Reassessing the Long-term Risk of Suicide After a First Episode of Psychosis | Psychiatry | JAMA Psychiatry | JAMA Network
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    1 Comment for this article
    Increased suicide rates in psychosis are likely to be confounded by heavy smoking
    Henri-Jean Aubin, M.D., Mh.D. | Hopital Paul Brousse,
    Dutta et al. have recently shown that after a first episode of psychosis, suicide occurred approximately 12 times more than expected based on rates from the general population, and that the risk remained at a high level after a decade: almost 4 times higher than in the general population.1 We would like to point out that addictive comorbidity and most importantly tobacco smoking may modify this relationship. The prevalence of smoking is above 60% among individuals with schizophrenia; they have a nearly six-fold increased likelihood to be current smokers.2 Schizophrenic smokers have higher rates of heavy smoking and high nicotine dependence, compared with smokers in the general population.2 They also show higher plasma concentration of nicotine and its main metabolite, cotinine, than their non-schizophrenic counterparts,3 even after smoking a single cigarette4 demonstrating high exposure to constituents of tobacco smoking. Cigarette smoking has been shown to be dose-dependently associated with increased rates of suicides, an association not found with ex-smokers.5 In one study, male smokers of 21+ cigarette per day had a relative risk of suicide of 3.6 compared to never-smokers.6 Thus, high cigarette exposure among psychotic individuals along with the high suicide rate among heavy smokers may be a confounder of the elevated suicide rate found by Dutta et al.1 Because of the strong association between suicide risk and smoking, research on suicide should take into account this major confounder. Thus, we can hypothesize that the increased suicide risk in the Dutta et al. study would have been lower if the authors had been able to adjust for smoking prevalence and intensity. It is likely that systematic interventions promoting smoking cessation in schizophrenic individuals would decrease their suicide rates.7
    1. Dutta R, Murray RM, Hotopf M, Allardyce J, Jones PB, Boydell J. Reassessing the Long-term Risk of Suicide After a First Episode of Psychosis. Arch Gen Psychiatry. Dec 2010;67(12):1230-1237.
    2. de Leon J, Diaz FJ. A meta-analysis of worldwide studies demonstrates an association between schizophrenia and tobacco smoking behaviors. Schizophr Res. Jul 15 2005;76(2-3):135-157.
    3. Williams JM, Ziedonis DM, Abanyie F, Foulds J, Benowitz NL. Increased nicotine and continine levels in smokers with schizophrenia and schizoaffective disorder is not a metabolic effect. Schizophr Res. Nov 15 2005;79(2-3):323-335.
    4. Williams JM, Gandhi KK, Lu SE, et al. Higher nicotine levels in schizophrenia compared with controls after smoking a single cigarette. Nicotine Tob Res. Aug 2010;12(8):855-859.
    5. Hughes JR. Smoking and suicide: a brief overview. Drug Alcohol Depend. Dec 1 2008;98(3):169-178.
    6. Miller M, Hemenway D, Bell NS, Yore MM, Amoroso PJ. Cigarette smoking and suicide: A prospective study of 300,000 male active-duty army soldiers. American Journal of Epidemiology. 2000;151(11):1060-1063.
    7. Ratschen E, Britton J, McNeill A. The smoking culture in psychiatry: time for change. Br J Psychiatry. Jan 2011;198:6-7.

    Conflict of Interest: • Dr Aubin has received sponsorship to attend scientific meetings, speaker honoraria and consultancy fees from Pfizer, McNeil, GlaxoSmithKline, Sanofi-Aventis, Lundbeck and Merck-Sereno. • Dr Berlin has received in the last 3 years sponsorship to attend scientific meetings, speaker honoraria and consultancy fees from Pfizer Ltd. • Dr Reynaud has received in the last 3 years sponsorship to attend scientific meetings, speaker honoraria, funding, and consultancy fees from Merck-Sereno, Shering-Plough, Lundbeck and Bristol-Myers-Squibb.
    Original Article
    December 6, 2010

    Reassessing the Long-term Risk of Suicide After a First Episode of Psychosis

    Author Affiliations

    Author Affiliations: Department of Psychosis Studies (Drs Dutta, Murray, and Boydell) and Department of Psychological Medicine and Psychiatry (Drs Dutta and Hotopf), Institute of Psychiatry, King's College London, London, England; Department of Psychiatry, Maastricht University, Maastricht, the Netherlands (Dr Allardyce); and Department of Psychiatry, University of Cambridge, Cambridge, England (Dr Jones).

    Arch Gen Psychiatry. 2010;67(12):1230-1237. doi:10.1001/archgenpsychiatry.2010.157

    Context  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.

    Design  Retrospective inception cohort.

    Setting  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).

    Participants  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.

    Main Outcome Measure  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.