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Suicidal Ideation and Behaviour in Patients with Persecutory Delusions: Prevalence, Symptom Associations, and Psychological Correlates

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Suicidal Ideation and Behaviour in Patients with Persecutory Delusions: Prevalence, Symptom Associations, and Psychological Correlates Comprehensive Psychiatry 93 (2019) 41–47 Contents lists available at ScienceDirect Comprehensive Psychiatry journal homepage: www.elsevier.com/locate/comppsych Suicidal ideation and behaviour in patients with persecutory delusions: Prevalence, symptom associations, and psychological correlates Daniel Freeman a,b,⁎, Emily Bold a, Eleanor Chadwick a, Kathryn M. Taylor a, Nicola Collett a,b, Rowan Diamond a,b, Emma Černis a,b, Jessica C. Bird a,b,LouiseIshama,b, Ava Forkert a,b, Lydia Carr a,ChiaraCausiera,FelicityWaitea,b a Department of Psychiatry, University of Oxford, UK b Oxford Health NHS Foundation Trust, UK article info abstract Keywords: Background: To determine the prevalence of suicidal ideation and behaviour - and their correlates - in patients Suicide with persecutory delusions. Persecutory delusions Methods: 110 patients with persecutory delusions in the context of non-affective psychosis were assessed for sui- Schizophrenia cidal thoughts and behaviours over the past month. Symptom and psychological assessments were also com- Depression pleted. Results: The severity of suicidal ideation was: no suicidal ideation (n = 26, 23.6%); wish to be dead (n = 21, 19.1%); nonspecific active suicidal thoughts (n = 14, 12.7%); suicidal thoughts with methods but no intent (n = 29, 26.4%); suicidal thoughts with intent but no specific plan (n = 13, 11.8%); and suicidal intent with plan (n = 7, 6.4%). In the past month, five patients (4.5%) had made an actual, interrupted, or aborted suicide attempt. The severity of suicidal ideation was associated with higher levels of depression, paranoia, hallucinations, anger, insomnia, negative beliefs about the self and others, pessimism, worry, and delusion safety-seeking behaviours and lower levels of psychological well-being and reward responsiveness. Severity of ideation was not associated with cannabis or alcohol use, working memory, pain, or meaningful activity levels. Conclusions: Patients with persecutory delusions are typically in a severe state of psychological stress, and at risk of suicide, as indicated by very high levels of suicidal ideation. This exploratory study also identifies correlates of suicidal ideation that could be investigated in causal research designs. © 2019 The Author(s). Published by Elsevier Inc. This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/). 1. Introduction [3]. In this paper, we set out to describe the prevalence of suicidal idea- tion and behaviours specifically in patients experiencing persecutory Suicidal ideation, thinking about killing oneself, is an obvious marker delusions in the context of schizophrenia and related disorders. of high psychological stress. Ideally, the presence of such thoughts in pa- Suicidal ideation and behaviour have been studied in relation to the tients attending mental health services would be an impetus for con- diagnosis of schizophrenia. People with schizophrenia have 12.9 times certed efforts to help reduce the distress. Typically, the presence of the risk of dying from suicide than other members of the general popu- suicidal thoughts is most often considered within risk assessment, lation [4]. Approximately 5% of patients with schizophrenia die by sui- when considering whether a person will attempt to kill themselves. cide [5], with almost half of these deaths occurring within the first five There is a chain – sometimes termed ‘ideation to action’ - of suicidal years of diagnosis [6]. In a meta-analysis, Hubers and colleagues [7] thoughts, developing a plan, intending to act, making an attempt, and found that suicidal ideation in patients with schizophrenia raised the making a lethal attempt [1,2]. The lifetime general population preva- risk of death by suicide six-fold compared with patients without suicidal lence rate of suicidal ideation is 9% and for suicide attempts it is 3% ideation. The link between suicidal ideation and suicide may even be [3]. Although most people who have suicidal ideation do not make a sui- stronger in schizophrenia than in mood disorders [8]. There are surpris- cide attempt, suicidal ideation is still a key link in the chain: 29% of indi- ingly few estimates, but approximately one quarter of patients with viduals who have had suicidal ideation make a suicide attempt and 56% schizophrenia have current suicidal ideation [9,10]. of individuals with suicidal ideation who had a plan make an attempt The diagnosis of schizophrenia comprises multiple independent psychotic experiences [11]. Our view is that advances in understanding and treatment will follow from a focussed approach on each of the dif- ⁎ Corresponding author at: Oxford Cognitive Approaches to Psychosis, University Department of Psychiatry, University of Oxford, Warneford Hospital, Oxford OX3 7JX, UK. ferent psychotic experiences. Our exemplar has been a programme of E-mail address: [email protected] (D. Freeman). work developing the theoretical understanding of persecutory https://doi.org/10.1016/j.comppsych.2019.07.001 0010-440X/© 2019 The Author(s). Published by Elsevier Inc. This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/). 42 D. Freeman et al. / Comprehensive Psychiatry 93 (2019) 41–47 delusions and using that knowledge to develop a much more efficacious spectrum psychosis (non-affective psychosis). The exclusion criteria treatment [12,13]. The practical implication is that we recruit and treat were: current receipt of another psychological therapy; insufficient patients who have a current persecutory delusion, one of the most com- comprehension of English; primary diagnosis of alcohol, or drug, or per- mon presentations in schizophrenia. These individuals have other psy- sonality disorders; being treated in forensic services; diagnosis of or- chotic experiences, such as hallucinations, but our clinical focus is on ganic syndrome; or a significant learning disability. The patients were reducing the paranoia, enhancing psychological well-being, and in- the first cohort entered into the trial. The trial had received approval creasing meaningful activity. We wished to determine levels of suicidal from an NHS Research Ethics Committee, and written informed consent ideation and behaviours in this group as indicators of both acute psy- was obtained for all participants. chological distress and risk of suicide. Patients experiencing persecutory delusions in the context of schizophrenia are likely to have high levels of 2.2. Assessments suicidal ideation and behaviours: rates of current suicidal ideation have been found to be greater for patients with positive symptoms [14]. 2.2.1. Suicidal ideation and behaviours Paranoid thinking specifically has been found to be associated with Columbia-Suicide Severity Rating Scale (C-SSRS)[23]. Draft guidance suicidal ideation. In a UK epidemiological study with over seven thou- from the United States Food and Drug Administration [26] has recom- sand adults, thinking that a group of people is plotting to cause you se- mended the C-SSRS for measuring and classifying suicidal ideation rious harm or injury was associated with 27 times greater odds of also and behaviour in clinical trials. This interviewer-rated measure from a reporting suicidal ideation in the past year and 17 times greater odds semi-structured interview assesses four suicide constructs for the of ever having made a suicide attempt [15]. In a network analysis with time-period of the last month. First, the severity of the highest level of 1685 adolescents, suicidal ideation occurring at some point over the life- suicidal ideation experienced by the patient is rated on an ordinal time was connected to hearing voices, persecutory ideation, and social 6-point scale from 0 (none) to 5 (suicidal intent with plan). A rating of anxiety [16]. In a cross-sectional structural equation model with 124 pa- 1 concerns a wish to be dead or wish to go to sleep and not wake up. In- tients with schizophrenia, anxiety and depression connected persecu- dividuals have non-specific thoughts about no longer wanting to be tory ideation and hallucinations with suicidal ideation and plans [17]. alive or sentient, and may say that they do not want to endure another And in a study of 78 patients with schizophrenia, persecutory ideation day. For a rating of 2 (Non-specific active suicidal thoughts), individuals was particularly linked to feelings of defeat and entrapment and suicidal are considering the possibility of ending their own life, but without par- ideation [18]. ticular methods in mind. They are often considering whether or not they Defeat and entrapment are at the heart of the psychological under- could or would take their own life. A rating of 3 concerns active suicidal standing of suicide [19,20], although there is no single cause, with psy- ideation with at least one method considered without intent to act. In- chiatric disorder, hopelessness, psychosocial crisis, and impulsivity all dividuals often have several possible methods in mind, and may be de- implicated [21]. In a study with 21 patients with persecutory delusions, liberating the costs and benefits of each method or whether they are suicidal ideation was associated with low self-esteem, negative social capable of carrying out each method. A rating of 4 concerns active sui- comparison, low self-compassion, negative beliefs about the self, de- cidal ideation with some intent to act (and a method), without a specific pression, and fears about madness [22]. We wished
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