-based intervention, dialectical behavioural therapy, problem-solving therapy, cognitive behavioural therapy and group therapy. No differences were found between treatment and control groups except in one study that found a difference in rates of suicidal ideation between individual cognitive behavioural therapy and treatment as usual. Suicide prevention in school settings: Forty-three studies were included here, of which 15 reported on universal education or awareness programs, 23 reported on selective interventions (e.g. gatekeeper training and screening programs), 3 reported on targeted interventions, and 2 examined a postvention response in schools. Of these studies the most promising appeared to be gatekeeper training and screening programs, although more research is necessary. Suicide prevention in online settings: These reviews found that, despite the number, and potential effectiveness of, online programs for young people with depression and/or anxiety disorders, there are currently no published studies reporting on the effects of online therapy for suicidal youth. Similarly a number of studies have been found that discuss the relationship between suicide and social media, however despite the popularity and the potential reach of social media, no actual interventions studies were identified. Discussion: Overall it is concluded that whilst we know much about the epidemiology of suicide among youth, there is a dearth of well-conducted studies that provide adequate evidence regarding what works in youth suicide prevention. This has implications both clinically and at a policy level. A greater emphasis on intervention studies – including novel interventions – would lead to better practice in terms of detecting and supporting suicidal young people, and could also contribute to a better informed, and more evidence-based, policy agenda around the world.
PSYCHOTIC EXPERIENCES AS A PREDICTOR OF THE NATURAL COURSE OF SUICIDAL IDEATION: A SWEDISH COHORT STUDY Ian Kelleher 1 , Martin Cederlöf 2 , Paul Lichtenstein 2 Royal College of Surgeons in Ireland, Karolinska Institutet, Stockholm, Sweden; 2 Karolinska Institutet, Department of Medical Epidemiology and Biostatistics, Nobels vag 12A, 17177 Stockholm, Sweden 1
Background: Psychotic experiences are far more prevalent in the population than psychotic disorders and are associated with a wide range of depressive, anxiety and behavioral disorders, as well as increased risk for psychotic disorder. Recently, psychotic experiences have been highlighted as a potentially valuable clinical marker of risk for suicidal behavior. There have been few studies to date, however, to assess psychotic experiences as a predictor of suicidality over time. Method: We wished to assess whether young persons with suicidal ideation at baseline assessment who reported psychotic experiences were at higher risk for persistence of suicidal ideation at follow up than young persons who also reported suicidal ideation at baseline but who did not report co-occurring psychotic experiences. A total of 2,263 Swedish adolescents were assessed at ages 13 to 14 years for psychotic experiences, suicidal ideation and internalizing and externalizing psychopathology. Participants were re-assessed at ages 16 to 17 years and 19 to 20 years. Results: Among 13- to 14-year olds with suicidal ideation, co-occurring psychotic experiences did not predict an increased odds of persistence of suicidal ideation to 16 to 17 years (OR=0.94, 95%CI=0.19-4.78). Among 16to 17-year olds with suicidal ideation, however, co-occurring psychotic experiences predicted a 6-fold increased odds of persistence of suicidal ideation to ages 19 to 20 years (OR=5.53, 95%CI=1.33-23.00). This finding was not explained by internalizing or externalizing psychopathology or by cannabis use.
S11
Discussion: Although most suicidal ideation is transient and does not require close clinical attention, for some individuals, suicidal ideation becomes persistent, causing long-term morbidity, mental distress and ultimately increasing the risk of attempted and completed suicide. Identification of individuals whose suicidal ideation is likely to become persistent, then, is an important, if complex, challenge in clinical psychiatry. Our results show that psychotic experiences are an important, but under-recognized, marker of risk for persistence of suicidal ideation, in particular from midadolescence. An increased emphasis on the clinical assessment of psychotic experiences in mental health services should be a priority
DEPRESSION AND SUICIDALITY IN FIRST EPISODE PSYCHOSIS: SUBORDINATION AND SHAME Rachel Upthegrove 1,2 , Jonathan Ives 3 , Amrita Sandhu 3 , Lisa Jones 3 , Kerry Ross 4 , Katerine Brunet 4 1 University of Birmingham; 2 Early Intervention Service; 3 School of Clinical and Experimental Medicine, University of Birmingham; 4 Early Intervention Service, Birmingham and Solihull Mental Helath Trust Suicidal behaviour in early psychosis is linked to depression and hopelessness, however the meaning and mechanisms of this association is understudied. We may accept a depressive dimension in psychosis, in keeping with a dimensional rather than categorical approach, however our concepts of this depression here has been transported wholesale from unipolar affective disorders. It is not clear that this is a valid approach. We will present a series of short papers exploring the development and phenomenology of depression and suicidal thinking in early psychosis. We aimed initially to have a clearer understanding of the ebb and flow of depression and suicidal thinking in the early phase of psychosis, whether these events are predictable and how they relate to the early course of psychotic symptoms. Ninety-two patients with first episode psychosis (FEP) completed measures of self harm, hopelessness, depression, and duration of untreated psychosis. Follow-up took place over 12 months. A combination of depression and suicidal thinking was present in 63%. Depression in the prodromal phase was the most significant predictor of future depression and acts of self-harm and thus may be key to the development of future depression and suicidal thinking. Exploring the relationship between early psychotic symptoms and suicidal ideation in detail, we examined the relationship of depression and suicidal thinking with appraisal of illness, voices and persecutors. Prospective data was gathered on 72 patients with acute FEP on depression, severity and experience of positive symptoms, insight and appraisals of illness using validated interviews over12 months. Malevolent voices, use of safety behaviours and subordination to persecutors was associated with depression and suicidal behaviour in acute FEP. Loss, shame, low level continuing positive symptoms and longer duration of untreated psychosis were associated with post psychotic depression. Negative appraisals remained stable despite recovery in other symptom domains. Thus depression in early psychosis may be propagated by the personal significance and content of positive symptoms experienced in FEP. In recovery, low level symptoms, longer period of illness and negative appraisals are significant factors. Using novel qualitative methodology, we went on to explore the subjective experience and phenomenological features of post-psychotic depression using photo-elicitation and unstructured interviews. The psychotic episode was a traumatic event followed by subjective doubt, shame and embarrassment. Common biological symptoms of depression did not feature. Participants rather felt that the psychotic episode had destroyed their personality and identity, leading to a loss of role, status and suicidal ideation; “It’s a feeling of worthlessness, feeling of no hope, feeling of you’re useless to anything, anyone . . . you got nothing to look forward to, it’s all taken away from you.” Efforts to predict and reduce suicide in psychosis may need to target the early phase of illness to reduce later risk. Understanding this dimension of psychosis in and of itself has the potential to improve and aid development of more effective and appropriately targeted interventions.