Psychiatry Research 325 (2023) 115232

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Psychiatry Research
journal homepage: www.elsevier.com/locate/psychres

Factors associated with suicide attempts in first-episode psychosis during

the first two years after onset
Alba Toll a, b, c, Emilio Pechuan a, Daniel Bergé a, b, c, Teresa Legido a, b, Laura Martínez-Sadurní a, b,
Khadija El-Abidi a, Víctor Pérez-Solà a, b, c, Anna Mané a, b, c, *
a
Institut de Neuropsiquiatria i Adiccions (INAD), Parc de Salut Mar, Barcelona, Spain
b
Fundació Hospital del Mar Medical Research Institute (IMIM), Barcelona, Spain
c
Centro de Investigación Biomédica en Red, Área de Salud Mental (CIBERSAM), Spain

A R T I C L E I N F O A B S T R A C T

Keywords: The risk of suicide in first-episode psychosis (FEP) is high. However, there are many unknowns about this
First episode psychosis phenomenon and the risk factors associated with higher risk are not well-understood. Therefore, we aimed to
Psychosis determine the baseline sociodemographic and clinical factors associated with suicide attempts in FEP patients
Schizophrenia
over two-years after psychosis onset. Univariate and logistic regression analyses were performed. Between April
Suicide
2013 and July 2020, 279 patients treated at the FEP Intervention Program at our hospital (Hospital del Mar,
Risk factors
Depressive symptoms Spain) were enrolled and 267 completed the follow-up. Of these, 30 patients (11.2%) made at least one suicide
Guilt feelings attempt, mostly during the untreated psychosis period (17 patients, 48.6%). Several variables—prior history of
suicide attempts and low functionality, depression, and feelings of guilt at baseline—were all significantly
associated with suicide attempts. These findings suggest that targeted interventions, especially in prodromal
stages, could play a key role in identifying and treating FEP patients with a high suicide risk.

1. Introduction potential risk factors include longer duration of untreated psychosis

Suicide is an important cause of death worldwide, responsible for
nearly 700,000 deaths annually, which is why it is widely considered a
major public health problem (World Health Organization, 2021). People
with psychiatric disorders are a high-risk group for suicide (Dutta et al.,
2010). In particular, risk of suicide is extremely high in patients with
schizophrenia and other psychotic disorders, notably, in the early illness
stages (Huang et al., 2018; Álvarez et al., 2022). Although a large body
of research has been performed in recent years in an effort to improve
the management of FEP, a recent review found that up to 21.6% of
patients with FEP made at least one suicide attempt, 27% had suicidal
ideation, and 1% to 4.3% of these patients died by suicide (Sicotte et al.,
2021).
Given these data, there is a clear need to better understand the risk
factors associated with attempted suicide. Although numerous factors
have been associated with suicide attempts in FEP patients, the two most
consistently reported variables across those studies are a personal his­
tory of suicide attempts and the presence of depressive symptoms
(Fedyszyn et al., 2012; McGinty et al., 2018; Nielssen et al., 2012). Other
(DUP), better insight, higher positive symptoms, and fewer negative
symptoms (Melle et al., 2010). Nonetheless, the findings of previous
studies are highly heterogeneous and it is still not clear which of these
variables are most strongly associated with the risk of a suicide attempt
(Huang et al., 2018; Álvarez et al., 2022; Sicotte et al., 2021).
Although many studies have evaluated the risk of suicide in FEP, only
a few (Salagre et al., 2021; Nordentoft et al., 2002) have sought to
determine whether certain specific symptoms (among positive, nega­
tive, and depressive symptoms) confer a higher suicide risk. Clearly,
there is an important need to determine the most relevant symptoms in
order to identify patients with the highest risk of suicide, which would
then allow for the initiation of early, targeted interventions in those
patients.
Although it is widely acknowledged that the high-risk period for
suicide is during the first few years of the disease (Nordentoft et al.,
2015), most of the studies that have evaluated suicide attempts in FEP
patients do not indicate the exact period (i.e., untreated psychosis, acute
psychosis, early or late recovery) in which the suicide attempts were
performed (Sicotte et al., 2021). The availability of such data would be

* Corresponding author at: INAD, Parc de Salut Mar, Passeig Marítim 25, Barcelona 08003, Spain.
E-mail address: manesantacana@yahoo.es (A. Mané).

https://doi.org/10.1016/j.psychres.2023.115232
Received 24 February 2023; Received in revised form 21 April 2023; Accepted 27 April 2023
Available online 28 April 2023
0165-1781/© 2023 Elsevier B.V. All rights reserved.
A. Toll et al.
highly valuable, as it would be for the development of evidence-based
treatment guidelines aimed at preventing suicide in this vulnerable
patient population.
In this context, the aim of the present study was to determine the
prevalence of suicide attempts over a two-year follow-up period in a
sample of FEP patients treated at a specialized First Episode Psychosis
unit. A second aim was to determine the baseline characteristics and
specific symptoms associated with suicide attempts in these patients.
2. Methods
2.1. Study population
The study sample was comprised of all patients who presented at our
center with FEP between April 2013 and July 2020. All patients were
treated at the ETEP program (Study and Treatment Program for First-
Episode Psychosis) at the Hospital del Mar (Barcelona, Spain).
ETEP is a public specialized early intervention unit for young adults
(age 18 to 35 years) diagnosed with FEP in Barcelona Litoral, with a
catchment area of 305,000 inhabitants. The program offers specific
follow-up and immediate engagement (no more than one week) after
hospitalization, after an emergency department visit, or after referral by
a general practitioner or other outpatient psychiatric services for a first
episode of psychosis. The program consists of a multimodal interven­
tion, including a comprehensive psychiatric evaluation followed by an
intensive medical and psychosocial treatment plan (including outpatient
and inpatient care), which has been described in detail elsewhere (Bergé
et al., 2016).
Inclusion criteria for the present study were as follows: (1) age 18–35
years; (2) fulfillment of DSM-IV-TR criteria for any of the following: brief
psychotic disorder; schizophreniform disorder; schizophrenia with <
one year of symptoms; unspecified psychosis; bipolar disorder; maniac
or depressive episode with psychotic features; schizoaffective disorder;
or depressive disorder with psychotic features; (3) no history of severe
neurological medical conditions or severe traumatic brain injury; (4)
presumed IQ level > 80 based on clinical records (past IQ assessments or
suggested by the patient’s educational or employment level); and (5) no
substance abuse or dependence disorders (excluding cannabis and/or
nicotine use).
This study was approved by the local ethics committee at Parc de
Salut Mar Hospital (2022/10,518). The study protocol complies with all
ethics criteria established by the Declaration of Helsinki and with all
local laws on patient confidentiality and data protection.
2.2. Clinical assessment and demographic data
At baseline, all patients underwent a comprehensive psychiatric
evaluation by two experienced psychiatrists (A.M. and D.B.). Socio­
demographic variables were registered (age, sex, place of residence, and
marital status). The Structured Clinical Interview for DSM-IV-TR Axis I
disorders was administered for diagnosis. We also evaluated the
following: alcohol use (categorized as yes/no), tobacco use (cigarettes/
day), and cannabis use (‘joints’ per week). Other variables assessed
included the following: personal history of suicide attempt (those sui­
cide attempts that occurred before the appearance of any psychotic
symptom); family history of suicide attempts; and DUP (in days), which
was defined as the time interval between onset of psychotic symptoms
and presentation at the psychiatric care unit to start treatment. The date
of symptom onset was determined through independent interviews with
the patient and/or parents (or relatives). If a discrepancy between the
patient and relatives was detected, or if no information was available
from a relative, the clinical team reached a consensus, based on the
available information, on the estimated date of onset and DUP.
The following instruments were administered to assess symptoms
and functionality: the Positive and Negative Syndrome Scale (PANSS)
for symptoms related to psychosis (Kay, 1990); the Global Assessment of
2
Psychiatry Research 325 (2023) 115232
Functioning (GAF) scale (Aas, 2011) to assess functionality; and the
Calgary Depression Scale for Schizophrenia (CDSS) for depressive
symptoms (Addington et al., 1990).
We also registered all suicide attempts, which were grouped into five
time periods, as follows: (1) untreated psychosis; (2) from baseline to
one month; (3) from one-to six-months; (4) from six months to one-year;
and (5) from one to two years.
Patients that attempted suicide during the DUP were visited in
emergencies and then were referred and attended in our early inter­
vention service where they were assessed (with the above-mentioned
scales) in less than a week. As the scales used in the baseline assess­
ment take into account the previous week, they could capture the psy­
chopathological state that patients were experiencing the days they
attempted suicide.
2.3. Statistical analysis
Data distribution normality was assessed with the Kolmogorov-
Smirnov test. A descriptive analysis of the sample was performed. The
total number (%) of suicide attempts was calculated overall and for each
time period.
Univariate analyses were performed to determine sociodemographic
and clinical differences at baseline between patients who completed or
not all follow-up procedures. Univariate analyses were also performed to
check for significant differences in sociodemographic and clinical fea­
tures at baseline between patients who attempted suicide during the
two-year follow-up and those who did not.
To identify the baseline variables significantly associated with sui­
cide attempts during follow-up, we carried out two logistic regression
models (STEP-WISE METHOD) with suicide attempt (yes/no) as the
dependent variable and the variables with a p < 0.01 on the univariate
analyses as the independent variables. In the first regression model
(model 1), the independent variables included the GAF and CDSS total
scores, and the PANSS sub-scales, together with the sociodemographic
and clinical characteristics. Consequently, the first regression model
included the following independent variables: age; sex; personal history
of suicide attempts (yes/no); CDSS total score; and GAF total score.
In the second regression model (model 2), which was performed to
determine the specific symptoms associated with suicide attempts, the
independent variables included the following: all PANSS subitems; all
CDSS subitems; GAF total score; and sociodemographic and clinical
characteristics. Consequently, the following independent variables were
included in this second model: age; sex; personal history of suicide at­
tempts (yes/no); GAF total score; and all PANSS and CDSS subitems with
a p value < 0.01 on the univariate analyses (PANSS subitems: guilt
feelings, depression, disorientation; CDSS subitems: hopelessness, guilty
ideas of reference, and pathological guilt).
All statistical analyses were performed with the IBM-SPSS Statistics
for Windows, v. 20 (IBM Corp.; Armonk, NY, USA). P values ≤ 0.05 were
considered statistically significant.
3. Results
3.1. Patient characteristics and suicide prevalence
A total of 279 FEP patients were initially enrolled in the study. Of
these, all but 12 completed all follow-up assessments, leaving a final
sample of 267 patients. Most (n = 164; 61.4%) of the patients were
males. The median (SD) age was 25.1 (8.1) years. The other clinical
characteristics are shown in the supplementary materials (Table 1).
There were no statistically significant differences at baseline be­
tween the patients who completed the study (n = 267) and those who
did not (n = 12) (supplementary material, Table 2).
A total of 30 (11.2%) patients made at least one suicide attempt
during the two-year study period. There were no suicide-related deaths.
Most of the attempts (n = 17, 48.6%) occurred during the untreated
A. Toll et al. Psychiatry Research 325 (2023) 115232

psychosis period, with a small peak after one-year (Fig. 1). Table 1
Differences at baseline in sociodemographic and clinical variables between FEP
3.2. Suicide risk factors patients who attempted suicide versus those who did not during the two-year
follow-up. Total study sample included 267 patients.
The univariate analyses (Table 1) showed that patients who No suicide attempt (n Suicide attempt (n P
attempted suicide during follow-up had more previous suicide attempts = 237) = 30)

than those who did not (x2 = 11.77; p = 0.004) and a lower GAF score at Age, mean (SD) 25.24 (8.06) 23.96 (8.5) 0.317
baseline (t = 2.97; p = 0.003). Sex, n (%males) 146 (61.6) 18 (60) 0.845
Living situation n (%) 0.215
For the baseline CDSS total scores and subitems (Table 3), patients
Homeless, shelter, or 3 (1.3) 1 (3.3)
who attempted suicide had higher baseline CDSS total scores (t = − 2.37; other
p = 0.018), more hopelessness (t = − 1.49; p = 0.001), more guilty ideas Living with family 161 (67.9) 14 (46.7)
of reference (t = − 2.23; p = 0.001), and pathological guilt (t = − 1.25; p Living with friends 28 (11.8) 6 (20)
= 0.006). Living alone 17 (7.2) 4 (13.3)
Living with partner 28 (11.8) 5 (16.7)
For the baseline PANSS sub-scales and subitems (Table 2), patients Marital status 0.326
who attempted suicide during the study period had more feelings of guilt Single 194 (81.9) 24 (80)
(t = − 3.19; p = 0.001), depressive symptoms (t = − 1.99; p = 0.007), and Married/Partner 38 (16) 4 (13.3)
disorientation (t = − 2.45; p = 0.001). Divorced, widowed, or 5 (2.1) 2 (6.7)
separated
On the multivariate analysis that considered both total and sub-scale
Alcohol use 154 (57.7) 112 (41.9) 0.722
scores (model 1) (Table 4), the model that best predicted the likelihood Personal history of suicide 10 (4.2) 6 (20) 0.004
of a suicide attempt over the two-year follow-up (R2 = 0.240) included attempt
the following baseline variables: personal history of suicide attempts; Family history of suicide 13 (5.5) 1 (3.3) 0.518
baseline GAF score; and baseline CDSS total score. These results show attempt
Tobacco use, n (%users) 163 (68.7) 22 (73..3) 0.245
that these three variables— the presence of previous suicide attempts
Cannabis use, n (%users) 138 (58.2) 18 (60) 0.231
(odds ratio [OR] = 5.91; 95% confidence interval [CI]: 1.63 to 21.47; p mean (SD)
= 0.007), a lower baseline GAF score (OR = − 0.94; 95% CI: − 0.91 to Tobacco use, cigarettes 7 (2.8) 4 (1.2) 0.736
− 0.98; p = 0.005), and a higher baseline CDSS score (OR = 1.11; 95% per day
Cannabis use in ‘joints’ 11.59 (18.56) 10.62 (16.09) 0.641
CI: 1.01 to 1.21; p = 0.032)—were associated with an increased suicide
per week
risk over the two-year follow-up. DUP in days 111.22 (195.33) 133.27 (148.54) 0.947
On the multivariate analysis (model 2) that considered specific GAF score 33.89 (14.63) 24.84 (11.09) 0.003
subitems (Table 5), the model that best predicted the likelihood of a
Abbreviations: FEP, first episode psychosis; DUP, duration of untreated psy­
suicide attempt during follow-up (R2 = 0.377) included the following
chosis; GAF, Global assessment of functioning; SD, standard deviation.
baseline variables: personal history of suicide attempts, guilt feelings,
and baseline GAF score. Thus, three variables—more previous suicide
presence of guilt feelings—were significantly associated with suicide
attempts (OR = 0.32; 95% CI: 0.14 to 0.49; p = 0.001), a higher presence
attempts during follow-up in this sample of FEP patients.
of guilt feelings (OR = 0.05; 95% CI: 0.01 to 0.08; p = 0.008), and lower
The 11.2% attempted suicide rate in this sample is consistent with
baseline GAF score (OR = − 0.03; 95% CI: − 0.06 to − 0.01; p = 0.021)—
previous reports in this patient population, including a recent meta-
were all significantly associated with a higher suicide risk during the
analysis (Álvarez et al., 2022). Importantly, we found that most at­
two-year follow-up.
tempts (48.6%) were made during the untreated psychosis period, a
finding that is in line with other studies (Dutta et al., 2010). These
4. Discussion
findings underscore the importance of providing the appropriate
detection and intervention in high-risk subjects for psychosis.
In the present study, 11.2% of patients with FEP made at least one
Although most suicide attempts occurred during the undiagnosed
suicide attempt during the two-year period after disease onset. Most of
period (n = 17), a second peak was observed from six to 12 months after
these attempts (48.6%) occurred during the untreated psychosis period.
onset. Although the reason for the increase during this period is not
Several variables—personal history of suicide attempts, worse baseline
clear, we speculate that it may be attributable to the less intensive care
functionality, higher depressive symptomatology and specifically higher
provided in this time period compared to the high level of care imme­
diately after onset. Another possible explanation for this peak could be
that patients perceive that it will be difficult to regain functionality over
time. Unfortunately, the study design does not allow us to answer this
question. Nonetheless, this finding underscores the importance of
closely monitoring patients to detect those who may be at risk —and
intervening rapidly when necessary—during the first-year after
diagnosis.
Several variables were significantly associated with a higher risk of
suicide attempt during the 2-year follow-up, including history of pre­
vious attempts. These findings are consistent with data from other
studies (Salagre et al., 2021; Nordentoft et al., 2015), which have also
found that a history of suicidal ideation/attempts and/or past
self-injurious behaviours were associated with a higher suicide risk in
patients with FEP. These findings also demonstrate the importance of
taking into account the patient’s past suicidal history in the manage­
ment of this illness.
Fig. 1. Distribution of suicide attempts (n = 30) in FEP patients over the two- Similar to the findings reported by Harris et al. (2008), we also found
year follow-up
that worse functionality at baseline was associated with a higher suicide
Abbreviations: 0, untreated psychosis period; 1 M, baseline to one month; 6 M,
risk. By contrast, other studies have not found any association between
one to six months; 1Y, month 6 to12; 2Y, one year to two years.

3
A. Toll et al. Psychiatry Research 325 (2023) 115232

Table 2 Table 4
Differences at baseline in PANSS scores between patients who attempted suicide Suicide risk factors in FEP patients over the 2 year follow-up: logistic regression
during the 2-year follow-up and those who did not. model (STEP-WISE METHOD) using total scale scores.
No suicide Suicide attempt p Predictor − 2log Nagelkerke x2 (df) OR (95% p
attempt (n = 237) (n = 30) likelihood R2 CI)
mean (SD)
Step 1 134.76 0.095 9.92
P1. Delusions 5.47 (3.42) 5.58 (1.62) 0.761 (1)
P2. Conceptual disorganization 3.95 (2.13) 3.27 (1.51) 0.273 Personal 7.67 (2.32; 0.001
P3. Hallucinatory behavior 3.29 (1.67) 3.81 (1.83) 0.265 history of 25.31)
P4. Excitement 3.62 (1.44) 3.42 (1.21) 0.253 suicide
P5. Grandiosity 2.43 (1.65) 1.96 (1.39) 0.112 attempt
P6. Suspiciousness/Persecution 4.48 (1.43) 4.92 (1.62) 0.441 Step 2 126.06 0.175 18.67
P7. Hostility 2.53 (1.39) 2.69 (1.52) 0.524 (2)
PANSS Positive 24.82 (7.57) 25.65 (6.72) 0.448 Personal 7.04 (1.95; 0.003
N1. Blunted affect 2.49 (2.65) 2.51 (1.53) 0.618 history of 25.46)
N2. Emotional withdrawal 2.65 (1.73) 3.01 (1.49) 0.767 suicide
N3. Poor rapport 2.25 (1.47) 2.42 (1.55) 0.436 attempt
N4. Passive/apathetic social 2.57 (1.49) 3.15 (1.64) 0.951 GAF score 0.95 (0.91; 0.009
withdrawal 0.99)
N5. Difficulty in abstract 2.49 (1.31) 2.73 (1.34) 0.841 Step 3 121.576 0.214 23.14
thinking (3)
N6. Lack of spontaneity and flow 2.04 (1.47) 2.08 (1.44) 0.933 Personal 5.91 (1.63; 0.007
of conversation history of 21.47)
N7. Stereotyped thinking 2.24 (1.34) 2.42 (1.45) 0.347 suicide
PANSS Negative 16.13 (8.03) 18.31 (7.85) 0.887 attempt
PG1. Somatic concern 2.12 (1.66) 2.04 (1.84) 0.589 GAF score − 0.94 0.005
PG2. Anxiety 3.37 (1.68) 4.15 (1.19) 0.948 (− 0.91;
PG3. Guilt feelings 1.65 (1.17) 2.51 (1.79) 0.001 − 0.98)
PG4. Tension 3.17 (1.18) 3.23 (1.48) 0.131 CDSS total 1.11 (1.01; 0.032
PG5. Mannerism and posturing 1.86 (1.19) 1.73 (1.22) 0.771 score 1.21)
PG6. Depression 2.01 (1.25) 2.54 (1.33) 0.007
PG7. Motor retardation 1.69 (1.04) 2.19 (1.13) 0.223 Abbreviations: CI, confidence interval; OR, odds ratio; df, degrees of freedom;
PG8. Uncooperativeness 2.72 (1.72) 2.42 (1.45) 0.307 CDSS, Calgary Depression Scale for Schizophrenia; GAF, Global Assessment of
PG9. Unusual thought content 2.91 (1.23) 3.46 (1.49) 0.489 Functioning.
PG10. Disorientation 1.65 (0.94) 2.19 (1.67) 0.001
PG11. Poor attention 3.25 (1.28) 2.77 (1.07) 0.344
PG12. Lack of judgement and 4.23 (1.64) 4.19 (1.44) 0.166 Table 5
insight
Suicide risk factors in FEP patients over the 2-year follow-up: logistic regression
PG13. Disturbing of volition 2.32 (1.49) 2.42 (1.74) 0.408
model (STEP-WISE METHOD) using scores on the scale subitems.
PG14. Poor impulse control 2.63 (1.24) 3.02 (1.49) 0.916
PG15. Preoccupation 3.22 (1.25) 3.54 (1.27) 0.495 Predictor − 2log Nagelkerke x2 (df) OR (95% p
PG16. Active social avoidance 3.14 (1.52) 3.31 (1.59) 0.744 likelihood R2 CI)
PANSS General Pathology 41.12 (11.78) 45.69 (11.78) 0.766
Step 1 44.09 0.276 8.71
PANSS TOTAL 82.15 (21.64) 89.65 (21.98) 0.868
(1)
Abbreviations: PANSS, Positive and negative symptom scale; SD, standard Personal 0.36 (0.18; 0.001
deviation. history of 0.54)
suicide
attempt
Step 2 33.16 0.343 19.62
Table 3 (2)
Differences in baseline CDSS scores between FEP patients who attempted suicide Personal 0.32 (0.15; 0.001
and patients who did not during the two-year follow-up. history of 0.55)
No suicide attempt Suicide attempt (n p suicide
(n = 237) = 30) attempt
mean (SD) PG3. Guilt 0.05 (0.02; 0.003
feelings 0.09)
CDSS1. Depressed mood 0.66 (0.81) 0.64 (0.72) 0.697 Step 3 27.63 0.377 31.12
CDSS2. Hopelessness 0.71 (0.83) 1.03 (1.23) 0.001 (2)
CDSS3. Self-depreciation 0.37 (0.78) 0.23 (0.52) 0.086 Personal 0.32 (0.14; 0.001
CDSS4. Guilty ideas of 0.43 (0.81) 0.86 (1.12) 0.001 history of 0.49)
reference suicide
CDSS5. Pathological 0.23 (0.53) 0.41 (0.96) 0.006 attempt
guilt PG3. Guilt 0.05 (0.01; 0.008
CDSS6. Mourning 0.16 (0.44) 0.14 (0.35) 0.543 feelings 0.08)
depression GAF score − 0.03 0.021
CDSS7. Early wakening 0.18 (0.59) 0.14 (0.66) 0.655 (− 0.06;
CDSS8. Suicide 0.33 (0.73) 0.23 (0.68) 0.294 − 0.01)
CDSS9. Observed 0.41 (0.68) 0.27 (0.46) 0.057
depression Abbreviations: CI, confidence interval; OR, odds ratio; df, degrees of freedom;
CDSS TOTAL 3.21 (4.08) 5.36 (5.14) 0.018 PG3, Positive and negative symptom scale, general pathology item 3; GAF,
Global Assessment of Functioning.
Abbreviations: CDSS, Calgary Depression Scale for Schizophrenia; SD, standard
deviation.
The presence of more depressive symptoms at baseline was associ­
ated with a higher risk of suicide attempts during follow-up. This finding
baseline functionality and suicide risk (Joa et al., 2009; Clarke et al.,
is in line with previous studies, which have consistently reported that
2006). It is important to note that functionality scores include risky
higher depressive symptoms increase suicide risk in this patient popu­
behaviours, which could influence the results.
lation (Sicotte et al., 2021; Clarke et al., 2006; Sanchez-Gistau et al.,

4
A. Toll et al.
2013). In patients with FEP, depressive symptoms are commonly present
at onset (Sicotte et al., 2021). However, it can be difficult to differentiate
between depressive symptoms and negative symptoms or emotional
distress associated with the psychotic episode (Tollefson et al., 1998).
Interestingly, when exploring different subitems, we found that more
guilt feeling at baseline were related with higher suicide risk in FEP over
two-years follow-up. This same association has been described in other
studies of patients with bipolar disorder and psychotic depression
(Upthegrove et al., 2010). In patients with psychosis, some studies have
found an association between suicide risk and ideas of loss, shame
and/or hopelessness (Duffy et al., 2019). Regarding FEP patients, one
study that included 290 FEP patients (Upthegrove et al., 2014) also
found an association between an increased suicide risk and more guilt
delusions. In our study, the univariate analysis showed that several
variables—hopelessness, guilty ideas of reference, and pathological guilt
(CDSS scale)—were associated with suicide attempts; however, these
variables lost significance on the multivariate analysis. These findings
suggest that certain symptoms (particularly guilt feelings) could be
considered an early warning signal when evaluating depressive symp­
toms in early intervention care.
We did not find any differences in suicide risk by age or sex. The
influence of sex on suicide risk in this population is not clear, mainly due
to the conflicting findings of previous studies, with some reporting a
higher risk in men (Madsen et al., 2016; Robinson et al., 2009) and
others finding a higher risk in women (Harris et al., 2008; Fialko et al.,
2006). Even so, in FEP and schizophrenia, the differences between sexes
on this matter seem less clear than in other populations (Sanchez-Gistau
et al., 2013). With regard to age, the available evidence suggests that
early onset psychosis confers a higher risk of suicide than adult-onset
psychosis (Joa et al., 2009; Chang et al., 2015). However, we were un­
able to assess this given that our patient population was limited to adults
≥ age 18.
DUP was not significantly associated with suicide attempts in our
study, a finding that is in line with previous reports (Salagre et al., 2021;
Clarke et al., 2006). However, the influence of DUP on suicide risk re­
mains unclear, mainly due to the contradictory results reported to date
(Nordentoft et al., 2015; Joa et al., 2009). Nonetheless, it is important to
note that most of the suicide attempts (48.6%) in our sample occurred
during the untreated psychosis period, even though no significant as­
sociation was observed between the DUP and suicide attempts. Although
these two findings seem contradictory, we hypothesize that the impor­
tant factor is the presence of the untreated psychosis per se rather than
the duration thereof, which could be prevented with early intervention
programs in high risk for psychosis subjects (Fusar-Poli et al., 2017).
In our sample, the patients’ living situation was not significantly
associated with suicide risk, perhaps because most of the patients were
living with someone, which could help to explain the lack of a significant
association. In any case, the role of the patient’s living situation is un­
clear, with some authors finding that living with others is protective
(Castelein et al., 2015) and others finding that this variable is not pro­
tective (Sicotte et al., 2021).
The presence of positive psychotic symptoms (or any positive sub­
item) at baseline was not associated with suicide risk in our sample. By
contrast, some authors have found that patients with schizophrenia with
more psychotic symptoms (even if subclinical) showed a higher risk of
suicidal ideation, self-injurious behavior, and suicide attempts (Bertel­
sen et al., 2007; Kelleher et al., 2014). In fact, this same association has
also been found in the general population and in other mental illnesses
(Yates et al., 2019). However, we cannot rule out a potential association
between positive symptoms and suicide attempts made prior to admis­
sion to our treatment program.
Negative symptoms at baseline were not associated with suicide risk
in this cohort, a finding that is in line with previous reports (Sicotte
et al., 2021; Sanchez-Gistau et al., 2013). Even so, it is worth noting that
some studies have found that patients with schizophrenia in whom
negative symptoms predominate appear to have a lower long-term risk
5
Psychiatry Research 325 (2023) 115232
of suicide (Kelleher et al., 2017; Barbeito et al., 2021). Some authors
have suggested that patients with prominent negative symptoms
(especially deficits in emotional expression) may have a significantly
lower capacity to experience the emotional anxiety and hopelessness
caused by the disease (Barbeito et al., 2021; Ventriglio et al., 2016). A
considerable proportion of FEP patients included in previous longitu­
dinal studies assessing suicidality where in the acute phase at baseline
assessment, where some negative symptoms could be secondary to other
sources (positive, depressive), and change over time. This fact could
help to explain the discrepancies with regard to the association between
negative symptoms and suicidality.
4.1. Strengths and limitations
The main limitation of this study is the observational design, which
means that we are unable to determine a cause-effect relationship be­
tween the study variables and suicide attempts. Another limitation is
that high risk for psychosis patients were not included in our First
Episode Program. Consequently, no clinical evaluations were performed
during the untreated psychosis period. Moreover, we cannot ensure that
patients were not psychotic in the attempts included in the history of
suicide attempts, although the throughout baseline assessment could
determine this with high certainty. By contrast, the main strength of this
study is the large sample size (n = 267), long follow-up (two years), and
low dropout rate (4.3%), all of which increase the likelihood that this is a
representative sample of FEP patients. Finally, another strength is that
we determined and grouped suicide attempts into five distinct time
periods, thus helping to better clarify the period of highest risk.
4.2. Conclusions
Patients with FEP are at a high suicide risk, especially during the
untreated psychosis period. Our findings indicate that the highest risk
factors for suicide in this patient population are a personal history of
suicide attempts, low functionality and the presence of depressive
symptoms (particularly, guilt feelings) at baseline.
These findings suggest that early intervention programs, especially
those performed in prodromal stages of the disease, could play a key role
in identifying and treating early psychosis patients at high risk of sui­
cide, especially considering that previous research has proven that tar­
geted early intervention strategies for these patients reduces suicide
rates.
Founding sources
This research did not receive any specific grant from funding
agencies in the public, commercial, or not-for-profit sectors.
CRediT authorship contribution statement
Alba Toll: Conceptualization, Methodology, Writing – original draft.
Emilio Pechuan: Investigation, Data curation. Daniel Bergé: Method­
ology, Software. Teresa Legido: . Laura Martínez-Sadurní: . Khadija
El-Abidi: . Víctor Pérez-Solà: Supervision. Anna Mané: Conceptuali­
zation, Methodology, Writing – review & editing.
Declaration of Competing Interest
Dr. Mané and Dr. Bergé have both received financial support to
attend meetings, travel support, and served as speakers for Otsuka,
Angelini and Janssen Cilag. The other authors of this manuscript have no
conflicts of interest to report.
Acknowledgments
We would like to thank all of the patients who made this study
A. Toll et al.
possible. We also thank Bradley Londres for professional English-
language editing.
Supplementary materials
Supplementary material associated with this article can be found, in
the online version, at doi:10.1016/j.psychres.2023.115232.
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