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. Author manuscript; available in PMC: 2021 Apr 1.
Published in final edited form as: Schizophr Res. 2020 Jan 13;218:240–246. doi: 10.1016/j.schres.2019.12.037

Suicidal Thoughts and Behavior (STB) and Psychosis-risk Symptoms among Psychiatrically Hospitalized Adolescents

Elizabeth Thompson a,b, Anthony Spirito a,b, Elisabeth Frazier a,b, Alysha Thompson a,b, Jeffrey Hunt a,b, Jennifer Wolff a,b
PMCID: PMC7299764  NIHMSID: NIHMS1549732  PMID: 31948902

Abstract

Background

Individuals in the early stages of psychosis have a markedly high risk for suicidal thoughts and behavior (STB). It is not well understood if STB among those with psychosis-risk symptoms is accounted for by co-occurring psychopathology (e.g., depression), unique experiences specific to psychosis-spectrum symptomatology (e.g., hallucinations, delusions), or combined effects of different factors. This cross-sectional study explored the link between psychosis-spectrum symptoms, co-occurring disorders, and STB.

Methods

This record review included 569 adolescents (mean age = 14.83) admitted to a psychiatric inpatient hospital due to exhibiting behavior indicating they were an imminent threat to themselves or others. Upon intake to the hospital, participants completed a diagnostic interview and self-report measures of suicidal ideation, suicide attempt history, and psychosis-spectrum symptoms. The primary analysis used linear regression to predict suicidal ideation from psychosis-spectrum symptom scores, controlling for known characteristics associated with STB including specific psychiatric disorders (i.e. depressive, anxiety, post-traumatic stress, and psychotic disorders), biological sex, and race.

Results

Psychosis-spectrum symptoms predicted suicidal ideation above and beyond the significant effects of a depressive disorder diagnosis and sex, as well as the non-significant effects of anxiety, PTSD, full-threshold psychosis, and race. Item-level correlations demonstrated that several psychosis-spectrum symptoms were significantly associated with ideation and lifetime suicide attempts.

Conclusions

Results indicate that within this sample of psychiatrically hospitalized youth, psychosis-risk symptoms were uniquely linked to STB. These findings suggest that attention to psychosis-spectrum symptoms, including several specific psychosis-risk experiences, may be clinically important for better assessment and treatment of suicidal youth.

Suicide is a major public health concern for youth, given that it is the second leading cause of death among individuals aged 10–24 years (Heron, 2019). Extensive research exploring risk factors for death by suicide has found that suicidal thoughts and behavior (STB), such as suicidal ideation and past suicide attempts, are among the strongest identified predictors for future suicide attempts and completion (Castellvi et al., 2017; Bentley et al., 2016). Although ideation is a clinically valuable indicator of risk for suicide, especially within the first year after ideation onset, most ideators do not ever attempt (the probability of a lifetime attempt is approximately 30%; Nock et al., 2008). Prior attempts are more predictive of future attempts than ideation, as the odds of a future attempt are estimated to be four times greater than individuals with ideation alone (i.e. no past attempts; Miranda et al., 2008). Nonetheless, there is a need to identify other types of risk factors given that the majority of youth who die by suicide do not have a documented history of previous attempts (Castellví et al., 2017), and a large proportion of people do not express ideation prior to attempts (Miranda et al., 2008; Poulin et al., 2014). Together, these data suggest that overt suicidal statements and behaviors may not be present for many experiencing suicidal thoughts, and understanding more subtle risk factors may aid in prediction and prevention.

Psychosis-spectrum experiences warrant attention within the suicide risk conversation given that among individuals who die by suicide, approximately 10% meet criteria for a psychosis-spectrum disorder (Arsenault-Lapierre et al., 2004). Further, based on a large non-clinical sample of adults, an estimated 17% of total suicide attempts and 29% of severe attempts were linked to psychotic experiences (DeVylder et al., 2015). Notably, those experiencing their first episode of psychosis, typically during late adolescence and early adulthood, have a particularly high risk for suicide. Individuals with early psychosis may have as high as 24 times the mortality rate of same age peers within their first year of psychotic illness, and suicide accounts for a large proportion of those deaths (Schoenbaum et al., 2017; Ventriglio et al., 2016). In their first episode of psychosis, 8–26% of individuals attempt suicide, with higher risk for those under the age of 18, and as many as 70% of those with untreated psychosis (prior to their “first episode” diagnosis) report STB (Barrett et al., 2010; Pompili et al., 2011).

Among people at clinical high risk for psychosis (i.e., experiencing attenuated psychotic symptoms), prevalence rates have been estimated to be approximately 66% for suicidal ideation (SI), and 18% for attempts (Taylor et al., 2015). Individuals with attenuated psychosis commonly experience co-morbid concerns including depression, anxiety, PTSD, mania, and substance use, which are independently linked to suicide (Addington et al., 2017; Rosen et al., 2006; Thompson et al., 2015). These difficulties may also contribute to or be exacerbated by psychotic processes, which may increase overall risk for suicide.

Much of the existing literature examining suicide and attenuated psychosis tends to focus on the link between STB and negative symptoms (e.g., avolition, anhedonia, blunted affect) or co-occurring difficulties including depression, trauma, substance use, and social and role dysfunction (Hawton et al., 2005; Tarrier et al., 2007). It is unclear, however, if increased risk for STB among those with psychosis is accounted for by co-occurring psychopathology, unique experiences specific to psychosis-spectrum symptomatology (e.g., “positive symptoms” such as hallucinations or delusional beliefs), or a combination or interaction of experiences. Some literature has found that while negative symptoms and functional impairment are associated with SI among individuals at risk for psychosis, ideation and positive symptoms (the characteristic symptoms of psychosis-risk syndromes, such as hallucinations and delusions) are not statistically linked (Gill et al., 2015). These findings are inconsistent with meta-analytic findings that among individuals with full-threshold psychosis, positive symptoms were found to statistically predict suicidal ideation whereas negative symptoms did not (Huang et al., 2018).

Other evidence indicates that positive psychosis-like experiences (e.g., subclinical hallucinations and delusions) may be associated with STB within general population and non-clinical college samples, even when adjusting for confounding mental disorders (DeVylder et al., 2015c; Hielscher et al., 2017; Koyanagi et al., 2015). Broad measures of psychotic experiences have been uniquely linked to increased odds of a suicide attempt among adults with borderline personality disorder (BPD), with other mental health disorders (i.e., depressive, anxiety, obsessive-compulsive disorders), and without BPD or another psychiatric disorder (Kelleher et al., 2017).

Specific subtypes of positive psychotic-like symptoms including perceptual abnormalities and persecutory ideation have been uniquely linked to ideation and attempts in large non-clinical samples, suggesting particular risk conveyed by these specific types of experiences (Capra et al., 2015). Similarly, among help-seeking adolescents in an outpatient setting, visual distortions were independently associated with SI, beyond the effects of depression and other types of psychosis-risk symptoms (Grano et al., 2015). Taken together, this evidence suggests that subclinical psychosis-spectrum experiences may be linked to STB, possibly beyond the effects of other mental health diagnoses and symptoms.

Almost no research has examined the relation between attenuated psychosis and STB within an adolescent acute care setting, where STB are prevalent, proximal, and severe. Additionally, exploration of the relation between psychosis-risk symptoms and STB, controlling for other disorders associated with heightened risk for suicide (i.e., depression, anxiety, and PTSD), may elucidate the unique contributions of different categories of symptoms. Further investigation into these experiences among a population hospitalized for STB may improve our understanding of the link between these clinically relevant experiences.

The current study explored the occurrence of psychosis-risk symptoms among adolescents presenting at an inpatient psychiatric hospital due to unsafe thoughts or behaviors, the majority of whom endorsed STB (e.g., SI and/or suicide attempts). The primary hypothesis was that psychosis-risk symptoms would be associated with STB variables, including SI and lifetime suicide attempt. It was further hypothesized that these psychosis-risk symptoms would be uniquely, statistically linked to STB beyond the effects of demographic and diagnostic characteristics linked to suicide risk in the literature, including sex (Miranda-Mendizabal et al., 2019), race (Balis & Postolache, 2008), and depression (Arsenault-Lapierre, Kim, & Turecki, 2004). The correlational associations between psychosis-risk symptoms and other clinical variables of interest (e.g., SI, lifetime suicide attempt, co-morbid diagnoses) are described. Endorsements of specific psychosis-spectrum experiences were compared among youth with high levels of SI versus those with relatively low SI, and among those with a lifetime suicide attempt, versus those without. Finally, psychosis-risk experiences were examined as predictors of both SI and lifetime suicide attempt, in separate regression analyses.

Methods

Participants

Participants included 569 youth, aged 12–18 years, admitted to a psychiatric inpatient facility in the Northeast United States from April 2017 to September 2018. During this time, a psychosis-risk screening tool (the PRIME Screen- Revised) was piloted within the hospital’s intake battery. Patients were admitted due to exhibiting behavior or making statements indicating they were an imminent threat to themselves or others (the majority are admitted for suicidal ideation or an attempt, while a minority are admitted for aggression, homicidal statements, disorganized behavior, overt psychosis, or other unsafe behaviors).

Procedures

This study was granted Institutional Review Board (IRB) approval for the review of records within the hospital’s electronic medical record system, using Epic software. Records included diagnostic interviews and self-report measures that were included within the standard hospital assessment protocol administered within 72 hours of admission.

Measures

Study measures, including a diagnostic interview (ChIPS) and self-report measures (the PRIME Screen, the Suicide Ideation Questionnaire-Jr, and a question probing history of suicide attempt), were administered using Research Electronic Data Capture (REDCap; Harris et al., 2009) at the time of intake. Measures were administered by psychology staff (a full-time psychology assistant whose primary role is intake assessment) and trainees (i.e., master and doctoral level students), all trained and supervised by licensed attending psychologists. All participants were given verbal instructions on how to complete the self-report measures, and a psychology team member monitored the completion of the surveys. Teens who were unable to complete the surveys independently due to comprehension, acute mental health, or behavioral concerns were not included in this sample (i.e., they did not complete the self-report battery).

Childhood Inventory of Psychiatric Syndromes (ChIPS)

The ChIPS (Weller et al., 2000) was used as part of standard unit procedures to identify diagnoses at intake. This highly structured diagnostic interview, designed for youth aged 6–18 years, efficiently assesses 20 mental disorders using Diagnostic and Statistical Manual of Mental Disorders (DSM-IV) criteria. Reliability and validity studies with youth in inpatient and outpatient settings demonstrate acceptable psychometric properties (Fristad et al., 1998a, 1998b; Teare et al., 1998). Psychology team members were trained to administration standards by a licensed psychologist, via a process including didactic instruction, observing and co-rating at least two interviews administered by trained staff, and finally, administering at least two ChIPS interview while being observed by trained staff until consensus and proficiency standards were achieved. Ongoing diagnostic supervision was also provided.

The gold-standard administration of the ChIPS includes both child and caregiver informants, however, due to limited access to caregivers while adolescents are hospitalized, the ChIPS was conducted with the patient as the sole informant. Patient report and clinical judgment were used to derive diagnoses, specifically, mood, anxiety (generalized, social, specific phobia, obsessive-compulsive disorder), PTSD, and full-threshold psychotic disorders. Of note, although there is substantial comorbidity between bipolar disorder and psychosis symptoms (Dunayevich & Keck, 2000), manic symptoms were not considered here due to the very low rate of these symptoms endorsed within this sample on the ChIPS. Similarly, rates of substance use disorders were low, and thus they were also not considered. Individuals who endorsed either substance use or manic symptoms were included in the current sample, despite our inability to systematically account for these experiences. Notably, all individuals endorsing mania also met criteria for depression.

PRIME Screen-Revised (PRIME)

The PRIME (Miller, 2004) is a 12-item screener that asks respondents how much they agree that they have experienced psychosis-risk symptoms, ranging from a general sense of something feeling odd or unusual, to more specific symptoms, such as hearing voices or believing someone is planning to hurt them. Ratings are based on a seven-point Likert scale ranging from 0 to 6, where responses of “5” (somewhat agree) or “6” (definitely agree) are considered positive endorsements, as defined and validated by PRIME creators. This measure has been validated for individuals age 12 and older. Both continuous total scores and rates of endorsement were used in the current analyses. PRIME score (a continuous sum of ratings), is used here as a proxy for psychosis-risk symptom severity.

The PRIME was designed based on and by the creators of the Structured Interview for Psychosis-risk Syndromes (SIPS; Miller et al., 2003), the research gold-standard and most widely used measure for psychosis-risk diagnosis in North America. The PRIME maps onto four out of the five positive symptoms assessed by the SIPS: unusual thoughts/delusional ideas, suspiciousness/persecutory ideas, grandiose ideas, and perceptual abnormalities/hallucinations. The fifth positive domain, disorganized communication, is not assessed by the PRIME. The ability of the PRIME to identify individuals at risk according to thorough interview-based assessment has been explored in multiple studies, with high sensitivity rates (0.80–1.00; Kline & Schiffman, 2014) and acceptable rates of overall accuracy (~70%; Kline et al., 2012; Thompson et al., 2013) within specialized clinic settings. The internal consistency for the PRIME was strong in this sample, Cronbach’s alpha = 0.91.

Suicidal Ideation Questionnaire- Junior (SIQ-Jr)

The SIQ-Jr (Reynolds, 1988) is a 15-tem questionnaire designed to evaluate the frequency of SI among adolescents. Respondents rate, on a 7-point scale, how often they have each thought, ranging from “almost every day” to “I have never had this thought”, within the past 30 days. Scores greater than 31 indicate high suicide risk, as empirically derived and defined by SIQ-Jr developers. The SIQ-Jr has demonstrated high internal consistency (0.93–0.96) and test-retest reliability (.93 for males, .87 for females), and acceptable evidence for concurrent validity as youth who attempt suicide had significantly higher mean scores (Reynolds & Mazza, 1999). In the current study, internal consistency for the SIQ-Jr was strong (Cronbach’s alpha = 0.97).

Lifetime suicide attempt

After completing the SIQ-Jr, participants were also asked to electronically self-report on one item that asked “Have you ever made an actual suicide attempt, where you were trying to kill yourself, even just a little”. This question was used as a dichotomous variable within this study, with “no” coded “0” and “yes” coded “1”.

Data Analyses

All study data was analyzed using SPSS Software for Windows, Version 24 (IBM Corporation, 2016). Prior to analyses, all data were examined to determine acceptability for proposed methods. Data was screened for normality, including distribution, skewness and kurtosis; all data was approximately normal and suitable for methods employed. There were no outliers for any of the variables within the final dataset.

Correlations were used to explore the interrelations between variables of interest. Pearson correlations were used for analyses including two continuous variables (i.e. SIQ, PRIME), point biserial correlations were used for one continuous variable and one dichotomous variable (e.g., SIQ and diagnostic status), and Phi coefficients were used for two dichotomous variables (e.g., suicide attempt and diagnostic status). All participants were classified as having low or high SI based on their SIQ score (low SIQ < 31). Participants were also classified based on their endorsement of a lifetime suicide attempt (i.e. at least one attempt or none). Fisher’s exact tests were used to compare rates of psychosis-risk (PRIME) symptom endorsement across low and high SIQ groups, and also across attempt groups. Next, stepwise linear regression was used to predict SIQ scores. In the initial model (step 1), SIQ was regressed on PRIME scores and demographic factors found to be correlated with SIQ in this sample (i.e., sex and minority status). ChIPS diagnoses (i.e. depression, anxiety, PTSD, and psychosis, all dichotomized based on the presence of diagnosis) were added to the model (step 2), to test the unique contribution of PRIME scores above these diagnoses. Finally, logistic regression was used to predict lifetime suicide attempt from PRIME scores. Significant findings were defined by p-values below .05, and statistical trends were defined by p-values between .05 and .10.

Results

Of the 569 participants in the study, 30 individuals were missing all ChIPS data. A total of 378 met criteria for a depressive disorder (372 had major depressive disorder [MDD], 6 participants had dysthymia; 31 were missing data)), 62 met criteria for a psychotic disorder (21 met for schizophrenia, 41 had unspecified psychosis, 34 were missing data), and 56 met criteria for both psychosis and major mood disorder (35 met for MDD and unspecified psychosis, 19 had schizophrenia and met criteria for MDD, and two met criteria for dysthymia with unspecified psychosis). A total of 309 participants (54%) reported at least one lifetime suicide attempt, including 42 (68%) with psychosis, and 244 (65%) of those with a depressive disorder. The subgroup of individuals who scored above the SIQ clinical cut-off (n = 295) had a significantly greater proportion of females and Caucasian individuals, and significantly more diagnoses of depressive disorder, anxiety, PTSD, and psychosis compared to the low SIQ group. There were no differences across groups in age, minority racial identities, or ethnicity. See Table 1 for sample characteristics. Notably, there were no significant correlations between PRIME scores and age, race, or ethnicity. There was a small trend-level correlation between PRIME scores and female sex (r = .08, p = .06)

Table 1.

Demographic and clinical characteristics of the sample.

Full Sample (n = 569) Low SIQ (< 31; n = 274) High SIQ (=/> 31; n = 295) Differences across SIQ groups
Mean age ± SD 14.83 ± 1.65 14.72 ± 1.70 14.92 ± 1.60 t = −1.44, df = 567, n.s.
Female sex: n (%) 341 (60%) 134 (49%) 207 (70%) χ2 = 26.75, df = 1**
Suicide attempt n (%) 309 (54%) 88 (32%) 221 (75%) χ2 = 104.86, df = 1**
Race/ethnicity: n (%)
Caucasian 379 (67%) 170 (62%) 209 (71%) χ2 = 4.95, df = 1*
African American 63 (11%) 35 (13%) 28 (10%) n.s.
Other race/ multiracial 109 (18%) 62 (23%) 47 (16%) n.s.
Hispanic 114 (20%) 56 (20%) 58 (20%) n.s.
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Note: n.s. = non-significant difference across groups.

*

p < .05

**

p < .01.

Significant positive correlations were found among lifetime suicide attempt, SIQ scores, PRIME scores, and ChIPS diagnoses of depression, full-threshold psychosis, anxiety, and PTSD disorders (Table 2). All correlations with mental health diagnoses were stronger for SIQ scores in comparison to lifetime suicide attempt. Depression diagnosis had the strongest correlations (moderate to strong) with the STB variables (SIQ and suicide attempt), followed by PRIME total score (moderate), anxiety and PTSD (weak to moderate), and then psychosis diagnosis had the smallest correlations (weak magnitude).

Table 2.

Correlation matrix including STB, psychosis, and mood variables.

1 2 3 4 5 6 7
1. Lifetime suicide attempt …
2. SIQ total score .47** …
3. PRIME total score .23** .43** …
4. Depression diagnosis .31** .56** .31** …
5. Psychosis diagnosis .10* .21** .42** .16** …
6. Anxiety diagnosis .17** .30** .22** .37** .12** …
7. PTSD diagnosis .18** .22** .24** .25** .10* .26** …
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Note:

*

p < .05

**

p < .01.

Pearson correlations were used for two continuous variables (i.e. SIQ, PRIME), point biserial correlation was used for one continuous variable and one dichotomous variable, and Phi coefficient was used for two dichotomous variables (i.e., suicide attempt, diagnoses).

Correlations between the PRIME items and the STB variables were explored controlling for depression, given that depression was moderately to strongly associated with the STB and PRIME variables (Table 2). Most of the PRIME items were positively correlated (weak to moderate) with SIQ total score and endorsement of at least one lifetime suicide attempt (Table 3). These psychosis-spectrum experiences appear to be more strongly linked to SI than occurrence of lifetime suicide attempt within this sample.

Table 3.

Correlations between PRIME item ratings and STB variables, controlling for depression diagnosis (n = 534)

PRIME items SIQ suicidal ideation score Lifetime suicide attempt
1. Odd or unusual things going on .25** .13**
2. Able to predict the future .07 .08t
3. Something interrupting or controlling me .18** .07
4. Superstitious .20** .07
5. Confusing real vs. imagination/dreams .26** .15**
6. Mind-reading .17** .08t
7. People planning to hurt me .36** .15**
8. Special natural or supernatural gifts .12** .09*
9. Mind is “playing tricks” on me .27** .11**
10. Hearing mumbling or talking .33** .19**
11. Thoughts being said out loud .26** .13**
12. “going crazy” .36** .14**
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Note:

*

p < .05

**

p < .01

t

10 < p < .05.

Pearson correlations were used for two continuous variables (i.e. SIQ and PRIME items), and point biserial correlations were used for one continuous variable and one dichotomous variable (i.e., suicide attempt and PRIME items). Bootstrapping (1000 samples) was used in each set of correlations to control for Type 1 errors.

Endorsements of PRIME symptoms were compared across low- and high-SIQ groups, using the author-recommended cutoff of 31 to indicate clinical significance. Similar comparisons were made across lifetime attempt groups (i.e. those who did and did not endorse one or more lifetime attempts). Fisher’s exact tests were used to compare rates of endorsement across groups (Table 4). Youth with more severe STB (higher SIQ scores or presence of lifetime attempt), compared to those with less STB (lower SIQ scores or no attempt), reported higher endorsement of 9 out of the 12 symptoms (odd or unusual experiences, being superstitious, confusion about reality, belief in mind-reading, belief that others are planning to harm them, feeling as though their mind is playing tricks, hearing mumbling or talking, thinking their thoughts are being said out loud, or feeling as if they are “going crazy”). One symptom, believing that something is interrupting or controlling them, was more commonly endorsed in the high SIQ group compared to the low SIQ group, but no significant differences were seen in endorsement across attempt groups. The two symptoms that were not more commonly endorsed within the more severe STB groups were believing that they may be able to predict the future and believing they may have natural or supernatural gifts.

Table 4.

Endorsement of PRIME items across STB groups

PRIME items Low SIQ (<31) n = 274 High SIQ (=/>31) n = 295 Fisher’s Exact p (2-sided) No Attempt n = 259 Lifetime Attempt n = 309 Fisher’s Exact p (2-sided)
1. Odd or unusual things going on 33 12.0% 102 34.6% <.001 47 18.1% 88 28.5% .004
2. Able to predict the future 22 8.0% 32 10.8% .257 21 8.1% 33 10.7% .318
3. Something interrupting or controlling me 29 10.6% 71 24.1% <.001 41 15.8% 59 19.1% .323
4. Superstitious 17 6.2% 63 21.4% <.001 28 10.8% 52 16.8% .052
5. Confusing real vs. imagination/dreams 24 8.8% 91 30.8% <.001 35 13.5% 80 25.9% <.001
6. Mind-reading 10 3.6% 31 10.5% <.01 12 4.6% 29 9.4% .034
7. People planning to hurt me 14 5.1% 80 27.1% <.001 27 10.4% 67 21.7% <.001
8. Special natural or supernatural gifts 18 6.6% 27 9.2% .279 21 8.1% 24 7.8% 1.000
9. Mind is “playing tricks” on me 18 6.6% 73 24.7% <.001 30 11.6% 61 19.7% .011
10. Hearing mumbling or talking 16 5.8% 79 26.8% <.001 26 10.0% 69 22.3% <.001
11. Thoughts being said out loud 12 4.4% 54 18.3% <.001 20 7.7% 46 14.9% .008
12. “going crazy” 17 6.2% 86 29.2% <.001 28 10.8% 75 24.3% <.001
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Note: Fisher’s exact tests were used to compare endorsement of symptoms across low and high SIQ groups, and across lifetime attempt and no attempt groups; endorsements were defined as respondents somewhat (rated “5”) or definitely (rated “6”) agreeing that they had a given experience.

To explore differences between participants who endorsed one or more PRIME items (i.e. rating any item “5” or “6”) versus those who had no PRIME endorsements, the sample was split into PRIME endorsement groups. A total of 301 participants (52.9%) endorsed one or more PRIME symptom (median of 2 endorsements). These groups did not differ on age, race, or ethnicity. Those in the PRIME endorsement group were more likely to be female (χ2 = 4.38, p = .04) and have diagnoses of psychosis (χ2 = 33.62, p < .001), depression (χ2 = 45.88, p < .001), anxiety (χ2 = 25.98, p < .001), and PTSD (χ2 = 17.86, p < .001). Compared to the group with no PRIME endorsements, the PRIME endorsement group also had higher SIQ scores (m = 44.70 vs. m = 23.32; t = −9.78, p <.001) and higher endorsement of lifetime suicide attempts (65.8% vs. 41.4%; χ2 = 33.43, p < .001).

As hypothesized, linear regression results indicated that PRIME score significantly predicted SIQ, controlling for the small effects of both sex and racial minority status (Table 5, Step 1). When the ChIPS diagnostic categories (depression, anxiety, PTSD, and full-threshold psychosis) were added to the model as covariates, higher PRIME scores, female sex, and the presence of a depression diagnosis all significantly predicted higher SIQ scores (Table 5, Step 2). Anxiety, PTSD, and psychosis diagnoses were not significant predictors of SIQ.

Table 5.

Stepwise linear regressions predicting SIQ scores (n = 499)

R2 Beta Statistic df p f2
Step 1 .27 --- F = 62.06 3, 498 < .001 ---
PRIME score 0.43 t = 11.05 495 < .001 0.25
Sex (0- female, 1- male) −0.26 t = −6.67 495 < .001 0.09
Minority status (0- Caucasian, 1- racial minority) −0.08 t = −2.00 495 < .05 0.01
Step 2 .42 F = 51.55 7, 498 < .001 ---
PRIME score 0.29 t = 7.19 491 < .001 0.11
Sex −0.15 t = −4.21 491 < .001 0.04
Minority status −0.04 t = −1.09 491 .279 <0.01
Depression Diagnosis 0.40 t = 10.10 491 <.001 0.21
Anxiety Diagnosis 0.06 t = 1.49 491 .137 <0.01
PTSD Diagnosis 0.02 t = 0.47 491 .636 <0.01
Psychosis Diagnosis 0.03 t = 0.71 491 .480 <0.01
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Note: SIQ- Suicidal Ideation Questionnaire Jr.

Finally, logistic regression was used to explore the predictive value of PRIME score on the lifetime suicide attempt outcome (0 = no attempt, 1 = one or more lifetime attempt). The model was statistically significant, χ2 (1) = 30.06, p < .001, and explained 7% (Nagelkerke R2) of the variance in suicide attempt. Although PRIME score was a statistically significant predictor of suicide attempt (B = .03, p < .001), the odds ratio indicates a very small effect (OR = 1.03).

Discussion

The purpose of this study was to examine whether psychosis-spectrum symptoms were related to STB in a sample of psychiatrically hospitalized adolescents. Significant correlations were found between STB variables (SI in the past month and lifetime attempt) and all other variables of interest. This indicates that STB is associated with symptoms of psychosis-risk, depression, anxiety, PTSD, and full-threshold psychosis. Correlational patterns among measured variables demonstrated stronger associations with SI than lifetime suicide attempt, which may be reflective of the fact that SI is more common.

The PRIME was positively correlated with all other variables, indicating that in addition to measuring psychosis-risk, the PRIME likely captures transdiagnostic experiences that are relatively common among youth with several mental health disorders and STB. Exploring item-level correlations demonstrated that several of the PRIME items (i.e., thoughts about others planning to hurt them, hearing mumbling or talking, and feeling like they are “going crazy”) were moderately correlated with SI, suggesting that these particular experiences may be more strongly linked to suicide risk and important to consider within the context of treatment.

Similarly, 9 of the 12 PRIME items were more commonly endorsed by youth with high, compared to low, levels of STB. These items were: feeling as though odd or unusual things were going on, being superstitious, confusion about what is real, belief in mind-reading, paranoid thoughts, mind-tricks and hallucination-like experiences, and a feeling of “going crazy”. Some of these items appear to be more specific to psychosis experiences (e.g., hallucinations, paranoia) whereas other symptoms may be more general experiences of losing control common to multiple psychiatric disorders (e.g., feeling like something is odd or different, experiencing mind tricks, feelings of “going crazy”).

Item-level correlations and findings from our endorsement comparisons across STB groups are consistent with prior research indicating that perceptual abnormalities and persecutory ideas may be more strongly related to STB than other types of positive symptoms (Capra et al., 2015; Grano et al., 2015). Our results also suggest that confusing or disorienting experiences (e.g., confusion about reality, experiencing mind tricks, believing that you are “going crazy”) are also linked to higher risk for SI and suicide attempts in this acute sample. Items linked to more magical or grandiose experiences (e.g., believing one can predict the future or has natural or supernatural gifts) were not significantly associated with the STB variables.

Regression findings indicated that psychosis-risk symptoms, as assessed by the PRIME, predict SI above and beyond the effects of a depressive disorder diagnosis (and biological sex). Although more research is needed to investigate how specific types of psychosis-risk symptoms influence STB (or vice versa), our results indicate a need to explore the interaction of these clinical experiences to improve individualized treatment. This finding suggests that assessing PRIME symptoms may help clinicians mitigate STB risk by identifying these symptoms, attending to these experiences in treatment as needed to reduce distress and/or symptom progression, and monitoring changes in symptoms and their relation to STB over time.

Although logistic regression results indicated that PRIME score only demonstrated a small effect on lifetime suicide attempt, this effect was significant. Given evidence that previous suicide attempt is one of the strongest predictors of future attempts (Miranda et al., 2008), characteristics linked to attempts should be thoroughly explored. Other findings from this study, such as the significantly elevated rates of attempts among individuals who endorsed one or more PRIME symptoms, also support the need to further explore the incremental value of the PRIME and similar tools for predicting suicide risk in teens.

Interestingly, although only 62 participants (11%) met full criteria for a psychotic disorder, over half the sample (n = 301, 53%) endorsed at least one psychosis-risk symptom. This suggests that many youth who are experiencing psychosis-spectrum symptoms that may confer risk for STB may not be readily identified by clinicians as having these risk symptoms based on results from a diagnostic interview. Further, of these 301 youth, 44 (8% of the full sample) did not meet criteria for a depressive disorder or psychosis based on self-report. In the absence of a major mood or psychosis diagnosis, youth with subthreshold psychosis symptoms may not be identified as being at risk for STB but still need to be screened for STB and monitored over time.

Limitations

This study focused on depressive disorders as the primary driving force behind STB. Although we also examined anxiety, PTSD, and psychotic disorders that are linked to increased risk for STB (Bentley et al., 2016), there are other psychiatric disorders associated with STB that we were unable to consider. For example, substance use disorders and bipolar disorder were not examined due to the low rate of substance abuse and manic symptoms reported in this sample by the adolescent on the ChIPS.

Another limitation was use of a single informant, the adolescent, to derive diagnoses. This data was part of standard clinical care and collateral information was not available to inform diagnoses in a systematic manner, so it was not reported here. Several mental health diagnoses, including psychosis and bipolar disorder, are characterized by lack of insight and impairment in judgment. Obtaining caregiver information about the adolescents’ mental health would improve our understanding of co-morbid concerns and symptoms relevant to suicide risk.

This study used the PRIME to screen for psychosis-risk symptoms, however, there were no follow-up interviews to determine if the adolescents would meet criteria for a psychosis-risk syndrome. It is possible that psychopathology distinct from psychosis-risk could account for some endorsement of PRIME symptoms. For example, PTSD or anxiety related to bullying may reasonably account for an individual stating that they believe someone is planning to hurt them. Similarly, feelings related to panic, OCD, or social anxiety may motivate adolescents to report that something feels unusual, their mind is playing tricks, or they feel like they are going crazy. In fact, the modest correlations observed between the PRIME and both PTSD and anxiety suggest that there may be some overlap across these diagnostic domains. Regardless of how these PRIME endorsements are conceptualized by respondents, they appear to be linked to STB and thus, warrant further exploration.

An additional limitation related to instrumentation is our reliance on self-report to assess STB and psychosis-risk symptoms, while diagnoses were derived via clinical interview. Data collection methods may influence reporting, and the use of uniform methods or multiple formats to assess each construct may facilitate richer data.

We were unable to explore symptom-level risk factors outside of the psychosis-risk domain. An extensive literature suggests that many individual characteristics that are more narrowly focused than broad diagnostic categories may account for STB. Some particularly compelling risk factors include exposure to violence, irritability, hopelessness, self-esteem, isolation, impulsivity, and emotion dysregulation (Frazier et al., 2016; Miranda-Mendizábal et al., 2017). Similarly, we were unable to explore sociodemographic and psychosocial characteristics that have been linked to suicidality among individuals with psychosis-spectrum symptoms, including sexual orientation, stigma, and school mobility (Devylder et al., 2015). While it was not possible to look at interactions between all of these characteristics within this study, continued research exploring these factors may improve our understanding of suicide risk and support efforts to predict and prevent future suicidal behaviors.

The current study was cross-sectional. It will be important to extend this research to measure longitudinal outcomes related to psychosis-spectrum symptoms and suicide risk. Despite our inability to explore long-term outcomes, SI is, in and of itself, distressing and warrants attention. Understanding experiences linked to current distress related to STB is critical for improving treatment.

Conclusion

Overall, results indicate that psychosis-risk symptoms were associated with STB and depressive disorders among adolescents psychiatrically hospitalized due to acute safety concerns. Furthermore, psychosis-spectrum symptoms statistically predicted the severity/extent of SI, beyond the effects of depression. Examination of psychosis-spectrum symptoms provided important information regarding patients’ risk for STB. These findings suggest that psychosis-spectrum symptoms may be clinically important for assessing suicide risk within and outside of the context of treatment for depressive disorders. Given that less than one third of patients disclose ideation before making a suicide attempt (Poulin et al., 2014), identifying multiple distinct predictive factors, such as psychosis-risk symptoms, rather than relying on adolescent disclosure of SI, is critical for better assessment and treatment of suicidal youth.

Acknowledgement

We would like to extend thanks to NIMH grant T32MH019927. We would also like to thank the adolescents on the inpatient unit where data was collected, for sharing their personal experiences.

Grant support. The first author is supported by a grant from the National Institute of Mental Health (T32 MH019927). The content is solely the responsibility of the authors and does not reflect the views of the National Institute of Mental Health. The funding body was not involved in the design of the study, the collection, analysis, and interpretation of data, or in writing the manuscript.

Footnotes

Author Disclosures. The authors do not have any conflicts of interest, including financial relationships, to disclose.

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