Suicide-related behaviours during initial treatment for first-episode psychosis: classification, a temporal course of risk, characteristics, and predictors

Submission note: A thesis submitted in total fulfilment of the requirements for the degree of Doctor of Philosophy to the School of Psychological Science, Faculty of Science, Technology and Engineering, La Trobe University, Bundoora.

Suicide-related behaviours (suicide attempts and suicides) are common among individuals who receive initial psychiatric treatment for a first episode of psychosis (FEP) and present a challenge for mental health services. Effective service-based preventive interventions require a sound understanding of these suicide-related acts. Accordingly, the present thesis focused on three aspects of suicide-related behaviours in first-episode patients which to date have received little research attention: a temporal course of risk, characteristics, and proximal predictors. The four retrospective studies comprising this thesis used clinical data of patients who commenced treatment at a specialist FEP service, the Early Psychosis Prevention and Intervention Centre (EPPIC), between 2002 and 2005. The aim of the first study was to develop a standardised tool for the classification of past suicide-related behaviours. The results supported the use of the instrument for that purpose, demonstrating good test-retest and inter-rater reliability, and construct validity. The second study examined the temporal pattern of risk of suicide-related acts over the initial 24 months of treatment, using suicidality ratings routinely collected at EPPIC. The risk was highest in the month following admission, rapidly decreased over the next six months, and continued to decline thereafter. The third study investigated the characteristics of suicide-related behaviours and found that the majority of those acts were impulsive, involved self-poisoning, and were precipitated by interpersonal conflict or distress due to psychotic symptoms. Help-seeking before or after suicide attempts was uncommon. The final study examined proximal risk factors for suicide-related behaviours during treatment for FEP, alongside the distal risk factors, and risk factors comprising socio-demographic and clinical variables assessed at patients’ admission to EPPIC. The results demonstrated that proximal non-suicidal self-injurious behaviour and proximal negative life events were the strongest. predictors of suicide-related acts. On the basis of the present findings a range of universal, selective, and indicated interventions could be developed and trialled by mental health services to prevent suicide attempts and suicides in first-episode patients. The universal approaches recommended in this thesis included: restricting access to antipsychotics and other prescribed medications, developing individualised crisis plans as early as possible following the patient’s admission to a psychiatric service, enhancing recognition of risk of suicide-related behaviours by family members of first-episode patients, and routine screening of risk of suicide-related behaviours throughout treatment to facilitate early detection and management of at risk patients. Skills training programmes focussing on emotion regulation, stress management, interpersonal effectiveness and problem-solving, were suggested selective and indicated interventions. An additional indicated intervention included monitoring of patients at increased risk of repeated suicide attempts. Future studies evaluating preventive interventions implemented by services treating first-episode patients could help to create evidence base for the most effective approaches to reducing the rates of suicide attempts and suicides in this population.