Suicidal Ideation and First Episode of Psychosis: Secondary Analysis of the Recovery after an Initial Schizophrenia Episode (RAISE) Data

Background and Purpose: Psychotic disorders, including schizophrenia, are related to increased risk for suicide, with first-episode psychosis being a particularly high-risk period.  Lifetime risk for suicidal ideation in first-episode psychosis is estimated to be 22-40% with risk in the first year of treatment being elevated by 60% as compared to other stages of illness.  Literature consistently supports the relationship between symptoms of depression and suicide, with growing evidence for the role that positive symptoms of psychosis play in risk. While investigations of first-episode psychosis are increasing, there remains a need to increase understandings of risk factors for suicide among individuals in a first-episode of psychosis.  This study aimed to explore demographic and clinical characteristics among individuals experiencing suicidal ideation in a first-episode of psychosis.

Methods: Data were obtained from National Institute of Mental Health's Recovery After an Initial Schizophrenia Episode (RAISE) project (n=404) that tested and compared two Early Treatment Programs (ETP) among adolescents and adults who were experiencing a first episode of psychosis. The outcome of suicidal ideation was measured post baseline by the Calgary Depression Scale (CDRS), symptoms of depression by the CDRS, and symptoms of psychosis by the Positive and Negative Syndrome Scale (PANSS).  Univariate and bivariate explorations of demographic and clinical characteristics were conducted along with Independent Samples T-Tests, Chi-Square tests, and Binary Logistic Regressions.

Results: Participants were on average 23.6 years of age (SD=5.06) and identified as male (73%), White (54%), and non-Hispanic/Latino (82%). The majority had a diagnosis of schizophrenia (53%) and reported the experience of untreated psychosis for on average 6 months (SD=.72).  Throughout the study period, 26% of participants endorsed having suicidal ideation, 84% hallucinations, 99% delusions, 100% varying degrees of depressive symptoms, and 8.2% made a suicide attempt. PANSS total (t(180)= -4.66, p < .001), PANSS positive (t(194)= -3.85, p < .001), and CDRS (t(401)= -9.65, p < .001) scores at baseline were independently significantly greater among participants who experienced suicidal ideation during the study period as compared to participants who did not experience suicidal ideation.  Within the PANSS positive subscale, the incidence of hallucinations (t(187)= -4.32, p < .001) and delusions (t(401)= -3.37, p < .001) were independently significantly greater among participants who experienced suicidal ideation than those who did not experience suicidal ideation.  The odds of experiencing suicidal ideation was higher for participants with a diagnosis of schizophrenia and schizoaffective disorder than participants with a diagnosis of schizophreniform, brief psychotic disorder, or psychotic disorder NOS (OR: 2.15, SE: .288, CI: 1.22 – 3.78).

Conclusions and Implications: These results emphasize the high-risk of individuals in a first-episode of psychosis experiencing suicidal ideation.  Findings point towards the implication that depression and positive symptoms (specifically hallucinations and delusions) contribute to risk factors for suicide and should be assessed for and treated in practice.  Future research is needed to further explore risk factors for suicide among individuals in a first-episode of psychosis to ultimately inform interventions aimed towards reducing premature suicidal death.