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The relationships of suicidal ideation with symptoms, neurocognitive function, and psychological factors in patients with first-episode psychosis
Schizophrenia Research, Volume 157, Issues 1–3, August 2014, Pages 12–18
Individuals with first-episode psychosis (FEP) have markedly elevated risk for suicide. Previous research on suicidality in early psychosis mainly focused on attempted and completed suicide. Data regarding risk factors for suicidal ideation, which is a common antecedent and predictor of suicide attempt, were limited. This study aimed to examine the prevalence of suicidal ideation and its relationships with clinical, neurocognitive and psychological factors in FEP patients.
Eighty-nine Chinese patients aged 15 to 25 years presenting with FEP to specialized early intervention service were recruited. A comprehensive set of assessments examining pre-treatment illness characteristics, symptom severity, neurocognitive function, and psychological factors were administered. Current suicidal ideation and history of suicide attempt were systematically evaluated.
Approximately 42% of patients expressed suicidal ideation after service entry. Univariate regression analyses found that suicidal ideation was significantly associated with past suicide attempt, depressive symptoms, emotion expressivity, hopelessness, future expectation, attentional impulsiveness, internal and external locus of control, and the likelihood of endorsing fear of social approval and survival and coping beliefs as reasons for living. Final multivariate model showed that previous suicide attempt, depression, less severe diminished expression, greater degree of hopelessness and lower level of internal locus of control independently predicted suicidal ideation.
Suicidal ideation was prevalent in FEP patients. Our findings implied that close monitoring and prompt intervention of those potentially modifiable risk factors for suicidal ideation including depression, hopelessness and perceived inadequate personal control may reduce suicide risk in the early course of psychotic illness.
Keywords: Suicidal ideation, First-episode psychosis, Depression, Negative symptoms, Hopelessness.
Psychotic disorders including schizophrenia are associated with markedly elevated risk for suicide ( Hawton et al., 2005 ). Evidence showed that suicide constitutes a major cause of premature mortality among individuals with schizophrenia ( Saha et al., 2007 ) whose lifetime suicide risk is estimated as 4.9% ( Palmer et al., 2005 ) and 20–40% will attempt suicide during the course of their illness ( Harvey-Friedman, 2006 ). Early phase of psychotic disorder was consistently found to be a particularly vulnerable period for suicide when compared to other stages of the illness (Nordentoft et al, 2004 and Palmer et al, 2005). Recent studies demonstrated that the first 1 to 2 years of treatment for first-episode psychosis (FEP) conferred the highest suicide risk (Nordentoft et al, 2004 and Dutta et al, 2010). A recent meta-analytic review confirmed a high rate of self-harm in FEP populations with 18.4% and 11.4% made at least one attempt before and after treatment, respectively ( Challis et al., 2013 ).
Suicidal ideation is a common antecedent of suicidal behavior (includes attempted and completed suicide). Previous studies showed that up to 40% of patients with schizophrenia reported suicidal ideation (Fenton et al, 1997 and Fialko et al, 2006). Systematic reviews also found that suicidal ideation was associated with increased risks of self-harm and suicide in schizophrenia (Haw et al, 2005 and Hawton et al, 2005). In fact, suicide risk can be conceptualized as a multi-stage process with suicidal ideation being regarded as a critical initial step along a continuum of increasing severity toward attempted and completed suicide (Hawley et al, 1991 and Kontaxakis et al, 2004). Emergence of suicidal ideation thus represents an early indicator of potential suicidal intent which may then result in suicide attempt, and it is suggested that better understanding of risk factors for suicidal ideation would facilitate suicide prediction and prevention ( Mann et al., 1999 ). Nonetheless, despite its significant clinical implications, relatively few studies have been conducted to examine prevalence and correlates of suicidal ideation in FEP patients.
Prior first-episode studies reported that the rate of suicidal ideation at initial presentation ranged between 26.2% and 56.5% (Nordentoft et al, 2002, Tarrier et al, 2007, Bakst et al, 2010, Barrett et al, 2010, Melle et al, 2010, and Upthegrove et al, 2010). Baseline suicidal ideation was found to strongly predict suicide attempt and suicide ideation at follow-up (Young et al, 1998 and Bertelsen et al, 2007). Discrepant findings, however, were observed with respect to the relationship between clinical variables and suicidal ideation in early psychosis, with some studies showing past suicide attempt (Bertelsen et al, 2007 and Bakst et al, 2010), depression (Bertelsen et al, 2007 and Bakst et al, 2010), hopelessness (Nordentoft et al, 2002 and Bakst et al, 2010) and psychotic symptoms (Nordentoft et al, 2002 and Bertelsen et al, 2007) as independent factors associated with suicidal ideation, but not others ( Tarrier et al., 2007 ). Of note, several methodological issues concerning investigation of risk factors for suicidal ideation warrant consideration. First, many studies that have assessed suicidal ideation in FEP used only a single item that is selected from a depression rating instrument (Bakst et al, 2010, Barrett et al, 2010, and Melle et al, 2010) which may compromise an accuracy of estimating the rate of suicidal ideation. Second, as this single-item measure generates a composite rating for overall suicidality combining suicidal ideation and attempt, such measurement overlap may thus obscure potentially significant relationships between various putative risk factors and suicidal ideation. Third, existing literature on prediction of suicidal ideation in FEP primarily focused on demographic and clinical characteristics. There is a lack of systematic evaluation of related neurocognitive and psychological variables including executive functions (Marzuk et al, 2005 and Miranda et al, 2012), impulsivity trait ( Brezo et al., 2006 ), perceived locus of control (Goldney et al, 1991 and Lester et al, 1991) and reasons for living (Hirsch and Ellis, 1996 and Pinto et al, 1998), which have otherwise been linked to suicidal ideation in normal population and patients with other psychiatric diagnoses.
To better understand the risk profiles for suicidal ideation in patients with psychosis, in particular those identifiable factors that emerged in the early stage of illness, is crucial to suicide prevention. In this regard, we present a study conducted in a representative Chinese cohort of young people presenting with FEP to a specialized early intervention program in Hong Kong with an aim to (1) examine the prevalence of suicidal ideation after service entry and (2) to identify clinical, neurocognitive and psychological factors associated with suicidal ideation.
2. Materials and methods
Participants were recruited from both outpatient and inpatient psychiatric units of three hospitals in Hong Kong Island and Kowloon West upon their enrolment to a specialized early intervention program for psychosis, namely Early Assessment Service for Young People with Psychosis (EASY). Since 2001, this publicly-funded service has been providing comprehensive assessment and phase-specific intervention for all individuals aged 15–25 years presenting with FEP in Hong Kong ( Tang et al., 2010 ). The program adopts case-management approach and assertively follows up patients for the first three years after their initial episodes. In this study, we excluded patients who had intellectual disability, psychotic disorders due to general medical condition or substance-induced psychosis. A total of 116 patients who were consecutively diagnosed as first-episode DSM-IV ( APA, 1994 ) schizophrenia, schizophreniform disorder, delusional disorder, brief psychotic disorder or psychosis not otherwise specified (NOS) were approached for study recruitment. Of the initial cohort, 25 refused participation and 2 failed to complete study assessments, and 89 patients were thus retained as the study sample. Study assessments were administered to participants by a research staff on average 40 days following service entry. Training on the use of assessments was provided to a research staff prior to participant recruitment. Regular meetings were held throughout the study period to ensure strict adherence to assessment rating manual and to resolve any ambiguity in clinical information during the data collection process. The study was approved by the local institutional review board and patients gave written informed consent before participation.
2.2.1. Suicidal ideation and history of suicide attempt
Suicidal ideation in the past week was assessed using Beck Scale for Suicidal Ideation (BSS) which is a 21-item self-report questionnaire with each item being rated on a 3-point scale (from 0 to 2, higher score indicates higher level of suicidality) ( Beck and Steer, 1991 ). The first 5 items of BSS were used to ascertain the presence of suicidal thoughts of an active or passive nature ( Beck and Steer, 1991 ). Participants who scored > 0 on one or more of these first 5 items were classified as “patients with suicidal ideation”, while those who scored 0 on all of these 5 items were considered as “patients without suicidal ideation”. History of suicide attempt was ascertained by the 20th item of BSS (0 = no previous suicide attempt, 1 = one past suicide attempt in lifetime, 2 = two or more past suicide attempts in lifetime). The Chinese version of BSS was used in this study with previous validation being conducted in early psychosis patients showing high internal consistency (Cronbach's alpha = 0.78).
2.2.2. Clinical assessments
Diagnosis of each participant was ascertained by senior research psychiatrist using all available information including Chinese-bilingual Structured Clinical Interview for DSM-IV (CB-SCID-I/P, So et al., 2003 ), informant histories and medical records. Previous validation study showed that CB-SCID-I/P yielded reliable DSM-IV diagnoses in Chinese patients with psychotic disorders ( So et al., 2003 ). Interview for Retrospective Assessment of the Onset of Schizophrenia (IRAOS, Hafner et al., 1992 ) was used to confirm the first-episode status and to assess duration of untreated psychosis (DUP) which was defined as time interval between onset of psychotic symptoms and service entry. Positive symptoms subscale of Positive and Negative Syndrome Scale (PANSS, Kay et al., 1987 ) was used to assess positive psychotic symptom level. Negative symptoms were measured by Scale of Assessment of Negative Symptoms (SANS, Andreasen, 1982 ). As negative symptom construct was consistently shown to comprise two distinct sub-domains of diminished expression (DE) and avolition–asociality (AA) ( Messinger et al., 2011 ), we thus derived DE and AA domain scores based on the method applied by previous research ( Foussias et al., 2009 ): DE comprised items of Affective flattening subscale (excluding global item) and poverty of speech item of Alogia subscale; and AA consisted of items of Avolition–apathy and Anhedonia–asociality subscales (excluding global items). Montgomery–Asberg Depression Rating Scale (MADRS, Montgomery and Asberg, 1979 ) was employed to assess depressive symptom severity. Total MADRS score excluding item 10, which evaluated suicidality, was computed for analysis. Level of insight was assessed by Birchwood Insight Scale (IS) which comprises three separate dimensions including awareness of illness, attribution of symptoms and need for treatment ( Birchwood et al., 1994 ). The Chinese version of IS, which was validated in local population ( Lam et al., 1996 ), was adopted in this study.
2.2.3. Psychological factors for suicidal ideation
Hopelessness was measured using the Chinese version of Beck Hopelessness Scale (CHOPE, Shek, 1993 ) which was translated and modified from the original Beck Hopelessness Scale ( Beck et al., 1974 ). CHOPE is a self-administrated questionnaire which comprises 20 statements evaluating the extent of negative attitudes about the future on a 6-point Likert scale (instead of true–false statements in the original scale), with higher score representing greater degree of hopelessness. Factor analysis of CHOPE generated three components including hopelessness, certainty about the future and future expectation factors ( Shek, 1993 ). Validation of CHOPE has previously been reported with high internal consistency and reliability ( Shek, 1993 ). Internality, Powerful Others, and Chance Scale (IPC) was used to measure locus of control which can be further divided into internal control, powerful others, and chance control factors ( Levenson, 1981 ). The Chinese version of IPC has been shown to have good psychometric properties in a previous study ( Chan, 2000 ). Barratt Impulsiveness Scale (BIS) was used to assess personality trait of impulsivity and comprises three separate dimensions including attentional, motor and non-planning impulsiveness ( Patton et al., 1995 ). Brief Reasons for Living Inventory for Adolescents (BRFL-A) was employed to assess how participants weighed a range of reasons that may be important for not committing suicidal behavior and comprises five factors including fear of social disapproval, moral objections, survival and coping beliefs, responsibility to family, and fear of suicide ( Osman et al., 1996 ). Chinese versions of BIS and BRFL-A were used and were shown to have satisfactory internal consistency with Cronbach's alpha above 0.7 in a previous validation study on patients with early psychosis.
2.2.4. Neurocognitive assessments
Two executive function tests were administered to evaluate the degree of cognitive inflexibility and impaired control of inhibition. Modified Wisconsin Card Sorting Test (MWCST, Nelson, 1976 ) was used with the number of perseverative errors and categories completed being measured as indices for cognitive flexibility. Hayline Sentence Completion Test (HSCT) Part B ( Burgess and Shallice, 1996 ) was employed to assess participants' ability to suppress inappropriate response which was suggested as a neurocognitive measure of impulsivity. Participant was firstly presented with sentences in which the last word was omitted but was strongly suggested by the rest of the sentence, and was then required to give a word that made no sense in the sentence context. To correctly perform the task, the participant was required to inhibit a strongly cued automatic response and to provide an unrelated answer. Total error score was computed according to the error classification and scoring procedure outlined by Burgess and Shallice (1996) as an index for executive inhibitory control. The present study adopted the Chinese version of HSCT which has previously been applied in a local first-episode schizophrenia population ( Chan et al., 2012 ).
2.3. Statistical analysis
The primary analysis of this study focused on identifying factors predicting the occurrence of suicidal ideation in FEP patients. First, a series of univariate logistic regression analyses were conducted with suicidal ideation status (i.e., participants with vs. without suicidal ideation) as dependent variable, and demographic, pre-treatment, clinical, neurocognitive, and psychological variables as candidate predictors. Second, those variables that showed a p value < 0.10 in preceding analyses were then entered into a multivariate regression model to determine which factors independently predicted suicidal ideation based on Wald statistics. The level of statistical significance was set at p < 0.05.
3.1. Characteristics of the sample
Eighty-nine participants were recruited and 48.3% (n = 43) were male. The mean age of the sample at intake was 20.5 years (S.D. = 3.3) and the mean educational level was 11.8 years (S.D. = 2.2). The median DUP of the sample was 109 days (mean = 239.9, S.D. = 364.1). The majority (50.6%) were diagnosed with schizophrenia-spectrum disorder (schizophrenia: n = 40; schizophreniform disorder: n = 5). For other non-affective psychoses, 24.7% (n = 22) of the cohort had brief psychotic disorder, 7.8% (n = 7) had delusional disorder and 16.9% (n = 15) had psychosis NOS. Of the 89 participants, 23 (25.8%) had engaged in pre-treatment suicide attempt and 37 (41.6%) expressed suicidal ideation after service enrolment.
3.2. Univariate associations with suicidal ideation
The associations of suicidal ideation with demographic, pre-treatment, clinical, psychological and neurocognitive factors are shown inTable 1 and Table 2. Patients with suicidal ideation were significantly more likely to have past suicide attempt, greater depressive symptom severity and lower DE score than those without suicidal ideation. Suicidal ideators were also found to have a higher degree of hopelessness, lower CHOPE future expectation factor score, greater attentional impulsiveness, lower level of internal locus of control, higher ratings on IPC Powerful Others and Chance subscales, and to be more likely to endorse fear of social approval but less likely to regard survival and coping beliefs as reasons for living than non-ideators.
|Variables of interest||Patients with suicidal ideation (n = 37)||Patients without suicidal ideation (n = 52)||OR||p value|
|Age at entry, mean (SD), y||20.1 (3.2)||20.8 (3.4)||− 0.94||0.312|
|Male sex, n (%)||15 (40.5)||28 (53.8)||− 0.58||0.217|
|Years of education, mean (SD)||11.7 (1.8)||11.8 (2.5)||− 0.99||0.952|
|Previous suicide attempt, n (%)||16 (43.2)||7 (13.5)||4.90||0.002|
|History of substance abuse, n (%)||3 (8.1)||5 (9.6)||1.21||0.807|
|Log (DUP + 1), mean, (SD)||1.8 (1.0)||1.8 (0.9)||− 0.99||0.965|
|Psychiatric diagnosis, n (%)||− 0.73||0.463|
|Schizophrenia-spectrum disorder a||17 (45.9)||28 (53.8)|
|Other non-affective psychoses b||20 (54.1)||24 (46.2)|
|PANSS positive symptom score, mean (SD)||17.8 (5.4)||19.1 (5.2)||− 0.95||0.286|
|PANSS general psychopathology score, mean (SD)||31.9 (9.7)||33.4 (10.5)||− 0.99||0.541|
|SANS diminished expression domain score c , mean (SD)||3.0 (3.8)||6.8 (9.3)||− 0.92||0.041|
|SANS avolition–asociality domain score d , mean (SD)||5.9 (7.7)||7.7 (9.2)||− 0.98||0.368|
|MADRS total score e , mean (SD)||14.1 (10.3)||9.8 (8.0)||1.05||0.049|
|IS Attribution of symptoms domain score, mean (SD)||2.3 (0.7)||2.3 (0.8)||− 0.96||0.895|
|IS Awareness of illness domain score, mean (SD)||2.0 (0.7)||2.1 (0.7)||− 0.83||0.553|
|IS Need for treatment domain score, mean (SD)||2.1 (0.6)||2.2 (0.7)||− 0.78||0.458|
|IS total score, mean (SD)||6.3 (1.4)||6.6 (1.2)||− 0.88||0.443|
a Schizophrenia-spectrum disorder included schizophrenia, schizophreniform disorder and schizoaffective disorder.
b Other non-affective psychoses included brief psychotic disorder, delusional disorder and psychosis not otherwise specified.
c Diminished expression domain score was computed by summing individual items of Affective Blunting subscale (excluding item of global rating for affective blunting) and poverty of speech item of Alogia subscale of SANS.
d Avolition–asociality domain score was computed by summing individual items of Avolition–apathy subscale and Anhedonia–asociality subscale excluding items of global ratings for both two subscales of SANS.
e MADRS total score was computed by summing individual items of MADRS excluding item 10 which measured suicidal thoughts.
Abbreviations: DUP = Duration of untreated psychosis; IS = Insight Scale; MADRS = Montgomery–Asberg Depression Rating Scale; PANSS = Positive and Negative Syndrome Scale; SANS = Scale for the Assessment of Negative Symptoms.
|Variables of interest||Patients with suicidal ideation (n = 37)||Patients without suicidal ideation (n = 52)||OR||p value|
|CHOPE Certainty about the future factor, mean (SD)||22.6 (3.9)||23.9 (3.3)||− 0.90||0.095|
|CHOPE Hopelessness factor, mean (SD)||35.3 (5.6)||28.9 (6.4)||1.19||< 0.001|
|CHOPE Future expectation factor, mean (SD)||17.4 (2.3)||18.8 (3.1)||− 0.83||0.029|
|BIS a Attentional impulsiveness, mean (SD)||19.7 (3.1)||17 (3.1)||1.32||0.001|
|BIS Non-planning impulsiveness, mean (SD)||27.7 (4.0)||26.6 (4.8)||1.06||0.281|
|BIS Motor impulsiveness, mean (SD)||22.6 (3.6)||21.4 (3.8)||1.09||0.149|
|Locus of control|
|IPC b Internal control factor, mean (SD)||27.8 (4.7)||32.8 (5.5)||− 0.82||< 0.001|
|IPC Powerful others factor, mean (SD)||25.8 (8.1)||21.9 (7.4)||1.07||0.028|
|IPC Chance factor, mean (SD)||28.7 (7.6)||25.2 (5.3)||1.10||0.016|
|Reasons for living|
|BRFL-A c Fear of social disapproval, mean (SD)||4.1 (1.1)||3.4 (1.3)||1.61||0.013|
|BRFL-A Moral objections, mean (SD)||3.5 (1.3)||3.2 (1.0)||1.28||0.206|
|BRFL-A Survival and coping beliefs, mean (SD)||4.2 (0.9)||4.8 (0.8)||− 0.41||0.003|
|BRFL-A Responsibility to family, mean (SD)||4.7 (0.9)||4.4 (1.2)||1.27||0.256|
|BRFL-A Fear of suicide, mean (SD)||3.9 (1.1)||3.6 (1.3)||1.21||0.319|
|MWCST categories completed, mean (SD)||4.5 (2.0)||4.5 (1.9)||1.0||0.999|
|MWCST perseverative errors, mean (SD)||3.0 (3.2)||3.3 (3.1)||− 0.97||0.647|
|Dyscontrol of executive inhibition|
|HSCT Part B total error score, mean (SD)||3.8 (3.9)||4.2 (4.0)||− 0.97||0.620|
a BIS is a self-report instrument consisting of 30 items and each item is rated on a 4-point scale with a higher score indicating greater impulsiveness.
b IPC is a 24-item self-rated questionnaire and an individual item is scored in a 6-point scale with a higher score indicating higher expectation of control by the source designated.
c BRFL-A is a 14-item self-report instrument and each item is rated on a 6-point scale with a higher score indicating greater importance of the item as a reason for staying alive.
Abbreviations: BIS = Barratt Impulsivity Scale; BRFL-A = Brief Reasons for Living Inventory for Adolescents; CHOPE = Chinese version of Beck Hopelessness Scale; HSCT = Hayline Sentence Completion Test; IPC = Internality, Powerful Others and Chance Scale; MWCST = Modified Wisconsin Card Sorting Test.
3.3. Predictors of suicidal ideation in multivariate model
Multivariate regression analysis revealed that previous suicide attempt, depression, less severe DE, hopelessness, and lower level of internal locus of control independently predicted suicidal ideation ( Table 3 ). Overall, 84.6% of the participants were predicted correctly with the model (78.6% and 89.2% for suicidal ideators and non-ideators, respectively), which accounted for 66.3% of the variance.
|Variables in the Equation||B||SE||Wald||df||p value||Exp (B)||95% CI|
|Previous suicide attempt||2.601||1.101||5.583||1||0.018||13.472||1.558–116.494|
|MADRS total score b||0.174||0.063||7.633||1||0.006||1.137||1.052–1.347|
|SANS diminished expression domain score c||− 0.378||0.128||8.721||1||0.003||0.685||0.534–0.881|
|CHOPE Hopelessness factor||0.164||0.066||6.185||1||0.013||1.179||1.035–1.342|
|IPC Internal control factor||− 0.169||0.084||4.051||1||0.044||0.845||0.717–0.996|
|Final model: Nagelkerke R2 = 0.663, χ2 = 44.31, p < 0.0001|
|Hosmer & Lemeshow test supported the goodness of fit of the model (χ2 = 1.262, df = 6, p = 0.989)|
a CHOPE Future expectation factor, IPC Powerful others factor and Chance factor, BIS Attentional impulsivity, BRFL-A Fear of social disapproval and Survival and coping beliefs, which were entered in the stepwise logistic regression model, were excluded as predictors of suicidal ideation after analysis.
b MADRS total score was computed by summing individual items of MADRS excluding item 10 which measured suicidal thoughts.
c Diminished expression domain score was computed by summing individual items of the Affective Blunting subscale (excluding item of global rating for affective blunting) and poverty of speech item of the Alogia subscale of SANS
Abbreviations: BIS = Barratt Impulsiveness Scale; BRFL-A = Brief Reasons for Living Inventory for Adolescents; CHOPE = Chinese version of Beck Hopelessness Scale; IPC = Internality, Powerful Others and Chance Scale; MADRS = Montgomery–Asberg Depression Rating Scale; SANS = Scale for the Assessment of Negative Symptoms.
Our findings showed that 41.6% of patients expressed suicidal ideation after service entry. This was consistent with the literature which revealed that approximately one-fourth to half of FEP patients reported suicidal ideation at initial presentation (Nordentoft et al, 2002, Tarrier et al, 2007, Bakst et al, 2010, Barrett et al, 2010, Melle et al, 2010, and Upthegrove et al, 2010). In line with previous first-episode studies, our data indicated past suicide attempt as a predictor of suicidal ideation (Bertelsen et al, 2007 and Bakst et al, 2010). We also confirmed results of earlier reports which found that depression and hopelessness were associated with suicidal ideation in first-episode populations (Nordentoft et al, 2002, Bertelsen et al, 2007, and Bakst et al, 2010). In particular, our results demonstrated that hopelessness predicted suicidal ideation independent of depression, thereby highlighting its critical role in determining suicide risk. Alternatively, substantial evidence indicated that depressive symptoms frequently emerged during early illness phase (Romm et al, 2010 and Cotton et al, 2012). Hence, close monitoring and early intervention for depression in FEP are crucial to minimizing suicidal ideation and attempt, particularly in the first few years of illness which is consistently shown to be a period with the highest suicide risk.
Our result that less severe DE was linked to suicidal ideation was in contrary to the majority of literature which suggested a lack of association between negative symptoms and suicidal behavior (Haw et al, 2005 and Hawton et al, 2005). Nonetheless, our findings concurred with some previous studies which revealed that negative symptom severity was inversely related to the risk of completed suicide in schizophrenia ( Fenton et al., 1997 ) and suicide attempt in FEP ( Bertelsen et al., 2007 ). In fact, it has been postulated that patients with prominent negative symptoms, particularly deficits in emotion expressivity, may have significantly impaired capacity to experience emotional distress caused by the illness ( Fenton et al., 1997 ). This may probably reduce the likelihood of developing a sense of hopelessness and suicidal ideation. Recent evidence also indicated that schizophrenia patients with affect flattening, a core feature of DE, was associated with a dysfunction in emotion perception ( Gur et al., 2006 ). Conversely, a null finding on the relationship between negative symptoms and suicidal ideation or attempted suicide as revealed by many previous reports may partly be attributable to the methodological limitation of examining negative symptoms as a unitary construct rather than separate symptom sub-domains of DE and AA ( Messinger et al., 2011 ). Evaluating negative symptoms by single composite rating as adopted by most prior studies may thus mask potential differential relationships of negative symptom sub-domains with suicidal ideation.
The impact of perceived locus of control on suicide risk in psychosis has, thus far, not been adequately investigated. Literature on suicide attempters with non-psychotic conditions showed that individuals having higher level of internal locus of control exhibited better psychosocial adjustment to stress, while those with greater external locus of control were more likely to experience learned helplessness which might in turn trigger depression, suicidal thoughts and attempts (Goldney et al, 1991, Lester et al, 1991, and Beautrais et al, 1999). In this study, we found that suicidal ideation was negatively related to internal locus of control and positively associated with external locus of control. Final multivariate model further confirmed the role of internal locus of control in independently predicting suicidal ideation in our first-episode cohort. Our results may therefore suggest that patients who perceive the illness and its consequence as beyond their personal control may be more prone to develop suicide ideation.
Consistent with most prior FEP (Pompili et al, 2011 and Challis et al, 2013) and schizophrenia research (Haw et al, 2005 and Hawton et al, 2005) on suicidality, we failed to find a significant association between positive symptoms and suicidal ideation. We also failed to demonstrate that insight into illness significantly distinguished suicidal ideators from non-ideators. This was in contrary to some past studies which showed that better insight was related to suicidal ideation and attempted suicide in FEP patients (Crumlish et al, 2005, Robinson et al, 2009, and Barrett et al, 2010). Our findings of lack of association between insight and suicidal ideation were, however, in agreement with all of those very few studies that have examined predictors of suicidal ideation in FEP (Nordentoft et al, 2002, Bertelsen et al, 2007, Tarrier et al, 2007, and Bakst et al, 2010). It should, however, be noted that in general the results on the relationship of insight with suicidality in psychosis were mixed ( Lopez-Morinigo et al., 2013 ). Some investigators reported that insight into specific symptoms rather than general awareness of the illness was related to suicidal ideation and attempts ( Amador et al., 1996 ), while others revealed that the effect of insight on suicide risk was primarily mediated by hopelessness and depression (Kim et al, 2003 and Bourgeois et al, 2004). Some even demonstrated that treatment-related insight improvement was associated with a reduced risk of attempted suicide ( Bourgeois et al., 2004 ). Alternatively, it is plausible that the timing of insight assessment performed in this study may be too early for the majority of patients to have fully developed insight into the illness. Additionally, insight scale applied in our study did not evaluate awareness of illness consequence which has been linked to suicidal ideation and attempt in chronic schizophrenia sample ( Schwartz, 2000 ).
Data regarding the relationship between neurocognition and suicidal ideation or attempt in psychotic disorders were limited with inconsistent results which may partly be attributable to methodological variations across studies, including differences in defining suicidality measure (i.e., completed suicide, suicide attempt, suicidal ideation or a combination of these suicide-related variables) and the choice of neurocognitive assessments administered. Five out of six previous studies that investigated the association of suicidality with neurocognitive functions focused on patients with chronic schizophrenia (De Hert et al, 2001, Kim et al, 2003, and Potkin et al, 2003 Delaney et al., 2012 ). One study found that higher intelligence predicted completed suicide ( De Hert et al., 2001 ), while another study revealed that patients with a history of suicide attempt had better executive function than those lifetime non-attempters ( Nangle et al., 2006 ). Three other studies which used a single composite rating in measuring suicidality (combining suicidal ideation and suicide attempt) demonstrated conflicting findings, with one showing a significant relationship between global cognition and suicidality ( Delaney et al., 2012 ) while the others suggesting lack of independent contributions of neurocognitive functions to suicidality (Kim et al, 2003 and Potkin et al, 2003). Yet, the only study that examined FEP sample failed to find a significant difference on neurocognitive performance between suicide attempters and non-attempters ( Barrett et al., 2011 ). Conversely, recent studies on non-clinical samples and patients with non-psychotic mental disorders suggested that dyscontrol of executive inhibition and cognitive inflexibility may be particularly implicated in the emergence of suicidal ideation (Marzuk et al, 2005 and Miranda et al, 2012) and attempted suicide (Swann et al, 2005 and Wu et al, 2009). However, our results indicated that neither two executive functions were related to suicidal ideation in FEP population.
The study results have to be interpreted considering the following methodological limitations. First, the evaluation of suicidal ideation relied on the participants' self-reports and was thus subject to the problem of under-reporting. Nonetheless, we employed BSS, a questionnaire that specifically and systematically enquired into the presence of suicidal ideation, thereby minimizing an under-estimation bias. Second, the cross-sectional study design precluded us from drawing conclusions about causal relationship between identified risk factors and suicidal ideation. Third, as it is suggested that correlates of suicide attempt and suicidal ideation might be different ( Nordentoft et al., 2002 ), hence caution should be exercised in generalizing our findings to suicide attempt. Fourth, it should be noted that this study did not investigate factors predicting transition from suicidal ideation into an attempt. Although evidence indicated that suicidal ideation is a predictor of attempted and completed suicide, it is also acknowledged that suicidal ideation does not necessarily convert to suicidal behavior. Thus, further longitudinal follow-up studies are required to identify factors determining progression from suicidal ideation toward an attempt.
Our results have several clinical implications. First, a significant proportion of FEP patients reported suicidal ideation after service entry. Thus, systematic suicide risk assessment including the presence of suicidal ideation should be conducted at intake and then on a regular basis during follow-up to facilitate early identification and intervention of high-risk cases. Second, patients with a previous suicide attempt should receive a more intensive monitoring of emergence of suicidal ideation. Third, given that depression, sense of hopelessness and perceived inadequate personal control, which were found to be associated with suicidal ideation, can be routinely assessed and potentially modifiable by treatment such as cognitive therapy, close monitoring and prompt intervention of these risk factors may reduce occurrence and perpetuation of suicidal ideation, and hence enhance suicide prediction and prevention in the early course of psychosis.
In conclusion, our results indicated a high rate of suicidal ideation in young people presenting with FEP. Previous suicide attempt, depression, fewer deficits in emotion expressivity, hopelessness and lower level of internal locus of control were found to be independently associated with suicidal ideation. Further prospective research investigating the longitudinal course of suicidal ideation and its dynamic relationships with clinical, neurocognitive and psychological variables is required to enhance understanding and thus prediction of the transition from suicidal ideation into an actual attempt.
Role of funding source
The study was supported by grant 21500.10202404 from the Research Grants Council, University Grants Committee, Hong Kong.
Author E.Y.H.C. designed the study. Author W.C.C. and E.S.M.Cs. managed literature search and statistical analysis and wrote the first draft of the manuscript. All authors contributed to and have approved the final manuscript.
Conflicts of interest
Author E.Y.H.C. has participated in the paid advisory board for Otsuka, has received educational grant support from Janssen-Cilag, and has received research funding from Astra-Zeneca, Janssen-Cilag, Eli Lilly, Sanofi-Aventis and Otsuka. The authors report no conflicts of interest. The authors alone are responsible for the content and writing of the paper.
We thank all the coordinating clinicians and staff from the psychiatric units at Queen Mary Hospital, Pamela Youde Nethersole Eastern Hospital and Kwai Chung Hospital for their kind assistance and support. We are also grateful to the individuals who participated in the study.
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