A call to action: informing research and practice in suicide prevention among individuals with psychosis.

Although it is well established that individuals living with psychosis are at increased risk for suicidal ideation, attempts, and death by suicide, several gaps in the literature need to be addressed to advance research and improve clinical practice. This Call-to-Action highlights three major gaps in our understanding of the intersection of psychosis and suicide as determined by expert consensus. The three gaps include research methods, suicide risk screening and assessment tools used with persons with psychosis, and psychosocial interventions and therapies. Specific action steps to address these gaps are outlined to inform research and practice, and thus, improve care and prognoses among persons with psychosis at risk for suicide.

Identification of Psychosis Risk and Diagnosis of First-Episode Psychosis: Advice for Clinicians.

Early detection of psychotic-spectrum disorders among adolescents and young adults is crucial, as the initial years after psychotic symptom onset encompass a critical period in which psychosocial and pharmacological interventions are most effective. Moreover, clinicians and researchers in recent decades have thoroughly characterized psychosis-risk syndromes, in which youth are experiencing early warning signs indicative of heightened risk for developing a psychotic disorder. These insights have created opportunities for intervention even earlier in the illness course, ideally culminating in the prevention or mitigation of psychosis onset. However, identification and diagnosis of early signs of psychosis can be complex, as clinical presentations are heterogeneous, and psychotic symptoms exist on a continuum. When a young person presents to a clinic, it may be unclear whether they are experiencing common, mild psychotic-like symptoms, early warning signs of psychosis, overt psychotic symptoms, or symptoms better accounted for by a non-psychotic disorder. Therefore, the purpose of this review is to provide a framework for clinicians, including those who treat non-psychotic disorders and those in primary care settings, for guiding identification and diagnosis of early psychosis within the presenting clinic or via referral to a specialty clinic. We first provide descriptions and examples of first-episode psychosis (FEP) and psychosis-risk syndromes, as well as assessment tools used to diagnose these conditions. Next, we provide guidance as to the differential diagnosis of conditions which have phenotypic overlap with psychotic disorders, while considering the possibility of co-occurring symptoms in which case transdiagnostic treatments are encouraged. Finally, we conclude with an overview of early detection screening and outreach campaigns, which should be further optimized to reduce the duration of untreated psychosis among youth.

Costs of Coordinated Specialty Care for First-Episode Psychosis: A Microcosting Analysis.

In this study, the authors measured and described the costs of coordinated specialty care (CSC) for first-episode psychosis in Ohio. A microcosting tool was used to estimate personnel and nonpersonnel costs of service delivery at seven CSC programs. Average annual cost per participant (N=511 participants) was estimated as $17,810 (95% CI=$9,141-$26,479). On average, 61% (95% CI=53%-69%) of annual program costs were nonbillable. Key cost drivers included facility costs, administrative tasks, and social services. Novel financing models may redress reimbursement gaps incurred by CSC programs.

Symptomatic and Functional Outcomes Among Individuals at High Risk for Psychosis Participating in Step-Based Care.

Validated, multicomponent treatments designed to address symptoms and functioning of individuals at clinical high risk for psychosis are currently lacking. The authors report findings of a study with such individuals participating in step-based care-a program designed to provide low-intensity, non-psychosis-specific interventions and advancement to higher-intensity, psychosis-specific interventions only if an individual is not meeting criteria for a clinical response. Among individuals with symptomatic or functional concerns at enrollment, 67% met criteria for a symptomatic response (median time to response=11.1 weeks), and 64% met criteria for a functional response (median time to response=8.9 weeks).

Metacognitive Skills Training and Computerized Cognitive Remediation among Individuals with First-Episode Psychosis: Influence on Social Cognition.

Background: Metacognitive skills training (MST) is often integrated into cognitive remediation programs for psychosis. Social cognition - the mental processes underlying social perception and behavior - is robustly related to outcomes in psychosis and is increasingly addressed with targeted treatments. Though metacognition and social cognition are related constructs, little is known about how MST may influence social cognition among individuals with psychosis participating in broad-based, non-social cognitive remediation. Methods: Individuals with first-episode psychosis who completed six months of metacognitive remediation (MCR; n=12) were compared to a historical control group who received six months of computerized cognition remediation (CCR; n=10) alone (ClinicalTrials.gov Identifier NCT01570972). Results: Though individuals receiving MCR experienced gains in emotion processing and theory of mind, these changes were not significantly different when compared to individuals receiving CCR. MST did not contribute to social cognitive change in the context of CCR. Discussion: Though MST may be relevant to facilitating social cognitive gains within broader cognitive remediation programs for first-episode psychosis, these benefits are limited and may not exceed those conferred by standard cognitive remediation. Opportunities for investigation of other potential mechanisms of social cognitive response to interventions remain.

Suicidal thoughts and behaviors among gender and sexual minorities: Adults ages 25-44 show highest rates of past month suicidal thoughts.

INTRODUCTION: Sexual and gender minority (SGM) people are at increased risk for suicidal thoughts and behaviors relative to their cisgender heterosexual peers. However, most research in this area has focused on youth, limiting our understanding of suicide risk among SGM adults. METHODS: To address this gap in the literature, the present study examined suicidal thoughts and behaviors among SGM adults across different age groups using a sample of 10,620 US adults. RESULTS: Consistent with the literature on youth, SGM adults showed higher rates of suicidal thoughts and behaviors than cisgender heterosexual adults. When examining prevalence rates across various age groups, young adults (18-25) showed greater suicidal thoughts and behaviors relative to adults ages 45+. However, adults ages 25-44 actually showed the highest rate of past month suicidal thoughts compared to adults ages 18-25. CONCLUSION: These findings suggest that suicide risk for SGM extends beyond youth and highlights the need for more research on middle-age SGM adults. Additional resources for SGM adults that are not only tailored toward youth and young adults are warranted.

ED Visits for Schizophrenia Spectrum Disorders During the COVID-19 Pandemic at 5 Campus Health Systems.

Importance: Although substantial research has reported grave population-level psychiatric sequelae of the COVID-19 pandemic, evidence pertaining to temporal changes in schizophrenia spectrum disorders in the US following the pandemic remains limited. Objective: To examine the monthly patterns of emergency department (ED) visits for schizophrenia spectrum disorders after the onset of the COVID-19 pandemic. Design, Setting, and Participants: This observational cohort study used time-series analyses to examine whether monthly counts of ED visits for schizophrenia spectrum disorders across 5 University of California (UC) campus health systems increased beyond expected levels during the COVID-19 pandemic. Data included ED visits reported by the 5 UC campuses from 2016 to 2021. Participants included persons who accessed UC Health System EDs had a diagnosis of a psychiatric condition. Data analysis was performed from March to June 2023. Exposures: The exposures were binary indicators of initial (March to May 2020) and extended (March to December 2020) phases of the COVID-19 pandemic. Main Outcomes and Measures: The primary outcome was monthly counts of ED visits for schizophrenia spectrum disorders. International Statistical Classification of Diseases and Related Health Problems, Tenth Revision diagnosis codes, categorized within Clinical Classification Software groups, were used to identify ED visits for schizophrenia spectrum disorders and all other psychiatric ED visits, from the University of California Health Data Warehouse database, from January 2016 to December 2021. Time-series analyses controlled for autocorrelation, seasonality, and concurrent trends in ED visits for all other psychiatric conditions. Results: The study data comprised a total of 377 872 psychiatric ED visits, with 37 815 visits for schizophrenia spectrum disorders. The prepandemic monthly mean (SD) number of ED visits for schizophrenia spectrum disorders was 519.9 (38.1), which increased to 558.4 (47.6) following the onset of the COVID-19 pandemic. Results from time series analyses, controlling for monthly counts of ED visits for all other psychiatric conditions, indicated 70.5 additional ED visits (95% CI, 11.7-129.3 additional visits; P = .02) for schizophrenia spectrum disorders at 1 month and 74.9 additional visits (95% CI, 24.0-126.0 visits; P = .005) at 3 months following the initial phase of the COVID-19 pandemic in California. Conclusions and Relevance: This study found a 15% increase in ED visits for schizophrenia spectrum disorders within 3 months after the initial phase of the pandemic in California across 5 UC campus health systems, underscoring the importance of social policies related to future emergency preparedness and the need to strengthen mental health care systems.

Within-Person Relationship between Attenuated Positive Symptoms and Suicidal Ideation among Individuals at Clinical High Risk for Psychosis.

Individuals at clinical high-risk for psychosis (CHR-P) are at increased risk for suicide. However, the relationship between attenuated positive symptoms and suicidal ideation are not well understood, particularly as they interact over time. The current study addressed this gap in the literature. We hypothesized that greater attenuated symptoms would be concurrently and prospectively associated with suicidal ideation. Further, we hypothesized that suspiciousness and perceptual abnormalities would have the strongest relationship with suicidal ideation. Within-person variation in symptoms and suicidal ideation were examined across 24 treatment sessions for individuals at CHR-P. Attenuated positive symptoms (unusual thought content, suspiciousness, grandiose ideas, perceptual abnormalities, and disorganized communication) and suicidal ideation were assessed at each session. Logistic mixed effect models examined concurrent and time-lagged relationships between symptoms and suicidal ideation among 36 individuals at CHR-P. Results indicated that suicidal ideation was more likely during weeks when participants reported more severe total attenuated positive symptoms. Further, suspiciousness was uniquely associated with suicidal ideation, both concurrently and at the following session. Post hoc models examined the reverse direction of this relationship, demonstrating that suicidal ideation also prospectively predicted suspiciousness at the following session. These results suggest that within-person attenuated symptoms, particularly suspiciousness, are associated with suicidal ideation among individuals at CHR-P. However, the bidirectional relationship between suspiciousness and suicidal ideation raises questions about causal nature of this relationship. Further research is needed to examine the dynamic interplay of suspiciousness and suicidal ideation.

An examination of the relationship between positive schizotypy and suicide risk using five distinct samples.

Individuals with schizophrenia are at increased risk for suicide. However, much less is known about suicide risk among individuals with schizotypic features. To address this gap in the literature, the current report examines the relationship between positive schizotypy and suicide risk using five distinct samples. Each of these five studies addresses unique, but complementary, questions regarding the relationship between positive schizotypy and suicide risk. Studies 1 and 2 investigate the cross-sectional relationship between perceptual aberrations and suicidal ideation. Study 3 examines the relationship between suicidal ideation and multiple positive schizotypic features (perceptual aberrations, magical thinking, paranoia, and referential thinking). Study 4 investigates the long-term relationship between perceptual aberrations and suicide risk through a 17-year follow-up. Finally, Study 5 examines the specificity of our findings using a psychiatric control group. Results across all five studies support a relationship between suicide risk and positive schizotypy. Specifically, perceptual aberrations were associated with suicide risk both cross-sectionally and longitudinally. Results also suggest that individuals with positive schizotypic features have rates of suicidal ideation that are comparable to those with high negative affect and are significantly greater than healthy controls. Taken together, these findings establish an empirical connection between positive schizotypy and suicide risk, thus expanding the purview of the suicide risk construct. (PsycInfo Database Record (c) 2023 APA, all rights reserved).

Variability in suicidal ideation during treatment for individuals at clinical high risk for psychosis: The importance of repeated assessment.

AIM: Suicide risk is elevated among individuals at clinical high risk for psychosis (CHR-P). The current study examined variability in suicidal ideation during treatment for individuals at CHR-P. METHODS: A retrospective chart review was used to examine the course of suicidal ideation during 16 sessions of individual psychotherapy for 25 individuals at CHR-P. RESULTS: Suicidal ideation was reported by 24% of participants at session 1 and 16% at session 16, with minimal within-subject change in the presence of suicidal ideation across the two time points. However, a more fine-grained investigation at each session indicated that 60% of individuals at CHR-P experienced suicidal ideation at least once during treatment. Additionally, there was great variability in suicidal ideation both within and between participants over the course of the 16 sessions. CONCLUSIONS: These findings highlight the importance of repeated assessment when examining suicidal ideation as a treatment outcome for individuals at CHR-P.

Rapid intensification of suicide risk preceding suicidal behavior among primary care patients.

BACKGROUND: Approximately half of those who attempt suicide report experiencing suicidal ideation and suicidal planning in advance; others deny these experiences. Some researchers have hypothesized that rapid intensification is due to past suicidal ideation and/or behaviors that are "mentally shelved" but remain available for rapid access later. METHOD: To evaluate this hypothesis, we examined (a) temporal sequencing of suicidal ideation, suicidal planning, and suicidal behavior, and (b) speed of emergence of suicidal behavior in a prospective cohort study of 2744 primary care patients. RESULTS: Of 52 patients reporting suicidal behavior during follow-up, 20 (38.5%) reported suicidal ideation and planning prior to their suicidal behavior, 23 (44.2%) reported suicidal ideation but not planning, and nine (17.3%) denied both suicidal ideation and planning. Over half (n = 30, 57.7%) reported the onset of suicidal ideation and/or planning on the same day as or after their suicidal behavior (i.e., rapid intensification). Rapid intensification was not associated with increased likelihood of reporting recent or past suicidal ideation, planning, or behaviors, suggesting rapid intensification does not depend on prior experience with suicidal ideation and/or behaviors. CONCLUSION: Detecting primary care patients at risk for this form of suicidal behavior may be limited even with universal suicide risk screening.

Impact of Treatment Initiation and Engagement on Deliberate Self-Harm Among Individuals With First-Episode Psychosis.

OBJECTIVE: Individuals with psychosis are at increased risk for suicide, with the greatest risk being present during the first few months after diagnosis. The authors aimed to examine whether treatment initiation within 14 days of diagnosis and treatment engagement within 90 days of initiation reduce the risk for deliberate self-harm (DSH) among individuals with first-episode psychosis (FEP). METHODS: A retrospective longitudinal cohort design was adopted by using Ohio Medicaid claims for 6,349 adolescents and young adults ages 15-24 years with FEP. Logistic regression was used to examine factors associated with treatment initiation and engagement. Cox proportional hazard models were used to estimate the impact of treatment initiation and engagement on DSH. Propensity score weighting was used to control for sociodemographic and clinical covariates. RESULTS: Approximately 70% of the sample initiated treatment, 55% of whom engaged in treatment. Treatment initiation and engagement were associated with both demographic and clinical variables. Treatment initiation significantly reduced the hazard of DSH (average treatment effect in the entire population: hazard ratio [HR]=0.62, 95% CI=0.47-0.81; average treatment effect among those treated: HR=0.64, 95% CI=0.52-0.80). In contrast, treatment engagement was not significantly associated with DSH. CONCLUSIONS: These results suggest that the initial treatment contact is essential for reducing DSH among adolescents and young adults with FEP. Additionally, the finding that treatment engagement did not reduce DSH suggests that standard clinical care may not be sufficient for reducing DSH in this population. These findings highlight the need for suicide-specific interventions for individuals with FEP.

An empirical investigation of the distinction between passive and active ideation: Understanding the latent structure of suicidal thought content.

INTRODUCTION: Although the distinction between passive and active suicidal ideation is well accepted by suicide researchers and clinicians, there has been very little empirical investigation into this distinction. The current study addressed this gap by examining the latent structure of suicidal ideation based on thought content. METHOD: Participants from two distinct samples of U.S. adults (n1 = 6200; n2 = 10,625) completed a self-report assessment of eight commonly experienced suicidal thoughts using the Self-Injurious Thoughts and Behaviors Interview-Revised. Exploratory structural equation modeling was used to examine the latent structure of suicidal thoughts. RESULTS: The two-factor model demonstrated significantly better fit than the one-factor solution across both samples. Thoughts typically classified as passive ideation strongly loaded onto one factor, whereas thoughts typically classified as active ideation loaded onto the second factor. The two factors were highly correlated and some suicidal thoughts exhibited meaningful cross-loading. CONCLUSION: Our results suggest that passive and active ideation are two distinct constructs. Although they often co-occur, passive and active ideation are not nested constructs and should not be viewed as gradients of one underlying construct. Our findings suggest that at a minimum both passive and active ideation should be included in all suicide risk assessments and screenings.

Promoting the Success and Sustainability of Coordinated Specialty Care Teams in Ohio.

Recent COVID-19-related federal legislation has resulted in time-limited increases in Mental Health Block Grant (MHBG) set-aside dollars for coordinated specialty care (CSC) throughout the United States. The state of Ohio has opted to apply these funds to establish a learning health network of Ohio CSC teams, promote efforts to expand access to CSC, and quantify the operating costs and rates of reimbursement from private and public payers for these CSC teams. These efforts may provide other states with a model through which they can apply increased MHBG funds to support the success of their own CSC programs.

Depression, suicide intent, and plan among adults presenting in an emergency department after making a suicide attempt: Exploratory differences by psychosis symptom experience.

Rates of suicide are significantly higher for individuals with schizophrenia spectrum disorders (SSDs) than those in the general population. With limited understandings of factors contributing to engaging in a suicide attempt among the psychosis population in the literature, the current study sought to preliminarily explore depression, suicide intent, and suicide plan among adults with and without psychosis symptom experiences who presented to an emergency department (ED) after making a suicide attempt. Electronic health record data were collected from the ED of an academic healthcare system in the Midwestern United States between 2011 and 2022. Patients included 1178 adults who arrived after making a suicide attempt. Trained research assistants conducted chart reviews and data were explored in SPSS28. A significantly smaller proportion of patients with psychosis had depressive symptoms and endorsed having suicide intent prior to their attempt in comparison to patients without psychosis. A smaller trending (p < .10) proportion of patients with psychosis endorsed having a suicide plan prior to their attempt than those with psychosis. Exploratory findings highlight the importance of EDs assessing for suicide risk beyond traditional approaches among patients with psychosis symptom experiences, including considerations for the potential of individuals not experiencing depression, suicide intent, or a suicide plan. Future research is particularly needed to examine psychosis symptomatology and the experience of distress as potential contributing factors to suicide behavior and death among patients with psychosis symptoms to better inform suicide risk assessment and intervention efforts.

Psychotic experiences, emotion regulation, and suicidal ideation among Chilean adolescents in the general population.

Psychotic experiences are associated with increased risk for suicide. Despite this well-established finding, very little is known about factors that contribute to this relationship. The current study investigated the relationship between psychotic experiences, emotion regulation, and suicidal ideation among 1,590 Chilean adolescents in the general population. Participants completed self-report measures of psychotic experiences (Community Assessment of Psychic Experiences), emotion regulation (Emotion Regulation Questionnaire), depression (Patient Health Questionnaire-9), and suicidal ideation (Columbia Suicide Severity Rating Scale). Statistical analyses included Mann-Whitney U tests, point-biserial correlations, logistic regression, and moderation analyses. Results suggest that paranoid ideation, bizarre experiences, and perceptual abnormalities were moderately associated with suicidal ideation. Additionally, greater expressive suppression and cognitive reappraisal were associated with suicidal ideation. Results from the logistic regression indicate that paranoid ideation, perceptual abnormalities, and expressive suppression have the strongest relationship with suicidal ideation, even when controlling for depression and relevant demographic variables. Additionally, paranoid ideation interacted with expressive suppression to predict suicidal ideation, with expressive suppression having the strongest relationship with suicidal ideation when paranoid ideation was low to moderate. Taken together, these findings support the broader literature suggesting that emotion regulation might be a transdiagnostic risk factor for suicidal ideation. Additional longitudinal research is needed to examine whether expressive suppression and other maladaptive emotion regulation strategies serve as a mechanism for suicidal ideation both in the general population and among individuals with psychotic experiences.

Assessment of Latent Subgroups With Suicidal Ideation and Suicidal Behavior Among Gun Owners and Non-Gun Owners in the US.

Importance: Firearm ownership is associated with increased risk for suicide. Objective: To examine patterns of associations among suicidal thoughts and behaviors among gun owners and non-gun owners in the US. Design, Setting, and Participants: In this survey study, cross-sectional online survey data were collected from March to April 2020 from US adults recruited via Qualtrics Panels. Quota sampling was used to approximate US census demographics. Main Outcomes and Measures: The primary outcomes were past-year passive suicidal ideation, active suicidal ideation, suicidal planning, suicidal behaviors, and nonsuicidal self-injury as measured by items from the Self-Injurious Thoughts and Behaviors Interview-Revised (SITBI-R). Simple latent class analysis (LCA) was used to assign participants to separate classes based on posterior probabilities, and multigroup LCA was used to assess whether the same construct was measured in specified groups. Results: Of 65 079 adults invited to participate, 10 625 (16.3%) completed the survey; 9153 responded "yes" or "no" to the firearm ownership item and were included in the analysis. Of these 9153 respondents (4695 [51.3%] male; mean [SD] age, 46.7 [16.8] years), 2773 (30.3%) reported owning a gun and 6380 (69.7%) reported not owning a gun. Compared with non-gun owners, gun owners were more likely to be male (1779 [64.2%] vs 2916 [45.7%]; χ21, 263.3; P < .001) and White (2090 [75.4%] vs 3945 [61.8%]; χ25, 232.9; P < .001) and to have served in the military (772 [27.8%] vs 609 [9.5%]; χ21, 571.4; P < .001). Five distinct patterns of SITBI-R item endorsement were extracted using simple LCA. Multigroup LCA indicated that the probability of SITBI-R item endorsement differed between gun owners and non-gun owners across subgroups. Among gun owners, the probability of past-month nonfatal suicide attempts was highest in class 4 (ranging from 16.8% for reaching out for help to 27.2% for starting, then changing one's mind). Gun owners in class 4 were characterized by high probabilities of endorsing thoughts about specific ways or methods to attempt suicide (100%) and preparatory behavior (100%). Among non-gun owners, the probability of nonfatal suicide attempts was highest in class 5 (ranging from 14.9% for reaching out for help to 29.7% for starting, then changing one's mind). Non-gun owners in class 5 were characterized by high probabilities of endorsing passive suicidal ideation (84.0%-100%), active suicidal ideation (86.7%-95.0%), and thoughts about specific ways or methods to attempt suicide (97.4%) and a specific place (92.1%) to attempt suicide. Conclusions and Relevance: In this study, in subgroups with lower probabilities of suicide attempt, gun owners and non-gun owners showed similar patterns of suicide risk item endorsement, but when the probability of a suicide attempt increased, gun owners were less likely than non-gun owners to endorse passive and active suicidal ideation. These findings suggest that assessing a broader range of suicide risk indicators may improve risk detection.

Improvements in metacognition mediate the effect of metacognitive remediation therapy: A non-randomized controlled study among individuals with first-episode psychosis.

AIM: Metacognitive remediation therapy (MCR) has been shown to help individuals with first-episode psychosis experience improvements in cognition, social functioning, vocational/educational functioning and quality of life. The theoretical model underlying MCR has yet to be empirically validated. METHODS: Seventy-three individuals with first-episode psychosis completed measures of metacognition and cognition at enrollment and after 6-months of care at a specialized clinical program for individuals with first-episode psychosis. Among this group, we compared changes in these variables between the 21 individuals who opted to participate in MCR and the 52 individuals who did not participate in MCR. RESULTS: Improvements in metacognition were moderated by MCR treatment participation. Consistent with the MCR theoretical model of change, increases in metacognition mediated the relationship between treatment and longitudinal changes in cognition. CONCLUSIONS: Our findings suggest that the benefits of MCR on cognitive functioning may stem, in part, from the ability of MCR to produce improvements in metacognitive functioning.