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


Schizophr Bull. 2022;48(2):414-424. 

In This Article


In this population-based sample 19 422 of Medicaid-enrolled adolescents and young adults with FEP, approximately 11.1% engaged in DSH. Significant risk factors for DSH across participants included female sex, specific mental and chronic physical health comorbidities, and history of child abuse and neglect, previous DSH, and suicidal ideation (Table 2). Death by suicide during the observation period was relatively rare (N = 22). Thus all analyses with regard to risk factors for death by suicide are exploratory and are included in supplemental materials (supplementary table S3). When compared with the general Ohio population, individuals with FEP were significantly more likely to die by all causes during follow-up, including suicide.

Broadly, our results regarding DSH in youth with FEP are similar to previous research with regard to the observed rate of DSH,[24–26] increased risk for DSH among individuals with psychiatric comorbidities and substance use[23,24,45] or a history of child abuse and neglect,[46,47] and an association between earlier age at psychosis onset and increased risk for DSH.[26] Further, the association between previous DSH or suicidal ideation prior to an initial FEP diagnosis and increased risk for DSH is also consistent with previous research in psychosis[23,25,26] and in the broader population of individuals presenting for self-harm.[48,49] As recent research suggests that DSH may itself be a marker for later development of a psychosis,[50] additional research capable of clarifying how DSH may influence the expression or etiology of psychosis is warranted. Of note, previous mental healthcare across settings (i.e., inpatient, outpatient, and emergency department) was associated with the increased risk of DSH. This finding may suggest that individuals with more involvement in the behavioral healthcare system have greater illness severity and thus are also at greater risk for DSH. Alternatively, this result may suggest that elevated risk for DSH remains during the initial phase of FEP despite connection with mental health services and thus should remain an early focus of care. Though evidence suggests elevated self-harm and suicide risk persists even with connection to specialized FEP services,[51] additional research investigating the influence of specific treatments on DSH risk is needed. Finally, the presence of a comorbid chronic medical condition was associated with increased risk for DSH. Though this pattern of results is consistent with other research on psychiatric populations[46,52] much less is known about how physical health contributes to self-harm and suicide among young people with FEP. As significant and various treatment disparities (e.g., undertreatment for medical comorbidities[53]) and challenges for physical health (e.g., medications that negatively influence metabolic function[54]) exist for individuals with serious mental illness[55] and FEP,[53] comorbid health conditions may cause additional stress and burden that subsequently influences risk for DSH.

Our findings provide important guidance about when individuals with FEP are at greatest risk of DSH. More specifically, the median time to DSH following an initial FEP diagnosis was 171 days (SD: 490.5 days; IQR: 22.0–563.0 days) across the study cohort. Though previous research has suggested that risk for suicide and self-harm is highest during the first few years following psychosis onset,[11] the current findings provide important insight on an even more acute period of elevated risk in the first three to six months following diagnosis. When considered along with our findings that previous mental healthcare system contact increases the risk for DSH in FEP, these results highlight that while swift connection with specialized services is an important strategy for improving clinical outcomes, ongoing and consistent assessment of risk for DSH and suicidal behavior among FEP individuals once they are service-connected remains important for safety management.

When comparing DSH among individuals with adolescence versus young adult psychosis onset, several discernable differences emerged. First, young adults tended to engage in DSH significantly sooner during follow-up than adolescents (median days to DSH were 108 and 208, respectively). Though we are unable to test this possibility with the current data set given our retrospective design, this difference may represent a greater lack of family support among the young adults relative to adolescents who may be more likely to live with immediate family. Next, female sex was associated with increased DSH risk in adolescents but not in young adults. Of note, previous research with regard to increased risk for DSH among females with psychosis has been inconsistent, with some studies noting increased risk[56] and others noting no significant relationship[26] or an increased risk for DSH among males.[25] Thus, our current results may provide some clarification with regard to the role of sex and risk for DSH in this population in suggesting that this factor is more pronounced in adolescents than in young adults.


First, because the data are from a single state Medicaid population, findings may not generalize to other states or non-Medicaid populations. Second, although our sample included both adolescents (15–19) and young adults (20–24), our limited age range means that individuals with illness onset at 25 and older were not included. Third, our use of claims data precluded examination of other important risk factors that may be associated with DSH and suicide (e.g., psychiatric symptoms, recent substance intoxication or withdrawal, cognition, family functioning). Fourth, though the use of DSH as an indicator of increased suicide risk is empirically justified, it is important to acknowledge that claims records do not distinguish NSSI from suicide attempts. Fifth, we recognize that DSH diagnoses are not always included in Medicaid claims data, resulting in outcomes that are underpowered or biased toward the null.[57,58] However, this limitation means that the risk we identify may be understated, further supporting the need for early intervention in FEP. Sixth, DSH that did not require medical attention also is not captured in this data. Seventh, cause of death as identified on death certificates is determined by medical examiners or coroners and may be misclassified.[59] Finally, study diagnoses are based on clinical claims review and were not subject to expert validation, and there may be inconsistencies in use of codes across treatment sites and providers.


Notable strengths include the examination of a large population-based sample of individuals with FEP. Second, we examined a wide array of risk factors for DSH and suicide including demographics, psychiatric and medical comorbidities, history of self-harm, and prior service history. Third, we conducted a longitudinal analysis capable of elucidating the timing of risk following an initial psychosis diagnosis. Thus, while previous studies have noted increased risk for DSH and suicide in the first few years following illness onset,[10] our approach allowed for a more precise investigation of the longitudinal course of risk with notable findings regarding acute risk first few months following FEP diagnosis. Finally, we explored differences in DSH risk-factors for adolescents and young adults. This approach improves understanding of how age can be considered in assessing and navigating risk in the context of broader healthcare services. Though early intervention services for psychosis generally treat individuals across developmental phases, in many other systems of care they are served in different settings (i.e., child versus adult systems). Thus, our findings, which identify specific risk patterns for adolescents versus young adults, may guide more targeted risk assessment in different settings.