Reassessing the long-term risk of suicide after a first episode of psychosis.
BACKGROUND
The long-term risk of suicide after a first episode of psychosis is unknown because previous studies often have been based on prevalence cohorts, been biased to more severely ill hospitalized patients, extrapolated from a short follow-up time, and have made a distinction between schizophrenia and other psychoses.


OBJECTIVE
To determine the epidemiology of suicide in a clinically representative cohort of patients experiencing their first episode of psychosis.


METHODS
Retrospective inception cohort.


METHODS
Geographic catchment areas in London, England (between January 1, 1965, and December 31, 2004; n = 2056); Nottingham, England (between September 1, 1997, and August 31, 1999; n = 203); and Dumfries and Galloway, Scotland (between January 1, 1979, and December 31, 1998; n = 464).


METHODS
All 2723 patients who presented for the first time to secondary care services with psychosis in the 3 defined catchment areas were traced after a mean follow-up period of 11.5 years.


METHODS
Deaths by suicide and open verdicts according to the International Classification of Diseases (seventh through tenth editions).


RESULTS
The case fatality from suicide was considerably lower than expected from previous studies (1.9% [53/2723]); the proportionate mortality was 11.9% (53/444). Although the rate of suicide was highest in the first year after presentation, risk persisted late into follow-up, with a median time to suicide of 5.6 years. Suicide occurred approximately 12 times more than expected from the general population of England and Wales (standardized mortality ratio, 11.65; 95% confidence interval, 8.73-15.24), and 49 of the 53 suicides were excess deaths. Even a decade after first presentation-a time when there may be less intense clinical monitoring of risk-suicide risk remained almost 4 times higher than in the general population (standardized mortality ratio, 3.92; 95% confidence interval, 2.22-6.89).


CONCLUSIONS
The highest risk of suicide after a psychotic episode occurs soon after presentation, yet physicians should still be vigilant in assessing risk a decade or longer after first contact. The widely held view that 10% to 15% die of suicide is misleading because it refers to proportionate mortality, not lifetime risk. Nevertheless, there is a substantial increase in risk of suicide compared with the general population.
Department of Psychosis Studies, Institute of Psychiatry, King's College London, England. rina.dutta@kcl.ac.uk
Rina
R
Dutta
Robin M
RM
Murray
Matthew
M
Hotopf
Judith
J
Allardyce
Peter B
PB
Jones
Jane
J
Boydell
D000293:Adolescent; D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D016001:Confidence Intervals; D004739:England / Q000453:epidemiology; D005260:Female; D005500:Follow-Up Studies; D055991:Health Records, Personal; D006801:Humans; D038801:International Classification of Diseases; D008131:London / Q000453:epidemiology; D008297:Male; D008875:Middle Aged; D015995:Prevalence; D011569:Psychiatric Status Rating Scales; D011618:Psychotic Disorders / Q000175:diagnosis / Q000401:mortality* / Q000523:psychology*; D012189:Retrospective Studies; D012307:Risk Factors; D012559:Schizophrenia / Q000401:mortality; D012565:Schizophrenic Psychology; D012606:Scotland / Q000453:epidemiology; D013405:Suicide / Q000523:psychology / Q000706:statistics & numerical data*; D013997:Time Factors; D055815:Young Adult