The Relationship between Cognition and Suicidal Ideation Among Individuals with Psychosis

Background and Purpose: Suicide is among the leading causes of death for individuals with schizophrenia.  A growing number of studies on suicide highlight the relationships between impaired neurocognitive abilities and suicidal outcomes (ideation and attempt) with findings often reporting poor cognitive functioning to be a protective factor against suicide.  Another important factor to consider is the role of insight in suicidal outcomes with research showing impaired insight may also function as a protective factor.  While more is known about these relationships within chronic illness, less is known within the context of a sample of individuals in earlier phases of illness.  This study aimed to examine the relationships between insight/judgment, negative symptoms, cognitive functioning, and suicidal ideation among a first-episode sample of participants in two age groupings: 20 years or younger versus 21 years or older.

Methods: Data were obtained from the Recovery After an Initial Schizophrenia Episode project of National Institute of Mental Health’s Early Treatment Program. Participants included 404 adults between ages 15 and 40 with schizophrenia or other psychotic disorders based upon the DSM-IV. Negative symptoms and lack of insight/judgment were measured at baseline using the Positive and Negative Syndrome Scale (PANSS), and suicidal ideation by the Calgary Depression Rating Scale (CDRS) across the full study period.  Cognitive functioning was measured by the Brief Assessment of Cognition in Schizophrenia (BACS) at baseline.  Data were analyzed using logistic regressions in SPSS25.

Results: Participants reported an average age of 24 and most often identified as male (73%), White (54%), and non-Hispanic/Latino (82%). One-hundred twelve participants (28%) resided in the 20 years of age or younger category and 254 (72%) in the 21 years of age or older category.  No significant relationships were found in Model 1 (among participants 20 years of age or younger), however several relationships were found in Model 2 (among participants 21 years or older).  Greater negative symptoms at baseline related to increased likelihood of experiencing suicidal ideation during the study time period holding all other variables constant(b= .081, SE= .030, OR= 1.08,p< .01).  Greater working memory and lack of insight/judgment at baseline related to decreased likelihood of experiencing suicidal ideation during the study time period holding all other variables constant (b= -.100, SE= .042, OR= .905,p< .05 and b= -.469, SE= .149, OR= .625,p< .01, respectively). 

Conclusions and Implications: The likelihood of experiencing suicidal ideation was significantly increased when working memory was stronger, insight/judgment was more impaired, and greater negative symptoms were present among participants who were 21 years or older in age.   These findings have important clinical implications for identifying characteristics that place an individual early in the course of schizophrenia at risk for suicidal ideation. More research is needed to further understandthe relationships between insight, cognition, suicidal ideation, and ageacross different phases of the condition and how this information can be utilized in social work practice to reduce the risk of suicide among individuals with schizophrenia.