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Psychotic Symptoms Are Red Flag for Suicide in Adolescents

August 29, 2013. With suicide ranking as one of the leading causes of death worldwide, identifying risk factors that could be used to prevent these tragic losses of life is key. Among adolescents—an age group for whom suicide risk is high—those with psychopathology who also experience psychotic symptoms appear to be especially vulnerable, according to a new longitudinal study led by Ian Kelleher of the Royal College of Surgeons in Ireland and published online July 17, 2013, in JAMA Psychiatry.

A number of risk factors for suicide, including psychopathology (especially depression) and the presence of psychotic symptoms, have been identified (see SRF related news story). However, because these risk factors are present in many individuals who do not go on to attempt suicide, identifying the individuals at highest risk, to whom interventions should be targeted, remains a challenge. In the current school-based, prospective cohort study, Kelleher and colleagues hypothesized that the presence of both psychopathology and psychotic symptoms would confer a higher level of risk than either factor alone. To test their hypothesis, they assessed the self-reported psychopathology, frank and attenuated psychotic symptoms, and suicide attempts of 1,112 adolescents (13-16 years old) at baseline, three months, and 12 months.

Within the total sample, 7 percent of subjects reported psychotic symptoms, such as hearing voices, at baseline. The suicide risk of this group was much higher than that of those not experiencing psychotic symptoms, with 7 percent reporting suicide attempts at three months, compared to 1 percent in the rest of the sample. By 12 months, 20 percent of those reporting psychotic symptoms at baseline had attempted suicide, as opposed to just 2.5 percent of the general population.

When the researchers looked at the subjects with psychopathology, they discovered that suicide risk varied substantially depending on whether or not they reported psychotic symptoms at baseline. Of those who hadn’t experienced psychotic symptoms, 3.5 percent and 13 percent had a later suicide attempt at three and 12 months, respectively. But, consistent with the researchers' hypothesis, the adolescents with psychopathology who also reported psychotic symptoms had a much higher risk: 14 percent reported a suicide attempt by three months (an odds ratio of 17.91) and 34 percent by 12 months (an odds ratio of 32.67).

The findings were not explained by nonpsychotic psychiatric symptom burden, multi-morbidity across domains of the psychopathology assessment scale, or substance use. Notably, among the adolescents with psychopathology, almost 80 percent of suicide attempts were made by patients who experienced psychotic symptoms (though they accounted for less than 25 percent of the population). “This highlights the importance of assessing psychotic symptoms in individuals with suspected psychopathology and the need to recognize suicide risk when these symptoms are present,” conclude the authors.—Allison A. Curley.

Kelleher I, Corcoran P, Keeley H, Wigman JT, Devlin N, Ramsay H, Wasserman C, Carli V, Sarchiapone M, Hoven C, Wasserman D, Cannon M. Psychotic Symptoms and Population Risk for Suicide Attempt: A Prospective Cohort Study. JAMA Psychiatry. 2013 Jul 17. Abstract

Comments on News and Primary Papers
Comment by:  John McGrath, SRF Advisor
Submitted 30 August 2013
Posted 3 September 2013
  I recommend the Primary Papers

This is an important study: It not only reaffirms how common psychotic symptoms are in otherwise well young people, but highlights that they are associated with serious mental health outcomes such as suicide attempts.

Psychotic experiences (or psychotic-like experiences) may be part of a non-specific response to psychological distress. Thus, diffuse non-clinical expressions of psychological distress may be accompanied by mild depression, mild anxiety, and psychotic-like experiences. There is now a solid body of consistent evidence suggesting that this is the case (too many studies to list from the groups in Maastricht, Dublin, Brisbane, and Tel Aviv).

The take-home message from Ian Kelleher's paper is that when screening for at-risk pluripotent mental states, we should be routinely asking people about the presence of psychotic experiences.

View all comments by John McGrath