A pilot 1-year follow-up randomised controlled trial comparing metacognitive training to psychoeducation in schizophrenia: effects on insight.

Poor insight in schizophrenia spectrum disorders (SSD) is linked with negative outcomes. This single-centre, assessor-blind, parallel-group 1-year follow-up randomised controlled trial (RCT) tested whether metacognitive training (MCT) (compared to psychoeducation) may improve insight and outcomes in outpatients with SSD assessed: at baseline (T0); after treatment (T1) and at 1-year follow-up (T2). Insight (primary outcome) was measured with (i) the Schedule for Assessment of Insight-Expanded version- (SAI-E), including illness recognition (IR), symptom relabelling (SR), treatment compliance (TC) and total insight scores (TIS); and (ii) the Beck Cognitive Insight Scale (BCIS). Between-group comparisons were nonsignificant, while within the MCT group (but not within controls) there was a significant medium effect size for improved TIS at T2 (d = 0.67, P = 0.02). Secondary outcomes included cognitive measures: Jumping to Conclusions (JTC), Theory of Mind (ToM), plus symptom severity and functioning. Compared to psychoeducation, MCT improved the PANSS excitement (d = 1.21, P = 0.01) and depressed (d = 0.76, P = 0.05) factors at T2; and a JTC task both at T1 (P = 0.016) and at T2 (P = 0.031). Participants in this RCT receiving MCT showed improved insight at 1-year follow-up, which was associated with better mood and reduced JTC cognitive bias. In this pilot study, no significant benefits on insight of MCT over psychoeducation were detected, which may have been due to insufficient power.

Investigating the relationship between cross-national suicide rates and COVID-19 first and second waves spread across the world: An exploratory study.

INTRODUCTION: COVID-19 spreads between people in close contact. Social isolation, which is linked with increased suicide risk, prevents COVID-19 from spreading. Suicide and COVID-19 may therefore represent two antagonistic phenomena. Specifically, we tested whether previous cross-national suicide rates inversely correlate with COVID-19 cases and deaths across countries. MATERIAL AND METHODS: We ran unadjusted bivariate correlations between the most updated (2016) cross-national Age-Standardised suicide rates and COVID-19 cumulative cases and deaths (as of: 30/08/2020, 11/10/2020 and 30/05/2021) across countries; and we controlled for WHO Income group, WHO region, suicide data quality, and urbanicity. RESULTS: Suicide rates negatively correlated with COVID-19 cumulative cases up to 30/08/2020 (r=-0.14, P=.064) and up to 11/10/2020 at an almost significant level (r=-0.149, P=.050) across 174 countries. As of 11/10/2020 this correlation became significant when controlling for WHO region (r=-0.17, P=.028), data quality (r=-0.181, P=.017) and urbanicity (r=-0.172, P=.039); and as of 30/08/2020 when adjusting for WHO region (r=-0.15, P=.047) and data quality a (r=-0.16, P=.036). No significant correlations between suicide rates and COVID-19 deaths were found. CONCLUSIONS: There seems to be an inverse correlation between previous cross-national suicide rates and COVID-19 cumulative cases across countries. Suicide and COVID-19 appear to behave, to some degree, as antagonistic phenomena, which challenges their prevention.

Pharmacological Treatment of Early-Onset Schizophrenia: A Critical Review, Evidence-Based Clinical Guidance and Unmet Needs.

Early-onset schizophrenia (EOS) - onset before age 18 - is linked with great disease burden and disability. Decision-making for EOS pharmacological treatment may be challenging due to conflicting information from evidence and guidelines and unidentified care needs may remain unmet.We searched for systematic reviews, meta-analyses and umbrella reviews of EOS pharmacological treatment published in PubMed over the past 10 years and selected five clinical guidelines from Europe, North-America and Australia. Based on predefined outcomes, we critically compared the evidence supporting EOS-approved drugs in Europe and/or North-America with guidelines recommendations. We also evaluated the coverage of these outcomes to identify unmet needs.One systematic review, nine meta-analyses and two umbrella reviews (k=203 trials, N=81,289 participants, including duplicated samples across selected articles) were retrieved. Evidence supported the efficacy of aripiprazole, clozapine, haloperidol, lurasidone, molindone, olanzapine, quetiapine, risperidone and paliperidone in EOS, all of which obtained approval for EOS either in Europe and/or in North-America. Cognition, functioning and quality of life, suicidal behaviour and mortality and services utilisation and cost-effectiveness were poorly covered/uncovered.Among the antipsychotics approved for EOS, aripiprazole, lurasidone, molindone, risperidone, paliperidone and quetiapine emerged as efficacious and comparably safe options. Olanzapine is known for a high risk of weight gain and haloperidol for extrapyramidal side-effects. Treatment-resistant patients should be offered clozapine. Future long-term trials looking at cognition, functioning, quality of life, suicidal behaviour, mortality, services utilisation and cost-effectiveness are warranted. Closer multi-agency collaboration may bridge the gap between evidence, guidelines and approved drugs.

Investigating the Role of Insight, Decision-Making and Mentalizing in Functional Outcome in Schizophrenia: A Cross-Sectional Study.

BACKGROUND: Recovery has become a priority in schizophrenia spectrum disorders (SSDs). This study aimed to investigate predictors of objective-general functioning and disability-and subjective-quality of life (QoL)-measures of functional outcomes in SSD. METHODS: Sample: n = 77 SSD outpatients (age 18-64, IQ > 70) participating in a randomised controlled trial. Baseline data were used to build three multivariable linear regression models on: (i) general functioning-General Assessment of Functioning (GAF); (ii) disability-the World Health Organization Disability Assessment Schedule (WHODAS-2.0); and (iii) QoL-Satisfaction Life Domains Scale (SLDS). RESULTS: Young age and being employed (R2 change = 0.211; p = 0.001), late adolescence premorbid adjustment (R2 change = 0.049; p = 0.0050), negative symptoms and disorganization (R2 change = 0.087; p = 0.025) and Theory of Mind (R2 change = 0.066, p = 0.053) predicted general functioning. Previous suicidal behaviour (R2 change = 0.068; p = 0.023) and negative and depressive symptoms (R2 change = 0.167; p = 0.001) were linked with disability. Previous suicidal behaviour (R2 change = 0.070, p = 0.026), depressive symptoms (R2 change = 0.157; p < 0.001) and illness recognition (R2 change = 0.046, p = 0.044) predicted QoL. CONCLUSIONS: Negative, disorganization and depressive symptoms, older age, unemployment, poor premorbid adjustment, previous suicide attempts and illness awareness appear to underlie a poor global functional outcome in SSD. Achieving recovery in SSD appears to require both symptomatic remission (e.g., through antipsychotics) and measures to improve mastery and relieve low mood.

Investigating the Contribution of Decision-Making, Cognitive Insight, and Theory of Mind in Insight in Schizophrenia: A Cross-Sectional Study.

INTRODUCTION: Insight in schizophrenia spectrum disorders (SSD) is associated with outcomes. Although the neurocognitive basis of insight is widely accepted, the specific contribution of decision-making (Jumping to Conclusions [JTC]), Cognitive Insight (CI), and Theory of Mind (ToM) to insight remains unclear. METHODS: The sample included N = 77 SSD outpatients aged 18-64 years from a randomized controlled trial of metacognitive training. Assessments included JTC-Beads Task, CI-Beck Cognitive Insight Scale, ToM-Hinting Task, and the Emotions Recognition Test Faces. STATISTICS: hierarchical multivariable linear regression models tested their contribution to total insight (TI) and three insight dimensions - illness recognition (IR), symptom relabelling (SR), and treatment compliance (TC) - measured with the Schedule for the Assessment of Insight - Expanded version, whilst adjusting for potential confounders. RESULTS: Bivariate analyses showed that CI was associated with TI (R2 change = 0.214; p < 0.001), IR (R2 change = 0.154; p = 0.003), and SR (R2 change = 0.168; p = 0.003), while JTC predicted IR (R2 change = 0.790; p = 0.020). Multivariable regression models showed that CI predicted TI (R2 change = 0.116; p = 0.036) and SR (R2 change = 0.166, p = 0.011), whereas JTC was linked with IR (R2 change = 0.710; p = 0.026). ToM was not linked with any insight score. No cognitive variable was associated with treatment compliance. DISCUSSION: Results supported the (meta)cognitive model of insight in SSD. JTC and CI emerged as the main (meta)cognitive processes underlying insight. Metacognitive interventions may therefore improve insight in SSD, although these therapies alone may fail to address treatment compliance.

Understanding the Influence of Personality Traits on Risk of Suicidal Behaviour in Schizophrenia Spectrum Disorders: A Systematic Review.

Risk of suicidal behaviour (SB) in schizophrenia spectrum disorders (SSD) is a major concern, particularly in early stages of the illness, when suicide accounts for a high number of premature deaths. Although some risk factors for SB in SSD are well understood, the extent to which personality traits may affect this risk remains unclear, which may have implications for prevention. We conducted a systematic review of previous studies indexed in MEDLINE, PsycINFO and Embase examining the relationship between personality traits and SB in samples of patients with SSD. Seven studies fulfilled predetermined selection criteria. Harm avoidance, passive-dependent, schizoid and schizotypal personality traits increased the risk of SB, while self-directedness, cooperativeness, excluding persistence and self-transcendence acted as protective factors. Although only seven studies were retrieved from three major databases after applying predetermined selection criteria, we found some evidence to support that personality issues may contribute to SB in patients with SSD. Personality traits may therefore become part of routine suicide risk assessment and interventions targeting these personality-related factors may contribute to prevention of SB in SSD.

Use of Ecological Momentary Assessment Through a Passive Smartphone-Based App (eB2) by Patients With Schizophrenia: Acceptability Study.

BACKGROUND: Ecological momentary assessment (EMA) tools appear to be useful interventions for collecting real-time data on patients' behavior and functioning. However, concerns have been voiced regarding the acceptability of EMA among patients with schizophrenia and the factors influencing EMA acceptability. OBJECTIVE: The aim of this study was to investigate the acceptability of a passive smartphone-based EMA app, evidence-based behavior (eB2), among patients with schizophrenia spectrum disorders and the putative variables underlying their acceptance. METHODS: The participants in this study were from an ongoing randomized controlled trial (RCT) of metacognitive training, consisting of outpatients with schizophrenia spectrum disorders (F20-29 of 10th revision of the International Statistical Classification of Diseases and Related Health Problems), aged 18-64 years, none of whom received any financial compensation. Those who consented to installation of the eB2 app (users) were compared with those who did not (nonusers) in sociodemographic, clinical, premorbid adjustment, neurocognitive, psychopathological, insight, and metacognitive variables. A multivariable binary logistic regression tested the influence of the above (independent) variables on "being user versus nonuser" (acceptability), which was the main outcome measure. RESULTS: Out of the 77 RCT participants, 24 (31%) consented to installing eB2, which remained installed till the end of the study (median follow-up 14.50 weeks) in 14 participants (70%). Users were younger and had a higher education level, better premorbid adjustment, better executive function (according to the Trail Making Test), and higher cognitive insight levels (measured with the Beck Cognitive Insight Scale) than nonusers (univariate analyses) although only age (OR 0.93, 95% CI 0.86-0.99; P=.048) and early adolescence premorbid adjustment (OR 0.75, 95% CI 0.61-0.93; P=.01) survived the multivariable regression model, thus predicting eB2 acceptability. CONCLUSIONS: Acceptability of a passive smartphone-based EMA app among participants with schizophrenia spectrum disorders in this RCT where no participant received financial compensation was, as expected, relatively low, and linked with being young and good premorbid adjustment. Further research should examine how to increase EMA acceptability in patients with schizophrenia spectrum disorders, in particular, older participants and those with poor premorbid adjustment. TRIAL REGISTRATION: ClinicalTrials.gov NCT04104347; https://clinicaltrials.gov/ct2/show/NCT04104347.

Aggression, Impulsivity and Suicidal Behavior in Depressive Disorders: A Comparison Study between New York City (US), Madrid (Spain) and Florence (Italy).

The association of aggression and impulsivity with suicidal behavior (SB) in depression may vary across countries. This study aimed (i) to compare aggression and impulsivity levels, measured with the Brown-Goodwin Scale (BGS) and the Barratt Impulsivity Scale (BIS), respectively, between New York City (NYC) (US), Madrid (Spain) and Florence (Italy) (ANOVA); and (ii) to investigate between-site differences in the association of aggression and impulsivity with previous SB (binary logistic regression). Aggression scores were higher in NYC, followed by Florence and Madrid. Impulsivity levels were higher in Florence than in Madrid or NYC. Aggression and impulsivity scores were higher in suicide attempters than in non-attempters in NYC and in Madrid. SB was associated with aggression in NYC (OR 1.12, 95% CI 1.07-1.16; p < 0.001) and in Florence (OR 1.11, 95% CI 1.01-1.22; p = 0.032). Impulsivity was linked with SB in NYC (OR 1.01, 95% CI 1.00-1.02; p < 0.001) and in Madrid (OR 1.03, 95% CI 1.02-1.05; p < 0.001). The higher suicide rates in NYC, compared to Madrid or Florence, may be, in part, explained by these cross-cultural differences in the contribution of aggression-impulsivity to SB, which should be considered by future research on SB prevention.

Actigraphic recording of motor activity in depressed inpatients: a novel computational approach to prediction of clinical course and hospital discharge.

Depressed patients present with motor activity abnormalities, which can be easily recorded using actigraphy. The extent to which actigraphically recorded motor activity may predict inpatient clinical course and hospital discharge remains unknown. Participants were recruited from the acute psychiatric inpatient ward at Hospital Rey Juan Carlos (Madrid, Spain). They wore miniature wrist wireless inertial sensors (actigraphs) throughout the admission. We modeled activity levels against the normalized length of admission-'Progress Towards Discharge' (PTD)-using a Hierarchical Generalized Linear Regression Model. The estimated date of hospital discharge based on early measures of motor activity and the actual hospital discharge date were compared by a Hierarchical Gaussian Process model. Twenty-three depressed patients (14 females, age: 50.17 ± 12.72 years) were recruited. Activity levels increased during the admission (mean slope of the linear function: 0.12 ± 0.13). For n = 18 inpatients (78.26%) hospitalised for at least 7 days, the mean error of Prediction of Hospital Discharge Date at day 7 was 0.231 ± 22.98 days (95% CI 14.222-14.684). These n = 18 patients were predicted to need, on average, 7 more days in hospital (for a total length of stay of 14 days) (PTD = 0.53). Motor activity increased during the admission in this sample of depressed patients and early patterns of actigraphically recorded activity allowed for accurate prediction of hospital discharge date.

Can metacognitive interventions improve insight in schizophrenia spectrum disorders? A systematic review and meta-analysis.

BACKGROUND: Patients with schizophrenia spectrum disorders (SSD) tend to lack insight, which is linked to poor outcomes. The effect size of previous treatments on insight changes in SSD has been small. Metacognitive interventions may improve insight in SSD, although this remains unproved. METHODS: We carried out a systematic review and meta-analysis of randomized controlled trials (RCTs) to examine the effects of metacognitive interventions designed for SSD, namely Metacognitive Training (MCT) and Metacognitive Reflection and Insight Therapy (MERIT), on changes in cognitive and clinical insight at post-treatment and at follow-up. RESULTS: Twelve RCTs, including 10 MCT RCTs (n = 717 participants) and two MERIT trials (n = 90), were selected, totalling N = 807 participants. Regarding cognitive insight six RCTs (n = 443) highlighted a medium effect of MCT on self-reflectiveness at post-treatment, d = 0.46, p < 0.01, and at follow-up, d = 0.30, p < 0.01. There was a small effect of MCT on self-certainty at post-treatment, d = -0.23, p = 0.03, but not at follow-up. MCT was superior to controls on an overall Composite Index of cognitive insight at post-treatment, d = 1.11, p < 0.01, and at follow-up, d = 0.86, p = 0.03, although we found evidence of heterogeneity. Of five MCT trials on clinical insight (n = 244 participants), which could not be meta-analysed, four of them favoured MCT compared v. control. The two MERIT trials reported conflicting results. CONCLUSIONS: Metacognitive interventions, particularly Metacognitive Training, appear to improve insight in patients with SSD, especially cognitive insight shortly after treatment. Further long-term RCTs are needed to establish whether these metacognitive interventions-related insight changes are sustained over a longer time period and result in better outcomes.

Toward a Biosignature of Suicide Reattempt.

Suicidal behaviour (SB) is a major public health issue, which encompasses both suicide attempts and suicide completions. Suicide tragically accounts for up to almost one million deaths across the world every year. So far, suicide prediction models have focused on the so-called classic risk factors (male gender, depression, alcohol-related problems, and so on). However, suicide is, thankfully, a very rare outcome. As a result, these suicide predictive models have performed very poorly due to the high number of false positives to pick up suicides.However, a history previous suicide attempts has been consistently reported to be the strongest predictor of a future SB. Hence, suicide prevention strategies may prioritise high-risk groups such as those who reattempt/repeat suicide. More specifically, an alternative to the classic 'clinical' risk assessment approach, which is based on rating 'clinical' risk factors, may be to identify biomarkers, which may increase the specificity and sensitivity of the aforementioned suicide prediction models, thus helping clinicians to predict future SB.Within this context, this chapter provides an up-to-date literature review literature on biomarkers of repeated SB. Three main conclusions can be drawn from our review. First, there is a paucity of studies on the role of biomarkers in repeated suicide attempts to date. Second, the vast majority of these studies focused on two biomarkers, which have been also more comprehensively researched in SB, namely, the serotonin system abnormalities and the HPA axis dysfunction. Finally, 'it seems to be unlikely that there is a single biomarker of (repeated) SB'. Rather, future research should look at the complex dynamic interaction of a wide range of biological, clinical and neuropsychological contributing risk factors leading up to SB.

Feasibility of a Virtual Reality-Based Psychoeducational Tool (VRight) for Depressive Patients.

E-health is opening new prospects in the management of mental disorders. Virtual reality (VR)-based interventions, which provide a safe nonjudging environment, may improve symptoms awareness in patients with depressive disorders. This study aimed to explore the feasibility of a novel VR software, the VRight, in depressive patients. Adult outpatients with depressive disorders presenting to our mental health clinic during December 2018 were invited to participate in the study. Participants completed a satisfaction survey at the end of the session, including questions about user-friendliness and about usefulness of the software. The Patient Health Questionnaire-9 (PHQ-9) was administered to participants before and after the VR-based intervention to assess depressive symptoms severity. We explored the correlation between the score difference and the variables: age, gender, and initial score. Twenty-eight patients (71.4 percent women, mean age: 51.18 ± 16.13 years) were recruited. Thirteen subjects had major depressive disorder (46.4 percent). Most of the patients (n = 26) were satisfied with the VR experience, which they found to be helpful. PHQ-9 score difference and the initial score correlated positively at a significant level. There was no significant correlation between score difference and age or gender. VRight was well accepted among depressive patients, showing high levels of satisfaction. The VRight could contribute to increase depressive symptoms awareness, which is of clinical relevance given the association of greater insight with positive outcomes in depression. Further studies are needed to confirm the effectiveness of VRight as a psychoeducational tool in clinical practice.

Study protocol of a randomised clinical trial testing whether metacognitive training can improve insight and clinical outcomes in schizophrenia.

BACKGROUND: Although insight in schizophrenia spectrum disorders (SSD) has been associated with positive outcomes, the effect size of previous treatments on insight has been relatively small to date. The metacognitive basis of insight suggests that metacognitive training (MCT) may improve insight and clinical outcomes in SSD, although this remains to be established. METHODS: This single-center, assessor-blind, parallel-group, randomised clinical trial (RCT) aims to investigate the efficacy of MCT for improving insight (primary outcome), including clinical and cognitive insight, which will be measured by the Schedule for Assessment of Insight (Expanded version) (SAI-E) and the Beck Cognitive Scale (BCIS), respectively, in (at least) n = 126 outpatients with SSD at three points in time: i) at baseline (T0); ii) after treatment (T1) and iii) at 1-year follow-up (T2). SSD patients receiving MCT and controls attending a non-intervention support group will be compared on insight level changes and several clinical and cognitive secondary outcomes at T1 and T2, whilst adjusting for baseline data. Ecological momentary assessment (EMA) will be piloted to assess functioning in a subsample of participants. DISCUSSION: To the best of our knowledge, this will be the first RCT testing the effect of group MCT on multiple insight dimensions (as primary outcome) in a sample of unselected patients with SSD, including several secondary outcomes of clinical relevance, namely symptom severity, functioning, which will also be evaluated with EMA, hospitalizations and suicidal behaviour. TRIAL REGISTRATION: ClinicalTrials.gov: NCT04104347. Date of registration: 26/09/2019 (Retrospectively registered).

COVID-19 and mental health: A review and the role of telehealth and virtual reality.

On March 12, 2020, with more than 20,000 confirmed cases and almost 1000 deaths in the European Region, the World Health Organization classified the COVID-19 outbreak as a pandemic. As of August 15, 2020, there are 21.5 million confirmed cases of COVID-19 and over 766,000 deaths from the virus, worldwide. Most governments have imposed quarantine measures of varied degrees of strictness on their populations in attempts to stall the spread of the infection in their communities. However, the isolation may have inflicted long-term psychological injury to the general population and, in particular, to at-risk groups such as the elderly, the mentally ill, children, and frontline healthcare staff. In this article, we offer the most up-to-date review of the effects of COVID-19 confinement on all the disorders listed in the Diagnostic and Statistical Manual of Mental Disorders. We make data-driven predictions of the impact of COVID-19 confinement on mental health outcomes and discuss the potential role of telemedicine and virtual reality in mental health screening, diagnosis, treatment, and monitoring, thus improving the above outcomes in such a difficult time.

Diagnostic stability of schizophrenia: A systematic review.

The objective is to systematically review previous literature on the diagnostic stability of schizophrenia, particularly to investigate prospective and retrospective consistency. We carried out a systematic literature search in PubMed and other minor sources from 1980 to July 2017. Specifically, prospective and retrospective consistency were examined. Thirty-nine studies were included, 5 focused on schizophrenia, 23 on psychotic episodes and 11 on psychiatric disorders in general. Samples sizes range from 60 to 10 058 subjects (total N = 39 965). The majority of studies (n = 26, 66.67%) were performed in Europe and North America and they had a prospective design (n = 27, 69.23%), with a median follow-up of 3 years. Prospective and retrospective consistency means were 84.29% and 67.15% respectively. Diagnostic change was also frequently measured (n = 12, mean 31.28%). The factors more commonly associated with diagnostic stability were: male sex, older age at the study inception, older age at onset, late stages of illness, family history of mental illness, poorer functioning and longer length of stay. Schizophrenia was found to have high diagnostic stability over time, although research on this topic is mainly focused in first psychotic episodes. More standardized methods are needed to further research diagnostic stability of schizophrenia over time and its determinants.

Suicidal Behavior and Personality Traits Contribute to Disability in First-episode Psychosis: A 1-Year Follow-up Study.

BACKGROUND: Disability encompasses impairments, activity limitations, and restrictions on participation. Improvement in functioning has therefore become a crucial outcome of treatment in psychosis. OBJECTIVE: The main aim of this study was to analyze the potential relationship between suicidal behavior after first episode of psychosis (FEP) and family disability. The second aim was to find out whether personality traits are associated with disability dimensions. METHOD: The study sample was composed of 65 FEP patients. The personal care, occupational, family, and social dimensions of disability were evaluated at 12 months after FEP. Bivariate and multivariate analyses were performed to explore any putative outcome factors associated with dimensions of disability. RESULTS: Personal care during the 1-year follow-up was significantly impaired in suicide attempters and significantly associated with sociopathic personality traits. A decline in occupational functioning was significantly associated with schizotypy traits. On the other hand, deterioration in family, social, and global functioning at 1 year after FEP was related to poor premorbid adjustment during late adolescence. CONCLUSIONS: Suicidal behavior prevention could improve psychosocial functioning, particularly personal care, in FEP. In addition, sociopathic and schizotypy personality traits as well as poor premorbid adjustment during late adolescence appear to be useful early markers of future disability.

Insight and risk of suicidal behaviour in two first-episode psychosis cohorts: Effects of previous suicide attempts and depression.

BACKGROUND: The role of insight dimensions - illness recognition (IR), symptoms relabelling (SR), treatment compliance (TC) - in suicide risk in first-episode psychosis (FEP) remains unclear. METHOD: The AESOP (n = 181) and GAP (n = 112) FEP cohorts were followed-up over 10- and 5 years. Survival analysis modelled time to first suicidal event in relation to baseline scores on the Schedule for the Assessment of Insight, whilst adjusting for demographic, clinical, psychopathological and neuropsychological variables. RESULTS: AESOP: those with previous suicide attempts scored higher on IR (7.6 ±â€¯1.9 vs. 5.9 ±â€¯3.0, p < 0.01) and total insight scores (TIS) (17.2 ±â€¯5.0 vs. 13.4 ±â€¯6.7, p = 0.03). IR (r = 0.23, p < 0.01), SR (r = 0.18, p = 0.04) and TC (r = 0.26, p < 0.01) correlated with depression. Univariable analyses: IR (HR = 1.14, 95% CI = 0.98-1.34, p = 0.09), TC (HR = 1.30, 95% CI = 0.99-1.71, p = 0.06) and TIS (HR = 1.06, 95% CI = 0.99-1.13, p = 0.08) were linked with suicidal behaviour. Multivariable regression models: depression (HR = 1.55, 95% CI = 1.22-1.97, p < 0.01) predicted suicidal behaviour. GAP: SR (6.4 ±â€¯3.1 vs. 4.5 ±â€¯3.4, p = 0.03) and TIS (16.8 ±â€¯6.4 vs. 12.8 ±â€¯7.4, p = 0.03) were higher in those with suicidal antecedents. IR (r = 0.32, p < 0.01) and SR (r = 0.27, p = 0.01) correlated with depression. Univariable analyses: TC (HR = 1.36, 95% CI = 1.01-1.83, p = 0.04) and TIS (HR = 1.06, 95% CI = 0.99-1.14, p = 0.08) were associated with suicidal behaviour. Multivariable regression models: previous suicide attempts (HR 5.17, 95% CI 1.32-20.29, p = 0.02) and depression (HR 1.16, 95% CI = 1.00-1.35, p = 0.04) predicted suicidal behaviour. CONCLUSIONS: Suicide attempts prior to FEP and depression at that point were associated with baseline insight levels and predicted risk of suicidal behaviour over the follow-up, which was not linked with insight. This may explain the apparent association of insight with suicidality in FEP.

Can risk assessment predict suicide in secondary mental healthcare? Findings from the South London and Maudsley NHS Foundation Trust Biomedical Research Centre (SLaM BRC) Case Register.

PURPOSE: The predictive value of suicide risk assessment in secondary mental healthcare remains unclear. This study aimed to investigate the extent to which clinical risk assessment ratings can predict suicide among people receiving secondary mental healthcare. METHODS: Retrospective inception cohort study (n = 13,758) from the South London and Maudsley NHS Foundation Trust (SLaM) (London, UK) linked with national mortality data (n = 81 suicides). Cox regression models assessed survival from the last suicide risk assessment and ROC curves evaluated the performance of risk assessment total scores. RESULTS: Hopelessness (RR = 2.24, 95% CI 1.05-4.80, p = 0.037) and having a significant loss (RR = 1.91, 95% CI 1.03-3.55, p = 0.041) were significantly associated with suicide in the multivariable Cox regression models. However, screening statistics for the best cut-off point (4-5) of the risk assessment total score were: sensitivity 0.65 (95% CI 0.54-0.76), specificity 0.62 (95% CI 0.62-0.63), positive predictive value 0.01 (95% CI 0.01-0.01) and negative predictive value 0.99 (95% CI 0.99-1.00). CONCLUSIONS: Although suicide was linked with hopelessness and having a significant loss, risk assessment performed poorly to predict such an uncommon outcome in a large case register of patients receiving secondary mental healthcare.

Insight and suicidality in psychosis: A cross-sectional study.

AIMS: We aimed to test whether specific insight dimensions are associated with suicidality in patients with psychotic disorders. METHODS: 143 patients with schizophrenia spectrum disorders were recruited. Suicidality was assessed by item 8 of the Calgary Depression Scale for Schizophrenia (CDSS). Insight was measured by the Scale of Unawareness of Mental Disorder (SUMD) and the Markova and Berrios Insight Scale. Bivariate analyses and multivariable logistic regression models were conducted. RESULTS: Those subjects aware of having a mental illness and its social consequences had higher scores on suicidality than those with poor insight. Awareness of the need for treatment was not linked with suicidality. The Markova and Berrios Insight scale total score and two specific domains (awareness of "disturbed thinking and loss of control over the situation" and "having a vague feeling that something is wrong") were related to suicidality. However, no insight dimensions survived the multivariable regression model, which found depression and previous suicidal behaviour to predict suicidality. CONCLUSIONS: Suicidality in psychosis was linked with some insight dimensions: awareness of mental illness and awareness of social consequences, but not compliance. Depression and previous suicidal behaviour mediated the associations with insight; thus, predicting suicidality.

Risk assessment and suicide by patients with schizophrenia in secondary mental healthcare: a case-control study.

OBJECTIVES: To investigate the role of risk assessment in predicting suicide in patients with schizophrenia spectrum disorders (SSDs) receiving secondary mental healthcare. We postulated that risk assessment plays a limited role in predicting suicide in these patients. DESIGN: Retrospective case-control study. SETTING: Anonymised electronic mental health record data from the South London and Maudsley National Health Service (NHS) Foundation Trust (SLaM) (London, UK) linked with national mortality data. PARTICIPANTS: In 242 227 SLaM service users up to 31 December 2013, 635 suicides were identified. 96 (15.1%) had a SSD diagnosis. Those who died before 1 January 2007 (n=25) were removed from the analyses. Thus, 71 participants with SSD who died from suicide over the study period (cases) were compared with 355 controls. MAIN OUTCOME MEASURE: Risk of suicide in relation to risk assessment ratings. RESULTS: Cases were younger at first contact with services (mean±SD 34.5±12.6 vs 39.2±15.2) and with a higher preponderance of males (OR=2.07, 95% CI 1.18 to 3.65, p=0.01) than controls. Also, suicide occurred within 10 days after last contact with services in half of cases, with the most common suicide methods being hanging (14) and jumping (13). Cases were more likely to have the following 'risk assessment' items previously recorded: suicidal history (OR=4.42, 95% CI 2.01 to 9.65, p<0.001), use of violent method (OR=3.37, 95% CI 1.47 to 7.74, p=0.01), suicidal ideation (OR=3.57, 95% CI 1.40 to 9.07, p=0.01) and recent hospital discharge (OR=2.71, 95% CI 1.17 to 6.28, p=0.04). Multiple regression models predicted only 21.5% of the suicide outcome variance. CONCLUSIONS: Predicting suicide in schizophrenia is highly challenging due to the high prevalence of risk factors within this diagnostic group irrespective of outcome, including suicide. Nevertheless, older age at first contact with mental health services and lack of suicidal history and suicidal ideation are useful protective markers indicative of those less likely to end their own lives.