Risk Factors for Deliberate Self-harm and Suicide Among Adolescents and Young Adults With First-Episode Psychosis

Aubrey M. Moe; Elyse Llamocca; Heather M. Wastler; Danielle L. Steelesmith; Guy Brock; Jeffrey A. Bridge; Cynthia A. Fontanella

Disclosures

Schizophr Bull. 2022;48(2):414-424.

Abstract and Introduction

Abstract

Little is known about the risk factors for deliberate self-harm (DSH) and suicide among adolescents and young adults with first episode psychosis (FEP) and the longitudinal course of DSH following the initial onset of illness. This study identifies risk factors for DSH and suicide death among Medicaid-covered adolescents and young adults with FEP along with the periods of greatest risk for DSH after diagnosis. A retrospective longitudinal cohort analysis was performed using Medicaid claims data merged with death certificate data for 19 422 adolescents and young adults (aged 15–24 years) diagnosed with the onset of FEP between 2010 and 2017. DSH per 1000 person-years and standardized mortality rates for suicide were determined. Hazard ratios of DSH and suicide were estimated by Cox proportional hazard models. During follow-up, 2148 (11.1%) individuals had at least one self-harm event and 22 (0.1%) died by suicide. The hazards of DSH were significantly higher for those with a previous DSH, suicidal ideation, child abuse and neglect, comorbid medical and psychiatric diagnoses, and prior mental health care. The median follow-up time for those who had DSH was 208.0 days (SD: 526.5 days) in adolescents and 108.0 days (SD: 340.0 days) in young adults. Risk of DSH was highest in the first 3 months following FEP. Individuals with FEP are at high risk for self-harm and suicidal behavior, and recognition of who among these individuals and when following illness onset they are at greatest risk may guide more precise clinical recognition and intervention.

Introduction

Psychotic disorders are serious illnesses that emerge during the youth and young adult years, often causing a significant functional impairment^[1] and illness-related burden.^[2] Individuals with psychosis are at elevated risk for early mortality, dying an estimated 20 years earlier than general-population peers.^[3] Suicide is a major contributor to this early mortality; suicide rates in psychosis are approximately 12 times greater than in the general population.^[4] An estimated 25–50% of individuals with psychosis attempt suicide during the course of illness,^[5] with 5–10% dying by suicide.^[6] As suicide is also the second leading cause of death in the United States among young people ages 15–24^[7] understanding risk factors for suicide among youth with psychosis is particularly important.

Suicide risk for individuals with psychosis is greatest among young adults^[8,9] early in the course of illness,^[10,11] with recent data suggesting that suicide is the leading cause of death in the five years following diagnosis^[12] and 8–10% of individuals with first-episode psychosis (FEP) attempt suicide during the initial years of treatment.^[13,14] Though most existing suicide research has included individuals with more chronic psychosis,^[15,16] risk factors for individuals with FEP have been identified (e.g., male sex, depression, substance use, previous suicide attempts).^[17,18] As rates of suicide and suicide attempts are elevated among youth with psychosis^[17] effective strategies for identifying and addressing risk may benefit from further examination of a continuum of suicidal behavior, including deliberate self-harm (DSH). DSH describes an act of non-fatal self-poisoning or self-injury irrespective of suicidal intent^[19] and thus includes non-suicidal self-injury (NSSI) without the intent to die^[20] and suicide attempts.^[21] DSH is a risk-factor for subsequent suicide^[22] and thus examining DSH in a population at elevated risk (i.e., youth with psychosis) may improve intervention and prevention. DSH is a strong predictor of suicide among people with psychosis over the course of illness,^[23] and studies indicate that approximately 11% of individuals with FEP engage in DSH.^[24,25] Though risk factors for DSH among people with psychosis have been identified (e.g., previous history of self-harm, substance abuse, depressed mood),^[26] the course of DSH in the period of time following an initial psychotic disorder diagnosis remains unclear.

Additionally, there is considerable clinical heterogeneity among individuals with psychosis^[27] that can hinder the identification of individual risk for DSH and suicide. Notably, the typical age of initial psychosis-onset spans broadly from the adolescent years to the late 20s, leading to significant developmental variation among FEP individuals. Recent attention has been given to the relevance of "emerging adulthood"^[28]—an early adulthood developmental phase characterized by transitions and uncertainty—and how the unique developmental tasks and challenges of this phase influence clinical presentation and inform treatment approaches for individuals with FEP.^[29,30] Relatedly, specific investigations of how developmental phase when illness begins may influence risk for DSH and suicide are relevant but relatively unexplored.

In summary, longitudinal investigations of who is at greatest risk when will provide a more refined understanding of risk factors among individuals with FEP, allowing for more precise identification and improved clinical management of DSH and suicide. Thus, the present study investigates the emergence of DSH and suicide following an initial diagnosis of psychosis among a population-based sample of adolescents and young adult FEP patients. In addition to assessing known risk factors for DSH and suicide among youth^[31] and in psychosis,^[26] we extended prior research by assessing developmental stage at the time of diagnosis (i.e., adolescent versus young adult) to determine its influence on risk for DSH and suicide. Given the elevated rates of self-harm and suicide among youth in general, observed rates of DSH and suicide among FEP individuals were also compared to general population controls. Collectively, this approach allowed for a more refined investigation of when and which individuals in the early stage of a psychotic disorder are at greatest risk for DSH. Notably, to the best of our knowledge, the current study is the largest investigation of DSH and suicide among youth following an initial psychosis diagnosis.

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Next Section

Abstract and Introduction
Methods
Measures
Results
Discussion
Conclusions and Implications for Clinical Practice
References

Table 1. Demographic Characteristics of Adolescent and Young Adult Medicaid Patients Experiencing a First Episode of Psychosis
Characteristic	Total (N = 19 422), %^a	Adolescents 15–19 Years (N = 10 594), %^b	Young Adults 20–24 Years (N = 8828), %^a	Odds Ratio of Adolescent Group^b	95% CI
Gender
Male	48.7	49.5	47.8	1.00	reference
Female	51.3	50.5	52.2	0.93	0.88–0.99
Race/ethnicity
Non-Hispanic white	55.3	56.5	53.8	1.00	reference
Non-Hispanic black	33.3	32.6	34.1	0.91	0.85–0.97
Hispanic	2.6	2.7	2.4	1.06	0.88–1.27
Other^c	8.9	8.2	9.7	0.81	0.73–0.89
Eligibility status at index diagnosis
Poverty	69.7	73.5	65.1	1.00	reference
Disabled	23.3	16.9	30.9	0.49	0.45–0.52
Foster care	5.3	9.3	0.6	14.27	10.75–18.95
Other^d	1.7	0.3	3.4	0.07	0.04–0.10
Area of residence
Metro	82.3	82.7	82.0	1.00	reference
Non-Metro	17.7	17.4	18.0	0.95	0.89–1.03
Psychiatric comorbidities^e
ADHD	30.9	41.4	18.3	3.15	2.95–3.37
Anxiety	56.4	60.3	51.7	1.42	1.34–1.50
Disruptive disorder	23.8	35.3	10.0	4.92	4.54–5.33
Intellectual disability	17.3	18.2	16.4	1.13	1.05–1.22
Personality disorder	16.5	16.4	16.6	0.98	0.91–1.06
Substance use disorder	56.1	51.1	62.1	0.64	0.60–0.68
Other mental health disorder^f	57.2	66.5	46.1	2.32	2.19–2.46
Chronic medical condition^e
No chronic medical condition	16.0	14.7	17.5	1.00	reference
Noncomplex, chronic medical condition	51.7	52.9	50.2	1.25	1.15–1.36
Complex, chronic medical condition	32.4	32.4	32.4	1.19	1.09–1.29
History of child abuse and neglect^e,g	2.3	3.3	1.3	2.64	2.13–3.28
History of deliberate self-harm^h	5.9	7.5	4.0	1.93	1.70–2.20
History of suicidal ideation^h	31.5	37.5	24.3	1.86	1.75–1.99
Index psychosis category
Affective Disorder	34.1	36.8	31.0	1.00	reference
Schizophrenia Spectrum Disorder	65.9	63.2	69.0	0.77	0.73–0.82
Prior inpatient mental health careⁱ	10.8	12.7	8.5	1.58	1.44–1.73
Prior emergency room mental health careⁱ	20.8	23.3	17.8	1.40	1.31–1.51
Prior outpatient mental health careⁱ	63.0	69.4	55.3	1.84	1.73–1.95
Incident deliberate self-harm	11.1	14.9	6.4	2.54	2.30–2.81

Note:
^aPercentages may not sum to 100 due to rounding.
^bYoung adults are the reference group.
^cOther race included Asian Americans, Native Americans/Alaska Natives, Native Hawaiians or other Pacific Islanders, more than one race, and unknown.
^dOther eligibility included incarceration and unknown Medicaid eligibility categories.
^eIncluded all claims in the 180 days prior to the index diagnosis and during follow-up period.
^fExcludes diagnosis codes for bipolar disorder and depression.
^gDiagnosis codes: ICD-9-CM: 995.50–995.59, E967.0–967.9; ICD-10: T74.1–T74.9, Z61.4–Z61.6, and Y07.9; (H) Included all claims in the 180 days prior to the index diagnosis and on index diagnosis date; (I) Included all claims in the 180 days prior to the index diagnosis

Table 2. Deliberate Self-Harm (DSH) in a Cohort of Adolescent and Young Adult Medicaid Patients Experiencing a First Episode of Psychosis
Characteristic	No. Patients	Person-y at Risk	First DSH Events, N	Unadjusted DSH Rate (Per 1000 Person-y)	Unadjusted HR of DSH	95% CI	Adjusted HR of DSH^a,b	95% CI
Total	19 422	36 932.4	2148	58.2
Age at index diagnosis
15–19 years	10 594	24 052.3	1579	65.6	1.00	reference	1.00	reference
20–24 years	8828	12 880.1	569	44.2	0.56	0.51–0.61	0.55	0.50–0.61
Gender
Male	9464	18 122.0	776	42.8	1.00	reference	1.00	reference
Female	9958	18 810.4	1372	72.9	1.70	1.56–1.86	1.74	1.59–1.90
Race/ethnicity
Non-Hispanic white	10 736	20 082.4	1374	68.4	1.00	reference	1.00	reference
Non-Hispanic black	6464	13 122.3	527	40.2	0.60	0.55–0.67	0.61	0.55–0.67
Hispanic	502	920.5	57	61.9	0.90	0.69–1.18	0.93	0.72–1.22
Other^c	1720	2807.1	190	67.7	0.94	0.81–1.09	0.96	0.83–1.12
Eligibility status at index diagnosis
Poverty	13 536	23 796.5	1520	63.9	1.00	reference	1.00	reference
Disabled	4526	10 213.1	384	37.6	0.64	0.58–0.72	0.79	0.70–0.88
Foster care	1037	2417.6	231	95.5	1.66	1.44–1.90	1.55	1.34–1.78
Other^d	323	505.2	13	25.7	0.38	0.22–0.66	0.54	0.31–0.93
Area of residence
Metro	15 991	30 801.5	1762	57.2	1.00	reference	1.00	reference
Non-Metro	3431	6130.9	386	63.0	1.07	0.96–1.20	0.92	0.82–1.03
Psychiatric comorbidities^e
ADHD	6003	12 532.9	861	68.7	1.65	1.51–1.81	1.57	1.44–1.72
Anxiety	10 948	18 622.7	1473	79.1	2.83	2.58–3.11	2.46	2.24–2.71
Disruptive disorder	4626	10 324.7	773	74.9	1.89	1.73–2.07	1.83	1.67–2.01
Intellectual disability	3369	8140.6	358	44.0	0.87	0.78–0.98	0.95	0.85–1.07
Personality disorder	3200	5391.7	556	103.1	2.65	2.40–2.92	2.54	2.30–2.81
Substance use disorder	10 898	17 593.7	1213	68.9	1.71	1.56–1.86	1.86	1.71–2.03
Other mental health disorder^f	11 118	21 719.0	1494	68.8	2.29	2.08–2.51	2.05	1.87–2.26
Chronic medical condition^e
No chronic medical condition	3102	6055.2	286	47.2	1.00	reference	1.00	reference
Noncomplex, chronic medical condition	10 033	18 655.1	1063	57.0	1.92	1.68–2.20	1.71	1.50–1.96
Complex, chronic medical condition	6287	12 222.0	799	65.4	2.32	2.02–2.67	2.17	1.89–2.49
History of child abuse and neglect^e,g	456	646.9	89	137.6	3.04	2.46–3.76	2.54	2.05–3.14
History of deliberate self-harm^h	1152	1083.7	582	537.0	10.34	9.40–11.38	8.85	8.02–9.76
History of suicidal ideation^h	6114	10 186.1	1220	119.8	3.28	3.01–3.57	2.89	2.65–3.15
Index psychosis category
Affective Disorder	6631	11 274.5	761	67.5	1.00	reference	1.00	reference
Schizophrenia Spectrum Disorder	12 791	25 657.9	1387	54.1	0.85	0.78–0.93	0.99	0.90–1.08
Prior inpatient mental health careⁱ	2095	3745.6	504	134.6	2.68	2.42–2.96	2.40	2.17–2.65
Prior emergency room mental health careⁱ	4035	7287.9	737	101.1	2.09	1.91–2.29	1.93	1.76–2.11
Prior outpatient mental health careⁱ	12 231	24 597.9	1612	65.5	1.60	1.45–1.77	1.41	1.28–1.56

Note:
^aAdjusted for age at index diagnosis, gender, and race/ethnicity.
^bAll raw P-values <.0001 except area of residence (P-value: .13), intellectual disability (P-value: .41), and index psychosis category (P-value: .77). FDR adjusted P-values remained virtually unchanged from raw P-values.
^cOther race included Asian Americans, Native Americans/Alaska Natives, Native Hawaiians or other Pacific Islanders, more than one race, and unknown.
^dOther eligibility included incarceration and unknown Medicaid eligibility categories.
^eIncluded all claims in the 180 days prior to the index diagnosis and during follow-up period.
^fExcludes diagnosis codes for bipolar disorder and depression.
^gDiagnosis codes: ICD-9-CM: 995.50–995.59, E967.0–967.9; ICD-10: T74.1–T74.9, Z61.4–Z61.6, and Y07.9.
^hIncluded all claims in the 180 days prior to the index diagnosis and on index diagnosis date.
ⁱIncluded all claims in the 180 days prior to the index diagnosis.

Table 3. Cox proportional Hazards Models for Deliberate Self-Harm Among Adolescent and Young Adult Medicaid Patients Experiencing a First Episode of Psychosis
Characteristic	Adolescents 15–19 Years Adjusted HR^a	95% CI	Young Adults 20–24 Years Adjusted HR^a	95% CI	Raw Interaction P	FDR Adjusted Interaction P
Gender
Male	1.00	reference	1.00	reference	.001	.005
Female	1.90	1.71–2.11	1.36	1.15–1.61
Race/ethnicity
Non-Hispanic white	1.00	reference	1.00	reference	.02	.05
Non-Hispanic black	0.66	0.58–0.73	0.48	0.39–0.59
Hispanic	0.90	0.66–1.23	1.04	0.63–1.72
Other^b	0.90	0.75–1.09	1.09	0.84–1.42
Eligibility status at index diagnosis
Poverty	1.00	reference	1.00	reference	.14	.27
Disabled	0.86	0.74–0.98	0.68	0.56–0.83
Foster care	1.54	1.33–1.78	2.34	1.21–4.54
Other^c	0.45	0.06–3.21	0.53	0.30–0.94
Area of residence
Metro	1.00	reference	1.00	reference	.85	.88
Non-Metro	0.92	0.81–1.05	0.90	0.73–1.11
Psychiatric comorbidities^d
ADHD	1.56	1.41–1.73	1.63	1.33–1.99	.71	.85
Anxiety	2.43	2.18–2.72	2.54	2.13–3.02	.68	.85
Disruptive disorder	1.92	1.74–2.13	1.35	1.03–1.76	.01	.05
Intellectual disability	0.96	0.84–1.10	0.93	0.74–1.17	.82	.88
Personality disorder	2.40	2.13–2.70	2.91	2.43–3.48	.08	.16
Substance use disorder	1.62	1.46–1.79	2.91	2.41–3.51	<.001	<.001
Other mental health disorder^e	2.00	1.78–2.24	2.17	1.84–2.57	.41	.70
Chronic medical condition^d
No chronic medical condition	1.00	reference	1.00	reference	.69	.85
Noncomplex, chronic medical condition	1.66	1.42–1.94	1.88	1.45–2.42
Complex, chronic medical condition	2.13	1.81–2.50	2.29	1.76–2.98
History of child abuse and neglect^d,f	2.46	1.96–3.10	3.14	1.77–5.56	.44	.70
History of deliberate self-harm^g	7.45	6.65–8.34	15.21	12.66–18.28	<.001	<.001
History of suicidal ideation^g	2.61	2.36–2.89	3.80	3.22–4.48	<.001	<.001
Index psychosis category
Affective Disorder	1.00	reference	1.00	reference	.88	.88
Schizophrenia Spectrum Disorder	0.99	0.89–1.10	0.98	0.82–1.16
Prior inpatient mental health care^h	2.28	2.03–2.56	2.84	2.32–3.48	.06	.15
Prior emergency room mental health care^h	1.80	1.62–1.99	2.37	2.00–2.82	.007	.03
Prior outpatient mental health care^h	1.39	1.24–1.57	1.45	1.22–1.73	.69	.85

Note:
^aAdjusted for age at index diagnosis, gender, and race/ethnicity and included an interaction term of the specified effect with age at index diagnosis.
^bOther race included Asian Americans, Native Americans/Alaska Natives, Native Hawaiians or other Pacific Islanders, more than one race, and unknown.
^cOther eligibility included incarceration and unknown Medicaid eligibility categories.
^dIncluded all claims in the 180 days prior to the index diagnosis and during follow-up period.
^eExcludes diagnosis codes for bipolar disorder and depression.
^fDiagnosis codes: ICD-9-CM: 995.50–995.59, E967.0–967.9; ICD-10: T74.1–T74.9, Z61.4–Z61.6, and Y07.9.
^gIncluded all claims in the 180 days prior to the index diagnosis and on index diagnosis date; (H) Included all claims in the 180 days prior to the index diagnosis.

Table 4. All Causes of Death, Suicide, and Unintentional Deaths Among Adolescent and Young Adult Medicaid Patients Experiencing a First Episode of Psychosis
Cause of Death	No. Patients	Person-y of Follow-up	Observed Deaths, N	Crude Mortality rate per 100 000 Person-y	Expected Deaths, N	SMR	95% CI
All causes of death
Total sample	19 422	40 278.8	124	307.9	32.5	3.8	3.2–4.5
Adolescents^a	10 594	26 807.5	65	242.5	18.6	3.5	2.7–4.4
Young adults^a	8828	13 471.3	59	438.0	13.9	4.2	3.3–5.4
Suicide
Total sample	19 422	40 278.8	22	54.6	4.9	4.5	2.9–6.8
Adolescents^a	10 594	26 807.5	16	59.7	3.0	5.4	3.2–8.6
Young adults^a	8828	13 471.3	6	44.5	1.9	3.2	1.3–6.6
Unintentional deaths
Total sample	19 422	40 278.8	33	81.9	13.4	2.5	1.7–3.4
Adolescents^a	10 594	26 807.5	13	48.5	7.3	1.8	1.0–3.0
Young adults^a	8828	13 471.3	20	148.5	6.1	3.3	2.1–5.0

Note: Calendar year, age, and gender matched from general Ohio population, 2010–2017.
^aAdolescents defined as 15–19 years at index diagnosis. Young adults defined as 20–24 years at index diagnosis.

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Risk Factors for Deliberate Self-harm and Suicide Among Adolescents and Young Adults With First-Episode Psychosis

Abstract and Introduction

Abstract

Introduction

Tables

Tables

Tables

Tables

References

Authors and Disclosures

Authors and Disclosures

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