Background
Relatively little is known about suicide in diagnostic subtypes of first episode psychosis (FEP). Our aim was to assess suicide rates and potential risk factors for suicide in FEP.
Methods
This is a national register-based cohort study of patients born in 1973–1978 in Sweden and who were hospitalized with a FEP between ages 15 and 30 years (n = 2819). The patients were followed from date of discharge until death, emigration, or 31st of December 2008. The suicide rates for six diagnostic subtypes of FEP were calculated. Suicide incidence rate ratios (IRRs) were calculated to evaluate the association between suicide and psychiatric, familial, social, and demographic factors.
Results
In total 121 patients died by suicide. The overall suicide rate was 4.3 (95% confidence interval [CI] 3.5–5.0) per 1000 person-years. The highest suicide rates were found in depressive disorder with psychotic symptoms and in delusional disorder. In an adjusted model, the strongest risk factors for suicide were self-harm (IRR 2.7, CI 1.7–4.4) or a conviction for violent crime (IRR 2.0, CI 1.3–3.2). Also having a first-degree relative with a schizophrenia/bipolar diagnosis (IRR 2.1, CI 1.2–3.6) or substance use disorder (IRR 2.0, CI 1.2–3.2) were significant risk factors for suicide.
Conclusions
Impulsive behavior such as self-harm as well as having a family history of severe mental disorder or substance use are important risk factors for suicide in FEP.
Patients with a first episode psychosis (FEP) have an elevated suicide risk and higher all-cause mortality (Allebeck, 1989, Craig et al., 2006, Dutta et al., 2010 and Bjorkenstam et al., 2013). In a cohort study of FEP patients in England and Scotland the suicide mortality was increased 12 times compared to the general population (Dutta et al., 2010). Previous studies have identified depressive symptoms, suicidal ideation/intent, negative events, non-suicidal self-harm, and depressive symptoms as risk factors for suicide in FEP (Fedyszyn et al., 2012). Dutta et al. (2011) also found male gender and presence of more pronounced psychiatric symptoms to be predictors of suicide in FEP. In a recent literature review, a substantial proportion of psychotic patients examined after violent suicide attempts, self-mutilation, homicide, and assault resulting in serious injury were found to be in their first episode of psychosis (Nielssen et al., 2012). Moreover, a substantial proportion of first-episode patients committed an act of less serious violence or attempted suicide prior to initial treatment (Nielssen et al., 2012). A history of violent offending has also been shown to be a risk factor for suicide among people diagnosed with schizophrenia (Webb et al., 2011). However, to the best of our knowledge, no earlier study has investigated the role of violent offending on suicide risk in FEP.
Although a delay in the clinical diagnosing of schizophrenia is common, most studies of suicide risk and risk factors for suicide in FEP have been performed on patients with established schizophrenia (Foley et al., 2008 and Pompili et al., 2011). However, self-harm has been shown to be common during the pre-treatment phase of first-episode psychosis (Harvey et al., 2008 and Nielssen et al., 2012) and one can assume that some patients may die by suicide early in the course of mental illness, before they have developed or been formally diagnosed with schizophrenia. Moreover, most studies of suicide in FEP have not been population based and have included a relatively small number of patients and suicides (Radomsky et al., 1999 and Bertelsen et al., 2007). For these reasons, more knowledge is needed about suicide rates and risk factors for suicide in FEP and in specified subtypes of FEP. Because the suicide risk is most increased in the early phase of psychotic disorder (Osby et al., 2000), this time period is particularly important to study.
We performed a nationwide register study of completed suicide across the broad spectrum of patients with a first inpatient diagnosed psychotic disorder in a cohort of young adults. Our aims were, first, to calculate suicide rates and second, to assess the significance of a range of potential risk factors for suicide across different FEP diagnoses.
