Original Investigation |

Psychotic Symptoms and Population Risk for Suicide Attempt:  A Prospective Cohort Study

Ian Kelleher, MD, PhD1; Paul Corcoran, PhD2; Helen Keeley, MD2; Johanna T. W. Wigman, PhD3; Nina Devlin, MD1; Hugh Ramsay, MD1; Camilla Wasserman, MA4; Vladimir Carli, MD, PhD5; Marco Sarchiapone, MD6; Christina Hoven, DrPH4; Danuta Wasserman, MD, PhD5; Mary Cannon, MD, PhD1
[+] Author Affiliations
1Department of Psychiatry, Royal College of Surgeons in Ireland, Education and Research Centre, Beaumont Hospital, Dublin
2National Suicide Research Foundation, Cork, Ireland
3Department of Psychiatry and Neuropsychology, Maastricht University, Maastricht, the Netherlands
4Department of Child and Adolescent Psychiatry, New York State Psychiatric Institute, Columbia University, New York
5National Swedish Prevention of Suicide and Mental Ill-Health, Department of Public Health Sciences, Karolinska Institutet, Stockholm, Sweden
6Department of Health Sciences, University of Molise, Campobasso, Italy
JAMA Psychiatry. 2013;70(9):940-948. doi:10.1001/jamapsychiatry.2013.140.
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Importance  Up to 1 million persons die by suicide annually. However, a lack of risk markers makes suicide risk assessment one of the most difficult areas of clinical practice.

Objective  To assess psychotic symptoms (attenuated or frank) as a clinical marker of risk for suicide attempt.

Design, Setting, and Participants  Prospective cohort study of 1112 school-based adolescents (aged 13-16 years), assessed at baseline and at 3 and 12 months for self-reported psychopathology, psychotic symptoms, and suicide attempts.

Main Outcomes and Measures  Suicide attempts at the 3- and 12-month follow-up and acute suicide attempts (defined as those occurring in the 2 weeks before an assessment).

Results  Of the total sample, 7% reported psychotic symptoms at baseline. Of that subsample, 7% reported a suicide attempt by the 3-month follow-up compared with 1% of the rest of the sample (odds ratio [OR], 10.01; 95% CI, 2.24-45.49), and 20% reported a suicide attempt by the 12-month follow-up compared with 2.5% 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). Adolescents with psychopathology who reported psychotic symptoms had a nearly 70-fold increased odds of acute suicide attempts (OR, 67.50; 95% CI, 11.41-399.21). Differences were not explained by nonpsychotic psychiatric symptom burden, multimorbidity, or substance use. In a causative model, the population-attributable fraction of suicide attempts would be 56% to 75% for psychotic symptoms.

Conclusions and Relevance  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.

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