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Clinical variables associated with suicide attempts in schizophrenia before and after the first episode

Psychiatry Research, In Press, Corrected Proof, Available online 15 July 2015


The aim of this study was to investigate variables associated with suicide attempts in schizophrenia before and after the first episode. We evaluated history of past sucide attempts, clinical symptoms, level of functioning and cognitive performances of 172 patients with first-episode schizophrenia at first admission. Information was collected regarding clinical symptom severity, treatment compliance, and suicide attempts during the follow-up. We found that 16.5% of the patients attempted suicide before admission, and 6.2% of them attempted suicide during the follow-up. The patients who had attempted suicide before admission were mostly women, and more likely to be hospitalized in first year of follow up. BPRS-depression subscale score at admission and alcohol/substance use appeared as independent variables that found associated with suicide attempts prior to admission in logistic regression analysis. The patients who attempted suicide during the follow-up had significantly higher BPRS-depression subcale scores at sixth months of follow-up. Treatment compliance during the first 6 months and duration of remission was lower in this group. Our findings suggest that longer duration of first hospital treatment, the presence of depressive symptoms, and nonadherence to treatment in early phases of follow up after FES are predictors of suicide attempts. On the other hand, keeping remission during the follow-up protects against suicide attempts.



  • We evaluated variables related to suicide attempts before and after the first episode of schizophrenia.
  • We found that 16.5% of the patients attempted suicide before first admission.
  • Level of depression at admission and alcohol/substance use appeared are found related to suicide attempts prior to admission.
  • Compliance to treatment in first six months of the follow up was lower in those attempted suicide during the follow up.

Keywords: First episode, Prevention, Risk factors of suicide, Schizophrenia, Suicide attempt.

1. Introduction

The risk of suicide within a few years following the first episode in schizophrenia is higher than in chronic schizophrenia (Crumlish et al, 2005, Melle and Ann Barrett, 2012, and Palmier-Claus et al, 2013). Long-term follow up studies have showed that the rate of death by suicide is 5–6% and non-fatal suicidal behavior occurs in approximately 50–60% of patients (Bertelsen et al, 2007 and Mauri et al, 2013). Suicide attempts in patients with schizophrenia often occur without warning or verbal expression of intent. Therefore, the predictive factors of suicide in schizophrenia are difficult to determine.

Previous studies demonstrated that the predictors of suicide in patients with chronic schizophrenia are male sex, younger age, higher education level, being single, treatment adherence, the presence of severe psychotic symptoms, more hospitalizations (>5), substance-use disorder, previous suicide attempts, family history of psychiatric illness, awareness of disease (insight), psychosis-related negative beliefs, and absence of social support (Pompili et al, 2007, Mauri et al, 2013, Fleischhacker et al, 2014, and Popovic et al, 2014). Risk factors for suicide in patients with first-episode schizophrenia (FES) are reported as longer duration of untreated psychosis (DUP), severe or variable depressive symptoms, using antipsychotic drugs, higher levels of feelings of guilt, and anxiety ( Barrett et al., 2010 , 2015 ; Melle and Ann Barrett, 2012 ; Palmier-Claus et al., 2013 ; Upthegrove et al., 2014 ), conviction of a violent crime, and having a first-degree relative with a schizophrenia/bipolar diagnosis ( Björkenstam et al., 2014 ), young age, female sex, and history of suicide attempt ( Nordentoft et al., 2015 ). Melle and Ann Barret (2012) also reported that risk of suicide attempt before first admission was associated with the length of untreated illness. In another recent study, Challis et al. (2013) reported that depressed mood and substance use were associated with deliberate self harm both before and after treatment, negative symptoms were associated with deliberate self harm after treatment but not before treatment. Younger age and the duration of untreated psychosis were also found associated with deliberate self harm before treatment but not after treatment ( Challis et al., 2013 ).

In our previous study sample of first-episode schizophrenia patients, we found that 18% of patients attempted at least one suicide before their first admission (Ucok et al, 2004 and Ucok et al, 2006). A portion of these individuals were at risk of terminating their life before the treatment process. There are few studies that examine the factors associated with suicide after the first episode. The aim of this study was to investigate variables associated with suicide attempts in schizophrenia before and after the first episode. Our hypothesis was that the identified predictors of suicide that had been validated in chronic schizophrenia were also valid in patients with first-episode schizophrenia.

2. Methods

2.1. Participants

Subjects in this study were recruited from an ongoing prospective study, namely First-episode Schizophrenia Follow-up Project since 1996. A total of 172 patients that were admitted to the Department of Psychiatry, Istanbul Faculty of Medicine who were diagnosed as having schizophrenia were considered for this study. Patients diagnosed as schizophrenia by means of the Structured Clinical Interview for DSM-IV (SCID) then were re-evaluated at a consensus meeting incorporating clinical and SCID data ( First et al., 1997 ). Inclusion criteria for the current study were defined as: being in acute phase of their first psychotic episode, and being between age of 15 and 45. A patient was accepted in his/her first psychotic episode if all following conditions were fulfilled: no past diagnosis of nonaffective possible psychosis; no previous antipsychotic treatment more than 15 days. The date of onset of the first identifiable positive symptoms was timed by the senior psychiatrist in research team on the basis of a best-estimate approach using data gathered from multiple sources including medical records, a direct patient, and family interview. We defined DUP from the time of onset of first positive symptoms to the first admission. Patients were excluded from the study if they had a history of affective or nonaffective psychosis, any organic disorder known to cause psychosis substance/alcohol abuse on admission, prior history of hospitalization and antipsychotic use for longer than 15 days ( Ucok et al., 2011 ). Information about suicide attempts before admission was gathered from the patients themselves and their families. The patients who agreed to enter the follow-up study were examined on a monthly basis in our outpatient clinics after treatment for their first episode. At each follow up examination, information was collected regarding clinical symptom severity, treatment compliance, and suicide attempts. Follow-up sample consisted of 136 patients whose duration of follow-up at least 12 months (mean 59.3±50 month,12–198 month). We also included 2 patients who attempted suicide during the follow up, although their duration of follow up was shorter than 12 month. Totally 138 patients' data were analyzed for follow-up period.

2.2. Clinical scales

The following scales were administered to the patients on their first admission, Scale for the Assessment of Negative and Positive Symptoms (SANS and SAPS), Brief Psychiatric Rating Scale (BPRS), Global Assessment of Functioning (GAF) Scale, Premorbid Adjustment Scale (PAS), Childhood Trauma Questionnaire (CTQ). BPRS, SANS and SAPS were carried out monthly at outpatient visits.

2.2.1. The Scale for the Assessment of Negative Symptoms (SANS) and the Scale for the Assessment of Positive Symptoms (SAPS)

SANS includes 25 items and scoring of each item ranges between 0 and 5 points. These items are categorized under five groups, such as alogia, avolution, and attention ( Andreasen, 1984 ). SAPS includes 34 items and each item is evaluated with a score ranging bewteen 0 and 5 points. These items are categorized under four groups: delusions, hallucinations, disorganized behavior, and formal thought disorder ( Andreasen, 1983 ).

2.2.2. Brief Psychiatric Rating Scale (BPRS)

BPRS-expanded contains 24 items and each item is evaluated on a 1–7 Likert-type scale. Although assessment of the first 14 items depends on the interview, the last 10 items are evaluated based on observation and interview ( Overall and Gorham, 1962 ).

2.2.3. Global assessment of functioning (GAF)

The GAF is a numeric scale (0 through 100) used to subjectively rate the social, occupational, and psychological functioning of patients in a hypothetical continuum of mental health-illness. The scale is presented and described in the DSM-IV. We used Hall's modified GAF, which is commonly used, because it provides improved inter-rater agreement ( Hall, 1995 ).

2.2.4. Premorbid adjustment scale (PAS)

The PAS was designed to measure premorbid functioning from a developmental perspective, conceptualizing good premorbid adjustment as the achievement of age-appropriate developmental and social milestones. The scale examines 4 areas of development: sociability and withdrawal, peer relationships, ability to function outside of the nuclear family, and capacity to form intimate socio-sexual ties at each of 4 developmental stages (i.e., childhood [up to age 11], early adolescence [12–15 years], late adolescence [16–18 years] and adulthood [19 years of age and older]) ( Cannon-Spoor et al., 1982 ). We used only childhood and early adolescence parts of the PAS in order to minimize the overlap between prodromal signs of psychosis.

2.2.5. Childhood trauma questionnaire (CTQ)

The CTQ is a self-report inventory that provides a brief screening of maltreatment experiences occurring before the age of 18 years. The participants respond to 28 questions on a 5-point Likert scale ranging from “never true” to “very often true”. It yields scores for childhood emotional abuse, physical abuse, sexual abuse, physical neglect and emotional neglect as well as a weighted total score. The CTQ is known for its good construct validity and internal consistency and test–retest reliability (Bernstein et al, 2003 and Paivio and Cramer, 2004).

2.3. Cognitive tests

A cognitive battery including The Rey Auditory Verbal Learning Test ( Rey, 1964 ), Stroop Test ( Golden, 1978 ), Wisconsin Card Sorting Test ( Heaton et al., 1993 ), Continuous performance test ( Beck et al., 1956 ), The Digit Span Test ( Wechsler, 1987 ), Trail Making Test ( Reitan, 1955 ), and N-back test were administered to each patient at baseline.

2.4. Statistics

Categorical variables were analyzed by “Chi-square” test. We used t-test for the analysis of parametric numerical variables with independent samples, and the Mann–Whitney U test for nonparametric numeric variables. Logistic regression analysis was performed to identify variables related to suicide attempts before the first admission. Threshold of signifance was defined as a p value below 0.05. Statistical analyzes were conducted with the SPSS 16.0 software.

3. Results

We found that 29 of 172 patients (16.5%) attempted suicide before admission to our clinic, and 11 of 138 patients (7.9%) attempted suicide during the follow-up after FES in totally 8134 months of follow-up. There were 0.016 suicide attempts for each year of follow-up. One patient had attempted suicide both before and after admission. Two patients comitted suicide (at 9th and 14th months of follow up), and one patient died because of unknown reasons. The clinical and demographic data of the patients with and without suicide attempt is shown in Table 1 .

Table 1 Clinical and sociodemographic characteristics of the patients.

Attempted suicide before admission   Attempted suicide after admission  
Yes (16.9%) No (% 83.1)   Yes (11.3%) No ( 88.7%)  
N (%) N (%) stripin: si0001.gif , p N (%) N (%) stripin: si0002.gif , p
Gender Female 17 (58.6) 52 (36.4) 4.97, 0.03 3 (27.3) 28 (32.6) 0.13, 0.72
Male 12 (41,4) 91 (63.6) 8 (72.7) 58 (67.4)
Voluntary work in first year Yes 4 (30.8) 6 (9.7) 4.14, 0.04 2 (20) 6 (12.8) 0.36, 0.55
No 9 (69.2) 56 (90.3) 8 (80) 41 (87.2)
Keeping remission status Yes 1 (7.7) 20 (40) 4.85, 0.03 0 (0) 14 (37.8) 3.89, 0.05
No 12 (92.3) 30 (60) 7 (100) 23 (62.2)
Compliance to medication-6th month Yes 12 (60) 50 (61) 0.06, 0.94 3 (30) 45 (68.2) 5.44, 0.02
No 8 (40) 32 (39) 7 (70) 21 (31.8)
Depot antipsychotic use Yes 3 (13.6) 28 (28.3) 2.33, 0.31 6 (60) 18 (24) 5.69, 0.05
No 19 (86.4) 71 (71.7) 4 (40) 57 (76)
Hospitalization in first year Yes 6 (33.3) 13 (12.9) 4.77, 0.03 2 (20) 11 (14.5) 0.21, 0.65
No 12 (66.7) 88 (87.1) 8 (80) 65 (85.5)
Second hospitalization Yes 4 (40) 17 (30.4) 6.44, 0.09 2 (25) 19 (46.3) 6.19, 0.10
No 6 (60) 38 (69.6) 6 (75) 22 (53.7)

The comparison of the patients who had a suicide attempt vs those who did not prior to admission showed that the rate of suicide attempts was higher in women (58.6% vs 36.4%), the rate of hospitalization in the first year was higher (33.3% vs 12.9%), and the ability to do voluntary work was higher (30.8% vs 9.7%) ( Table 1 ).

The patients who had attempted suicide before admission had significantly higher scores of both depression and suicide subscales of BPRS at their first presentation. Also, BPRS subscale scores of depression and negative symptoms at discharge and 3rd month of follow-up were higher in patients with suicide attempt, respectively.

There were differences between the two groups in terms of the trend of PAS social adjustment subscale scores ( Table 2 ). There were no significant difference in age, education, marital status, untreated psychosis period, early onset (≤17 years), alcohol and substance abuse, history of negative life events, family history of mental illness, and childhood trauma subscale scores between the patients with and without a suicide attempt before FES.

Table 2 The mean, SD and test values of clinical scale scores of the patients.

  Attempted Suicide BA-Yes a (Mean±SD) Attempted Suicide BA-No (Mean±SD) t, Z/p Attempted suicide AA-Yes b (Mean±SD) Attempted Suicide AA-No (Mean±SD) t, Z/p
Baseline BPRS depression subscale score 8.69±3.11 6.22±2.93 t=−4.10 7.45±3.62 6.47±2.84 t=−1.05
p=0.001 p=0.30
Baseline BPRS suicide item score 3.31±1.62 1.72±1.02 Z=−4.96 2.20±1.48 1.95±1.22 Z=0.46
p=0.001 p=0.6
Baseline BPRS bizzare item score 2.96±1.73 3.61±1.53 t=1.96 3.70±1.82 3.62±1.55 t=−0.16
p=0.05 p=0.8
Baseline SANS avolution subscale score 10.28±3.40 10.13±4.65 Z=−0.01 11.80±3.39 9,36±4,36 Z=−1.80
p=0.9 p=0.07
GAF score at first admision 42.50±9.89 49.25±12.82 t=2.14 40.63±10,84 49.35±13.12 Z=−0.64
p=0.04 p=0.5
BPRS depression subscale score at discharge 5.81±3.11 4.38±1.68 t=−3.30 4.55±3.36 4.64±2.15 t=0.13
p=0.001 p=0.9
BPRS depression subscale score—6th month 4.88±2.69 4.13±1.80 Z=−0.97 6.22±3.42 4.11±1.68 Z=−2.01
p=0.3 p=0.04
BPRS positive subscale score—6th month 4.82±2.86 6.01±4.09 Z=−0.94 3.67±2.40 5.76±3.56 Z=−2.15
p=0.3 p=0.03
Number of Schneiderian symptoms at 3rd month 2.07±1.41 1.29±1.34 t=−2.79 1.36±1.63 1.36±1.30 t=−0.05
p=0.01 p=0.9
Total score of Schneiderian symptoms at 3rd month 7.57±5.58 4.62±5.06 t=−2.76 5.00±5.98 4.72±4.78 t=−0.18
p=0.01 p=0.8
PAS-Peer relationships childhood 0.50±1.17 1.31±1.51 t=1.75 1.00±1.41 1.28±1.54 t=0.34
p=0.08 p=0.7

a Attempted Suicide Before Admission, Attempted Suicide BA.

b Attempted Suicide After Admission, Attempted Suicide AA.

Further, no significant difference was found among the cognitive test results between the two groups. When we analyzed suicide attempt before admission as a dependent variable in logistic regression analyzes, only the BPRS-depression subscale score on admission and alcohol/substance use appeared as independent variables that significantly contributed to suicide attempts prior to admission ( Table 3 ).

Table 3 Variables related to suicide attempts before first admission in logistic regression analysis.

  B S.E Wald df Sig. Exp (B)
Baseline BPRS depression subscale score 0.421 0.183 5.305 1 0.02 1.523
Alcohol use −3.231 1.612 4.019 1 0.045 0.040
PAS–Peer relationships–Childhood −0.845 0.632 1.789 1 0.18 1.711
DUP −0.093 0.090 1.074 1 0.3 0.911
Baseline GAF score −0.037 0.043 0.722 1 0.4 0.964
Gender 0.996 1.266 0.619 1 0.4 2.708
Education (years) −0.100 0.206 0.234 1 0.6 0.905
Age 0.021 0.085 0.062 1 0.8 1.021
Stressful life events before admission 0.142 2.940 0.002 1 0.9 1.153

When the patients with and without suicide attempt during the follow up after FES were compared, treatment compliance during the first 6 months and duration of remission was lower in the group who had attempted suicide. The rate of depot antipsychotic usage was higher in the group that had attempted suicide compared with the group without suicide attempts ( Table 1 ). There was no difference between those who attempted suicide during the follow up and others in terms of duration of follow-up (44.5±49.3 vs 58.9±53.1, Z=0.69, p=0.4). No other significant difference was found.

The patients with suicide attempt had significantly higher BPRS depression subcale scores at 6th month. The difference in SANS avolution subscale score was at trend level between the two groups ( Table 2 ). In addition, we observed that the patients who had attempted suicide had longer duration of hospitalization (Z=−2.30, p=0.02). In terms of the cognitive tests, there was no significant difference between the two groups.

4. Discussion

There are few studies aimed at investigating the predictors of suicide before admission to hospital. Previous studies that examined the relationship between suicidal behavior in patients with schizophrenia usually investigated them after admission to hospital. Therefore, in our study, the incidence of suicide attempts in first-episode schizophrenia and variables associated with suicide attempts were evaluated in two separate periods; before and after admission.

Symptoms of depression have been shown to be one of the important predictors of suicide (Challis et al, 2013, Palmier-Claus et al, 2013, and Sanchez-Gistau et al, 2013). In line with the previous studies, depression scores were found to be higher in patients with more frequent suicide attempts. In addition, in our study we found that patients who attempted suicide had higher negative symptoms subcale scores. These findings show that depressive symptoms should be carefully investigated both in the prodromal period and during the first episode, and that patients should be treated to prevent suicide attempts.

In contrast to theprevious studies (Melle and Ann Barrett, 2012 and Mauri et al, 2013), a significantly higher proportion of patients who attempted suicide before admission were women in our study. This may be expected as there are more nonfatal suicide attempts by women, but there are more successful suicides by men in general.

Mauri et al. reported that the hospitalization rates were higher in patients with schizophrenia who had attempted suicide ( Mauri et al., 2013 ). Similarly, we found that the patients who attempted suicide after admission had higher rates of hospitalization. This finding suggest that attempting suicide is a natural component o negative course of the illness.

In our study, we observed lower rates of continuation of paid/volunteer work or education in patients who had attempted suicide prior to admission. Similarly, we noted that patients who attempted suicide before and after the admission had lower GAF scores. These findings revealed that professional and general functionality were worse in patients who attempted suicide before their first admission. According to these findings, a suicide attempt prior to the first admission in schizophrenia is predictive for an unfavorable prognosis.

In contrast to the findings of previous studies, we found no relationship between the duration of untreated psychosis periods and suicide attempts (Barrett et al, 2010 and Mauri et al, 2013).

Cognitive deficits have previously been reported to be related to negative symptoms. We found a relationship between suicide attempts and depression but not negative symptoms. The lack of relationship between cognitive functioning and suicide attempts may be due to the weak relationship between negative symptoms and suicide.

There were several limitations to this study. The sample includes patients who were admitted to a university hospital and usually hospitalized during the first episode, and it did not represent the complete population in a given catchment area. All these factors limit the generalizability of our findings. The retrospective collection of data concerning admissions led to difficulty in the detection of prior suicide attempts because they were either unknown to or could not be remembered by members of the patients' families. As all potential risk factors are measured at time of first diagnosis, we do not know much about the patients before admission, and about their life situation at time of suicide attempt before first admission. Furthermore, because of stigma related to mental illness, patients and families are tend to conceal the suicide attempts. Medical records do not necessarily show it, because most suicide attempters do not visit hospitals after attempting suicide. All of these factors make our findings vulnerable to reporting bias.

In summary, present study indicate that longer duration of first hospital treatment, the presence of depressive symptoms, and nonadherence to treatment in early phases of follow up after FES are predictors of suicide attempts. Clinicans' efforts to treat depressive symptoms effectively, to achieve and keep remission and to improve the adherence may help to reduce suicide attempts after FES.


The authors declare no conflict of interest.


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a Department of Psychiatry, Faculty of Medicine, Istanbul University, Millet Street Capa, Istanbul, Turkey

b Department of Neuroscience, Institute for Experimental Medical Research (DETAE), Istanbul University, Istanbul, Turkey

Corresponding author.