Individuals who have attempted suicide and also have a history of self-harm should be thoroughly assessed for psychotic symptoms in order to prevent delayed treatment and the risk for repeated suicide attempts, say researchers.
They found that these patients formed a distinct subgroup among patients with schizophrenia, and characteristically had a significant delay in treatment and a high rate of repeated suicidal behavior, despite an early onset of psychotic symptoms.
Indeed, among 36 schizophrenia patients with a history of suicide attempt and self-harming behavior (highly repetitive, nonfatal, and primarily cutting), the average duration of untreated psychosis was 181 weeks. This compared with 32 weeks for 52 schizophrenia patients with a history of suicide attempt only and 28 weeks for 163 with schizophrenia and no suicidal behavior.
The researchers, led by Erlend Mork (University of Oslo, Norway), note that patients who had attempted suicide and self-harmed were significantly younger at psychosis onset than were the other groups, by about 4.9–6.7 years, and had their first contact with mental health services earlier. However, for more than half of these patients, this first contact was for reasons other than psychosis.
“It is thus unlikely that the observed treatment delay is explained by unfamiliarity with mental health services,” the researchers comment in BMC Psychiatry.
“Rather we could speculate that early onset of depression, possibly in combination with repeated self-harm behaviors and/or other symptoms and behavior such as suicidal ideation and impulsive aggression may have delayed a thorough diagnostic assessment of their psychotic symptoms.”
Patients who attempted suicide and self-harmed did have significantly higher levels of current impulsivity/aggression and depression than did those who only attempted suicide or had no suicidal behavior.
And the addition of current depressive symptoms to multinomial logistic regression analysis rendered the significantly increased risk for treatment delay of more than a year in suicidal patients with versus without self-harm no longer significant.
Of concern, the patients with suicidal and self-harm behaviors were significantly more likely than those with suicidal behavior only to have made repeat suicide attempts, at 78% versus 33%. The median number of attempts was two and the maximum was seven.
“The high frequency of suicide attempts combined with higher levels of impulsive aggression and depressive symptoms suggest that this group may be at increased risk for severe suicidal behavior in the future,” says the team.
“Assessment of non-suicidal self-harm should be part of standard suicide risk assessment of schizophrenia patients.”
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