Young men with suicidal behavior have high psychosis risk

Young men who display suicidal behavior were likely to be later diagnosed with psychosis, according to findings recently published in JAMA Network Open.

“Most primary care physicians see few new cases of psychosis each year and therefore have little opportunity to increase personal experience. Ideally, primary care physicians would have better information about the symptoms that could help them identify patients at [clinical high risk] and who should undergo further assessment for psychotic symptoms,” Sarah A. Sullivan, PhD, of the Centre for Academic Primary Care at the University of Bristol, U.K., and colleagues wrote.

Researchers studied 13 prespecified symptoms culled from the literature in 81,793 adults who did not have a psychosis diagnosis and 11,690 adults who had. Of all participants, 57.4% were women and 40% were older than 60 years.

Researchers found the strongest association with being diagnosed with psychosis occurred in patients who had displayed suicidal behavior (OR = 19.06; 95% CI, 16.55-21.95). The highest positive predictive value for suicidal behavior was in men younger than 24 years of age (33%; 95% CI, 24.2-43.2), followed by women aged 25 to 34 years (19.6%; 95% CI, 13.7-27.2).

Other associations were:

bizarre behavior (OR = 21.7; 95% CI, 7.94-59.28);

cannabis-related problems (OR = 15.92; 95% CI, 11.23-22.58);

depression symptoms (OR = 12.11; 95% CI, 11.53-12.72);

blunted effect (OR = 7.69; 95% CI, 3.83-15.44);

obsessive compulsive disorder symptoms (OR = 6.91; 95% CI, 5.5-8.69);

social isolation (OR = 6.64; 95% CI, 5.05-8.74);

role-functioning problems (OR = 5.6; 95% CI, 4.39-7.15);

ADHD-like symptoms (OR = 7.22; 95% CI, 5.96-8.74);

sleep disturbance (OR = 3.22; 95% CI, 2.94-3.54);

mania symptoms (OR = 4.66; 95% CI, 4.39-4.93); and

smoking-related problems (OR = 2; 95% CI, 1.9-2.1).

“This information will help primary care physicians undertake the difficult task of determining which patients, consulting with nonspecific symptoms, are more likely to develop psychosis. Our methods could be used by primary care physicians to flag those patients who need further assessment,” Sullivan and colleagues wrote.

“Our findings may also reduce the number of those with psychosis who reach secondary care via routes such as emergency services, because some may have an identifiable pattern in prior primary care consultations. Our work indicates that some patients consult their primary care physician as long as 5 years before the diagnosis, providing a lengthy window of opportunity for early referral,” they added.

In a related editorial, Hannah E. Brown, MD, of the department of psychiatry at Massachusetts General Hospital, said that while the subject of research was important, the lack of specificity of the symptoms makes it difficult to apply these findings to practice.

“This study’s main strengths include both the timely topic of early detection and intervention and the study design itself (nested case-control) within a large database. Important limitations include the lack of specificity of the symptoms the authors preselected and the lack of information regarding comorbid diagnoses.”

“This lack of symptom specificity has clinical implications; discerning appropriate patients to refer to specialty early intervention becomes more difficult and imprecise, which may slow timely care. Another important limitation is the wide range of psychotic diagnoses included in this study (ie, not only primary psychotic illnesses),” Brown continued.

Even so, Sullivan et al’s findings point out the critical role PCPs play in ascertaining which patients are at high risk for, and would benefit from, early intervention for psychosis, she wrote. – by Janel Miller

Disclosure s : Neither Brown nor Sullivan report any relevant financial disclosures. Please see the study for all other authors’ relevant financial disclosures.