What are the risk factors for suicidal behavior in individuals with a first episode of psychosis and what are the protective factors?

There are many risk factors that can contribute to suicidal behavior for individuals experiencing psychosis including age, gender, marital status, phase of illness, employment status, history of attempts, presence of psychotic symptoms, depression, social functioning and social isolation, substance use, and cognitive inflexibility. The period of greatest risk for individuals with psychosis is during the first year after onset which usually occurs during the late teens to early twenties. Risk is generally high after the “post-psychotic” period or up to 6 months after hospital discharge. Although young age and early phase of illness are key high risk factors, suicidal ideation and behavior can persist throughout the lifespan for individuals with psychotic disorders. Let’s examine the key risk factors for psychosis in general.

• Males with psychosis are at higher risk than females for completing suicide. Also, females with psychosis are at higher risk for suicide than females in the general population or other high risk groups.
• Single individuals with psychosis die by suicide more than do individuals who are in relationships which is important because most individuals with psychosis are single.
• Risk of suicide is greater when the individual is unemployed or not engaged with a regular activity such as school or volunteer work. Most individuals with psychosis are unemployed.
• Over 50% of individuals with schizophrenia who die by suicide have made a previous attempt and 50% or more make more than one attempt.
• There is no evidence that suicidal behavior occurs more frequently in response to psychotic symptoms. Rather, suicidal behavior occurs mostly because individuals are distressed or overly preoccupied by the psychotic symptoms they are experiencing. Further, about 20% of individuals with psychosis experiencing command hallucinations to kill themselves will act on them.
• Risk for suicidal behavior is increased during a depressive episode, but depressed mood alone is a risk factor. Hopelessness is key risk factor in first-episode psychosis.
• Individuals with poor social functioning may be at greater risk due to lack of problem-solving skills, impulsiveness and aggression, poor social skills, and social isolation. Loss of social support especially of family or of a therapist, is a large risk factor. Not being able to return home after hospitalization also increases risk.
• Substance use and abuse increases risk especially when co-morbid with a psychotic disorder
• Cognitive inflexibility (“tunnel vision”) and ineffective decision making wherein an individual can’t think of alternatives increases risk.

Research has shown that protective factors are associated with reduced risk of suicide in people with psychotic disorders. Experts have identified several important protective factors.

• An accepting and supportive social environment including family support and acceptance
• Effective problem-solving skills which can help reduce stress
• Having a reason for living
• Possessing a positive attitude toward mental health providers and accessibility to care
• Limited access to lethal or deadly means of suicide
• Skills and abilities associated with good pre-morbid functioning

For a comprehensive review of this topic, see the SAMHSA webinar Recognizing Suicidal Ideation and Behavior in Individuals with First Episode Psychosis.

For help with managing suicidal individuals see ZeroSuicide.