Suicidal thoughts and behaviors in first-episode psychosis: looking beyond averages to uncover groups with less favorable outcomes

By Roxanne Sicotte, Dr. Srividya N. Iyer, Dr. Amal Abdel-Baki

Psychosis is a condition in which the perception of reality is often altered, and delusions, hallucinations or strange behaviors may occur. Experiencing a first episode of psychosis can often lead to distress. The onset of first-episode psychosis (FEP ) typically happens during the transition to adulthood, a major turning point in life.

Previous studies have reported that, at the time of first contact with services, up to 50% of young people with FEP have suicidal thoughts, and nearly 10% attempt suicide. Fortunately, suicidal thoughts and behaviors decrease over the course of treatment.

However, two studies identified that while this decrease was true for the majority of persons with FEP, there were subgroups who had different and more concerning patterns of change in their suicidal thoughts over the first 2 and 3 years of treatment. Some persons continued to present suicidal thoughts while others experienced more suicidal thoughts over time.

The approach used by these studies allows to better understand how suicidal thoughts change over time and to identify charactertics of the subgroups likely to show a less favorable course (e.g, persistent or worsening suicidal thoughts). Such understanding can help tailor interventions specifically to people at increased risk of suicide. Given that there have been few studies that have used such approaches to identify and describe subgroups with different patterns of suicidal thoughts and behaviors, our study aimed to fill this gap.

Our objectives were to identify trajectories of suicidal ideation over a five-year period following entry into early intervention services for psychosis, to identify the characteristics of individuals following each trajectory, and to compare the distribution of suicide attempts across the identified trajectories. Our study covered a longer period than previous studies, i.e., the first 5 years following the beginning of treatment for psychosis. This is important since the first five years are critical and impact long-term symptoms and functioning. We also considered multiple characteristics that may increase the risk of suicidal ideation (sex, age, occupation, functioning, previous suicide ideation and attempts, maladapative personality traits/disorder, illness severity and alcohol, cannabis, cocaine, and amphetamine use disorders).

Our study included 567 persons with FEP, aged 18 to 30, followed in two early intervention services for psychosis in Montreal, Canada between 2005-2018. Of these, 7 died by suicide, including 4 during the first year of follow-up. Based on a sub-sample of 382 young people who reported whether or not they had suicidal thoughts or attempted suicide for at least three of the six measurement timepoints (at admission and then yearly for five years), we identified three subgroups of people following different trajectories of suicidal ideation.

For 85% of the young people with FEP in our study, the probability of suicidal ideation was low and decreased over the first five years of follow-up. However, for 7% of young people with FEP, suicidal ideation persisted throughout follow-up with a marked increase in the first year. Those who had already experienced suicidal ideation and suicide attempts prior to entering services, and those who had an alcohol use disorder at admission were more likely to follow this trajectory of persistent suicidal ideation. Those young persons were also more likely to attempt suicide over follow-up.

For another 8%, suicidal ideation decreased during the first year of follow-up and then increased at the very end. Those with a history of suicidal ideation and a cocaine use disorder at admission to services had a higher risk of following this trajectory.

Our findings highlight the need for professionals working with persons with FEP to assess suicidal risk regularly and throughout follow-up. Professionals should be particularly attentive at the very beginning of treatment, when more young people report suicidal ideation and suicide attempts, and at the end of treatment, as some people experience an increase in suicidal ideation when they are being transferred to another service. Young people with a history of suicide ideation or attempts, a substance use disorder when entering services, and those with persistent suicidal ideation may especially benefit from suicide asssessment and interventions at the start of and throughout treatment.

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Article Details
Heterogeneity in the Course of Suicidal Ideation and its Relation to Suicide Attempts in First-Episode Psychosis: A 5-Year Prospective Study
Roxanne Sicotte, Srividya N. Iyer, Éric Lacourse, Jean R. Séguin, Amal Abdel-Baki
First Published April 18, 2023 Research Article
DOI: 10.1177/07067437231167387
The Canadian Journal of Psychiatry

About the Authors

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Roxanne Sicotte is a PhD candidate at the Department of psychiatry, Faculty of Medicine, Université de Montréal, Canada. Her work focuses on the evolution of suicidal thoughts and behaviors in first-episode psychosis. She is a psychoeducator with experience working with people with psychotic disorders. She is a trainer in suicide prevention.

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Dr. Srvidya N. Iyer is a Full professor at the Department of psychiatry, Faculty of Medicine and Health Sciences, McGill University, Canada. She is a psychologist by training and her research focuses on youth mental health and early intervention for psychosis, in Canadian and global contexts with the overarching goal of ensuring that more young people globally have access to high-quality mental health care, and experience better outcomes, well-being, and social and economic participation. (https://www.mcgill.ca/tcpsych/faculty/srividyaiyer)

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Dr. Amal Abdel-Baki is a Full professor at the Department of psychiatry, Faculty of Medicine, Université de Montréal, Canada. She is a psychiatrist and head of the CHUM’s Youth Mental Health Service and JAP clinic (premierepisode.ca). She is a researcher at the CHUM research center, the AQPPEP president (AQPPEP.ca) and a member of the CCEIP Board of Directors (epicanada.ca). Her work focuses on the factors influencing the outcomes of young people with psychotic disorders, on the development of new specialized treatment approaches, and on the organization of care and large-scale implementation of new models of care. (https://recherche.umontreal.ca/nos-chercheurs/repertoire-des-professeurs/chercheur/is/in17791/)