The development of insight and its relationship with suicidality over one year follow-up in patients with first episode psychosis

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Abstract

Objective

Insight into psychosis has been linked to suicidality, although inconsistently. The co-variation between insight and suicidality over time is under-investigated. The aim of the present study was to investigate predictors of suicidality in patients with first episode of psychosis (FEP) over one year, focusing on the relationship between insight and suicidality.

Methods

Patients with FEP (n = 146) were interviewed as soon as possible after treatment starts and at one year follow-up.

Results

At baseline 37% of patients were suicidal, significantly reduced to 20% at follow-up. The effect of insight on suicidality was in different directions at different time-points, with insight at baseline increasing and insight at follow-up decreasing the risk of suicidality at follow-up. Patients with stable levels of insight across baseline and follow-up did not differ in risk for suicidality at follow-up. However, patients who lost insight from baseline to follow-up were more often suicidal at follow-up, whilst patients who gained insight were more seldom suicidal at follow-up. Other predictors of suicidality at follow-up were more depressive episodes before study entry, longer duration of untreated psychosis, more suicide attempts six months prior to follow-up, and depression at follow-up.

Conclusion

The results indicate that the effect of insight on suicidality in FEP-patients depends on time of assessment and of changes in insight. Gaining insight during treatment was associated with reduced risk for suicidality, whilst losing insight had the opposite effect, underlining the need to monitor insight over time and tailor interventions according to illness phase.

Introduction

Suicidal behaviour is prevalent in psychotic disorders. Approximately 5% of patients with schizophrenia kill themselves (Palmer et al., 2005), and as many as 50% of patients have suicidal thoughts or attempt suicide (Bolton et al., 2007). Studies show that suicidal behaviour occurs both before treatment starts and after treatment has commenced (Barrett et al., 2010a, Bertelsen et al., 2007). Hence, identifying and treating suicidal symptoms are a major target in clinical practise.

Insight into psychosis has been defined as the awareness of having a mental disorder, its symptoms, and need for treatment (David, 1990). Poor insight is a common feature of schizophrenia (Amador and Gorman, 1998), associated with poor treatment adherence (Lincoln et al., 2007) and thus a potential obstacle to recovery. High insight is associated with lower symptom levels (Mintz et al., 2003), better social function (Olfson et al., 2006) and work performance (Lysaker et al., 2002), but also with more depression (Mintz et al., 2003) and hopelessness (Carroll et al., 2004). There are findings of an inconsistent link between insight and suicidality. Some studies find that higher insight is related to increased suicidality (Barrett et al., 2010a, Foley et al., 2008, Robinson et al., 2009), others to decreased suicidality (Bourgeois et al., 2004, Steblaj et al., 1999) and some studies find no relationship (Barrett et al., 2010a, Hawton et al., 2005, Restifo et al., 2009). Taken together, this indicates that there are different profiles between insight and distress.

Both suicidality and insight fluctuate over time (Tarrier et al., 2006, Wiffen et al., 2010). The level of one of these phenomena here-and-now might not be related to historical levels – or predict future levels – of the other. In line with this, we have previously shown that insight measured at study entry in FEP patients was significantly associated with the concurrent level of suicidality (Barrett et al., 2010b) but not with previous suicidal behaviour i.e. prior to study entry (Barrett et al., 2010a), indicating the importance of measuring insight and suicidality at the same time-point. The aim of the present study was thus to investigate predictors of suicidality in an expanded sample of FEP-patients, particularly focusing on the development of insight over one year follow-up and its relationship with suicidality.

Section snippets

Participants

The present study included patients from the Thematically Organized Psychosis (TOP) study in Oslo, Norway. The patients were recruited consecutively from inpatient and outpatient psychiatric units from October 2002 until February 2011 from major hospitals in Oslo, Norway covering a catchment area of approximately 485,000 inhabitants. Inclusion criteria were as follows: age: 18–65 years and a first episode of a psychotic disorder according to the DSM-IV (American Psychiatric Association, 1994)

Results

Differences in background and baseline variables in patients with suicidality and in those without suicidality at one year follow-up are shown in Table 1. Twenty-nine patients (20%) were suicidal at follow-up compared to 54 (37%) at baseline, a statistically significant reduction (p < .001). Nineteen patients (13%) were suicidal at both points in time. Patients who were suicidal at follow-up had significantly poorer premorbid childhood social and academic functioning, longer DUP, and more

Discussion

The aim of the present study was to investigate predictors of suicidality in patients with FEP over a one year follow-up period, specifically focusing on the relationship between insight and suicidality. Predictors of suicidality at follow-up were longer DUP, more depressive episodes before study entry, depression at follow-up, and more suicide attempts for the last six months prior to follow-up. Interestingly, we found that whilst insight at baseline increased the risk for suicidality at one

Role of funding source

Funding for this study was provided by the South-Eastern Norway Regional Health Authority (grants #2006258, #2007004, and #2011085) and Oslo University Hospital Trust; and by the Research Council of Norway through its Centres of Excellence funding scheme, project number 223273. The funding sources had no involvement in the study design, data collection, analysis and interpretation of data, in the writing of the manuscript, or in the decision to submit the paper for publication.

Contributors

EAB, IA, OAA and IM contributed to the study design. EAB, EM, AF, and RN contributed to the data collection. EAB conducted the statistical analyses. EAB and IM interpreted the data and drafted the manuscript. All authors participated in critical revision of manuscript drafts and approved the final version.

Conflict of interest

OAA has received speaker's honorarium from Lilly, GSK, Otsuka, and Lundbeck. All authors declare that they have no conflicts of interest.

Acknowledgements

We thank the patients for participating in the study. We also thank the Section of Early Psychosis Treatment at Oslo University Hospital for necessary arrangements for the work on this paper and the study group at NORMENT, K.G. Jebsen Centre for Psychosis Research for their data collection and administrative contribution.

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