Psychotic symptoms signal adolescent suicide attempt risk



Psychotic symptoms in adolescents are a clinical marker of high risk for suicide attempts, particularly in those with psychopathology, according to findings from the Saving and Empowering Young Lives in Europe study.

Of 1,112 adolescents aged 13-16 years who were part of the randomized, prospective cohort study, 7% reported psychotic symptoms at baseline, and of those, 7% attempted suicide within 3 months, compared with 1% of the rest of the sample (odds ratio, 10.01), and 20% attempted suicide within 12 months, compared with 2.5% of the rest of the sample (OR, 11.27), Dr. Ian Kelleher of Beaumont Hospital, Dublin, and his colleagues reported July 17 online in JAMA Psychiatry.

Among those with baseline psychopathology, 23% reported psychotic symptoms, compared with 4% of the rest of the sample (OR, 8.13), and the percentage of those with both psychopathology and psychotic symptoms at baseline who reported a suicide attempt by 3 months was 14% (OR, 17.91). More than a third (34%) of those with both psychopathology and psychotic symptoms at baseline attempted suicide by 12 months (OR, 32.67), the investigators reported (JAMA Psychiatry 2013 July 17[doi:10.1001/jamapsychiatry.2013.140]).

"Although the presence of psychopathology without psychotic symptoms at baseline predicted suicide attempts over time, albeit to a lesser degree than psychopathology with psychotic symptoms, some participants who were not experiencing psychotic symptoms at the time of the assessment may have experienced such symptoms closer to the time of their suicide attempt," the investigators noted.

To assess for this possibility, they looked specifically at acute suicide attempts – those occurring within the 2 weeks prior to the 3- and 12-month assessments – and found that subjects with psychopathology who did not report psychotic symptoms did not have significantly increased odds of such suicide attempts (OR, 1.09).

"Those with psychopathology who did experience psychotic symptoms, on the other hand, had a nearly 70-fold increased odds of acute suicide attempts (OR, 67.50)," they wrote, adding that in absolute terms, those with psychotic symptoms comprised less than a quarter of the total groups with psychopathology, but accounted for nearly 80% of the acute suicide attempts in the group.

The association between psychotic symptoms and suicide attempts was not explained by nonpsychotic psychiatric symptom burden or by multimorbidity, the investigators added.

The findings underscore the importance of assessing psychotic symptoms in individuals with suspected psychopathology, and the need to recognize suicide risk when these symptoms are present, they said.

"It is also important to recognize that most such symptoms do not present as true hallucinations; that is, they may occur with intact reality testing and thus may be attenuated rather than frankly psychotic," they noted.

As for why psychotic symptoms predict suicidal behavior, the reasons are not readily clear, but it is possible that psychotic symptoms are a marker of increasing severity of psychopathology, the investigators said.

Also, individuals who experience psychotic symptoms may have increased sensitivity to stress, as well as poor coping skills, which might contribute to a greater risk of suicidal behavior in the face of acute life stressors, they said, adding that shared risk factors for suicidal behavior and psychotic symptoms, such as childhood traumatic experiences, also might play a role.

Given that suicide is among the leading causes of death worldwide, and that suicide risk assessment is recognized as one of the most difficult areas of clinical practice, the findings offer some hope for improving recognition of risk based on the presence of psychotic symptoms.

"An important clinical implication of these findings is the need for a new clinical focus on careful assessment of psychotic symptoms (both attenuated and frank) in patients with nonpsychotic disorders; this should be considered a key element of suicide risk assessment," the investigators said.

Participants in the Saving and Empowering Young Lives in Europe (SEYLE) study – a randomized clinical trial aimed at assessing prevention strategies for suicidal behavior – were school-age students from 11 countries. Those included in the current analysis were students from 17 randomly selected schools in Ireland who completed questionnaires that included information about psychopathology and psychotic symptoms, and who completed 12 months of follow-up.

Additional research, including research among older age groups, is needed, the investigators wrote.

"Further community and clinical research on suicidal behavior and psychotic symptoms would be valuable, as would research on underlying mechanisms that might explain this relationship and research that provides targets for intervention," they concluded

The SEYLE project is supported by a grant from the European Union Seventh Framework Programme. Dr. Kelleher was supported by an Interdisciplinary Capacity Enhancement Award from the Health Research Board Ireland.

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