The dynamic relationship between insight and suicidal behavior in first episode psychosis patients over 3-year follow-up

Abstract

Studies have established the high risk of suicide in first episode psychosis (FEP). Between 15% and 26% of FEP patients attempt suicide at least once before their first contact with psychiatric services and 2-5% die from suicide. Also, many patients with schizophrenia spectrum disorders lack insight into having a mental disorder. However, the relationship between insight changes and suicidal behavior in FEP remains poorly understood. In the present study information about suicidal behavior over a 3 years period was available on a cohort of 397 FEP patients, of whom 270 were assessed in the three dimensions of insight (into mental illness, the need for treatment, and the social consequences) at baseline, 1 and 3 years after treatment initiation. Survival analyses examined time to suicidal behavior in relation to (i) insight at baseline, (ii) the closest insight measure to the suicide attempt, and (iii) changes in insight during the follow-up. No associations were found between baseline insight dimensions and time to suicidal behavior. However, poor insight at the evaluation closest to the suicide attempt was associated with an increased risk of suicide. Stability of insight did not affect the risk of suicidal behavior, while changes in either direction were linked with an increased risk of suicidal behavior, particularly worsening insight. Insight in psychosis is a dynamic concept and we demonstrated the relationship between insight and suicide risk to be equally dynamic. Poor insight seems to increase the risk, especially when insight levels change. Repeated insight assessment to detect change from early psychosis may play a role in suicide prevention.

Suicidal Ideation in Patients Experiencing a First‐episode Psychosis: Findings From the 2‐Year Follow‐up of the “Parma Early Psychosis” Program

“…Moreover, Robinson et al () observed that greater insight was a relevant predictor of suicide attempts in FEP patients. In contrast, more recent longitudinal studies found no stable association between insight and suicide risk in FEP individuals (Ayesa‐Arriola et al, ).…”

Introspective accuracy for substance use across a year of treatment for first episode psychosis

“…For example, better insight is linked to greater depression ( Lysaker et al, 2007 ; Ramu et al, 2019 ; Tariku et al, 2019 ), but this is inconsistently observed ( Arraras et al, 2019 ; Konsztowicz and Lepage, 2019 ). Relatedly, increased suicidality and attempts are sometimes ( Ozturk et al, 2018 ; Villa et al, 2018 ), but not always ( Ayesa-Arriola et al, 2018 ) associated with better insight.…”

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

“…Insight, which includes illness awareness, symptom relabelling and treatment compliance [ 57 ], was postulated to increase suicide risk in early psychosis [ 30 ], although three later independent FEP cohorts did not confirm this [ 22 , 58 ]. One may question whether specific personality traits may be linked with higher/lower levels of insight.…”

“…Indeed, up to 5% of patients with schizophrenia die from suicide [ 18 ] and between 20% [ 19 ] and 40% of patients receiving mental healthcare who end their lives suffer from a psychotic disorder [ 20 ]. Risk of suicidal behaviour (SB) is particularly high in the first episode of psychosis (FEP) [ 15 , 21 , 22 , 23 , 24 ], although great caution is also needed ten years or longer after first presentation [ 23 ]. Specifically, there has been an increase in the incidence of reactive psychoses, i.e., a set of acute-onset and short-lived psychotic conditions triggered by psychosocial trauma [ 25 ].…”