Psychotic Symptoms Increase Teens' Risk for Suicidal Behavior

Psychotic symptoms greatly increase the risk for suicidal behavior in adolescents in the general population as well as those with diagnosable psychiatric disorders, research from the United Kingdom shows.

Ian Kelleher, PhD, Royal College of Surgeons in Ireland, Beaumont Hospital, Dublin, and colleagues found that psychotic symptoms, primarily auditory hallucinations, increased the risk for any suicidal behavior by 10-fold in both early and mid adolescence.

Adolescents with depressive disorders who also experienced psychotic symptoms were nearly 14-fold more likely to express severe suicidal behavior, including suicide plans and acts, compared with adolescents with depressive disorders who did not experience psychotic symptoms.

And among all those with suicidal ideation, adolescents who also reported psychotic symptoms had a nearly 20-fold increased risk of having suicidal plans or acts compared with those who also had suicidal ideation but who did not report psychotic symptoms.

"The immediate clinical relevance of these findings is that all patients presenting at risk for suicidal behaviour should receive a thorough assessment of psychotic symptoms and not just a screening to rule out psychotic disorder," investigators write.

"It is important that clinicians are aware of the significance of psychotic symptoms in nonpsychotic patients in terms of risk for suicidal behaviour."

The study was published online October 29 in the Archives of General Psychiatry.

Marker of Risk

Psychotic symptoms have been implicated as a potentially important marker of risk for suicidal behavior, but there have been no epidemiological studies reporting on psychotic symptoms and suicidality in persons who have been clinically assessed for suicidal behavior, the investigators note.

Data for the current study were derived from 2 complementary but independently conducted Irish general population studies: the Adolescent Brain Development (ABD) study, involving 1131 students aged 11 to 13 years, and the Challenging Times (CT) study, involving 743 students aged 13 to 15 years.

The interview instrument used in both studies was the Schedule for Affective Disorders and Schizophrenia for School-aged Children, Present and Lifetime versions (K-SADS).

Some 22% of the ABD sample reported psychotic symptoms, most within the past 3 months.

A total of 7% of the same sample reported suicidal behavior — 6.8% suicidal ideation; 3.7% specific suicide plans; and 0.4% (1 participant) who reported a suicidal act.

Seven percent of the CT sample similarly reported psychotic symptoms, and 13% reported suicidal behavior.

Of these, 13.2% reported suicidal ideation; 5% reported specific suicidal plans; and 3.3% reported a suicidal act.

"In both the ABD and CT studies, adolescents with a diagnosable psychiatric disorder plus psychotic symptoms were at greater than 5-fold increased odds of suicidal behaviour compared with adolescents with a diagnosable psychiatric disorder but no psychotic symptoms," the authors add.

Psychotic Symptoms and Odds of Suicidal Behavior

	All Suicidal Behavior Adjusted for Sex, Odds Ratio	P Value
ABD study overall sample	10.23	< .001
CT study overall sample	10.50	< .001
ABD study with psychiatric disorder	5.13	.03
CT study with psychiatric disorder	5.31	.02

Suicidal Plans

"Strikingly," investigators add, the majority of adolescents with suicidal plans or acts reported psychotic symptoms in both the ABD (60%) and the CT (55%) studies.

"This is a particularly important fact given that suicide plans and history of parasuicide have been shown to be among the most predictive risk factors for completed suicide," they write.

The authors also note that young people rarely volunteer information on psychotic symptoms unless questioned directly about such experiences.

On the other hand, they have found that adolescents are usually willing to talk about their experiences in response to direct, sensitive questioning.

The authors have disclosed no relevant financial relationships.

Arch Gen Psychiatry. Published online October 29, 2012.