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Self-harm in first-episode psychosis

  • Samuel B. Harvey (a1), Kimberlie Dean (a1), Craig Morgan (a1), Elizabeth Walsh (a1), Arsime Demjaha (a1), Paola Dazzan (a1), Kevin Morgan (a1), Tuhina Lloyd (a2), Paul Fearon (a1), Peter B. Jones (a3) and Robin M. Murray (a4)...
Abstract
Background

Little is known about self-harm occurring during the period of untreated first-episode psychosis.

Aims

To establish the prevalence, nature, motivation and risk factors for self-harm occurring during the untreated phase of first-episode psychosis.

Method

As part of the æSOP (Aetiology and Ethnicity in Schizophrenia and Other Psychoses) study, episodes of self-harm were identified among all incident cases of psychosis presenting to services in south-east London and Nottingham over a 2-year period.

Results

Of the 496 participants, 56 (11.3%) had engaged in self-harm between the onset of psychotic symptoms and first presentation to services. The independent correlates of self-harm were: male gender, belonging to social class I/II, depression and a prolonged period of untreated psychosis. Increased insight was also associated with risk of self-harm.

Conclusions

Self-harm is common during the pre-treatment phase of first-episode psychosis. A unique set of fixed and malleable risk factors appear to operate in those with first-episode psychosis. Reducing treatment delay and modifying disease attitudes may be key targets for suicide prevention.

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Copyright
Corresponding author
Dr Samuel B. Harvey, Department of Psychological Medicine, Institute of Psychiatry, King's College London, Weston Education Centre, 10 Cutcombe Road, London SE5 9RJ, UK. Email: s.harvey@iop.kcl.ac.uk
Footnotes
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Declaration of interest

None.

Funding detailed in Acknowledgements.

Footnotes
References
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Self-harm in first-episode psychosis

  • Samuel B. Harvey (a1), Kimberlie Dean (a1), Craig Morgan (a1), Elizabeth Walsh (a1), Arsime Demjaha (a1), Paola Dazzan (a1), Kevin Morgan (a1), Tuhina Lloyd (a2), Paul Fearon (a1), Peter B. Jones (a3) and Robin M. Murray (a4)...
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Author's Response

Samuel B Harvey
22 May 2008

We wish to thank Falcane, Carlton, Janigro and Franco for their interest in our recent paper (1). The results they share from their own review of self harm amongst children and adolescents with first episode psychosis are both interesting and concerning. They report nearly a thirdof young patients engaged in self harm immediately prior to their first admission to hospital. While this is significantly higher than the 11% wereported in our study, it is difficult to make direct comparisons without knowing more about the comparability of the two services and populations. It should also be noted that our study included all cases presenting to any mental health service, while their study only included admissions, thus focusing on a potentially higher risk group. Despite this, their results did prompt us to re-examine the effect of age within our data. Aswe initially reported, young age did not seem to confer any increased riskof self harm in our sample. Our sample included 44 adolescents aged between 16 and 18 years of age. Of these, six (13.6%) engaged in some form of self harm during the pre-treatment period of psychosis. We were not able to determine whether adolescents with first episode psychosis presented with a different range of risk factors for self harm.

Yours sincerely

Dr S B Harvey

References

1. Harvey SB, Dean K, Morgan C, Walsh E, Demjaha A, Dazzan P, et al. Self-harm in first-episode psychosis. Br J Psychiatry 2008;192(3):178-84.

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Suicidality in Children and adolescents with first episode psychosis

Tatiana Falcone, Child Psychiatrist
23 April 2008

Dear Editor

We will like to thank Dr Harvey and colleagues for bringing attentionto the frequency of self harm during the first episode psychosis. Our datawhich we are submitting for publication indicates an even greater concern in this population. Retrospective review of all psychotic patients admitted to a child and adolescent psychiatry unit from 2003-2006. Out of 1500 cases reviewed, 102 patients below the age of 18 were identified withfirst onset psychosis between the ages of 8 years old and 18 years old they carried the following diagnosis Psychosis NOS, schizophreniform disorder, schizoid personality disorder. In our sample 32% of the patientshad a recent history of self harm (suicidal attempt) just prior to the admission for their initial psychosis. Contrary to Dr Harvey et al we we did not found male gender was associated with higher incidence of self harm and violence against others, but it was associated with high severityon the attempt. Interestingly enough 28.43 % of our group accessed the legal system first and later the mental health system, secondary to violence against others. Poor insight of psychotic patients may predisposethem to make wrong choices and end up in the legal system before entering the mental health arena. Previous non-psychotic psychiatric history was reported by 74 patients. The most frequent commorbidity was ADHD followed by, Intermittent Explosive Disorder, separation anxiety, Oppositional defiant disorder, and emotional instability manifested by depression, explosiveness, or violence against self or others. Labile affect is a key symptom when suspecting an organic brain disorder, as is poor attention and motor abnormalities. When psychosis presents earlier in life are theremore physiologic factors at play than later in the 3rd or 4th decade? Future research is needed to detect any differences what triggers psychosis in childhood versus adult cases. Observation that children who are often more disinhibited than adults is consistent with this higher percentage and particularly from an inpatient service. The immature brain continues to develop into young adulthood, when myelination, pruning, and other neuronal maturation remain incomplete. It is understandable then whythere maybe a difference in rates of self harm with even higher numbers inchildren and adolescents. Male gender, negative symptoms and persecutory delusions are clearly linked to greater treatment delay; this could also explain the increased rate in males. The quality of the initial treatment intervention for the first psychotic episode is critical. Each progressivepsychotic episode impacts brain development, social and family relationships. Investing efforts in improving the approach to treatment ofthe first psychotic episode may improve the eventual life outcome. There should be a low threshold for hospitalization of psychotic children, sincethe suicide attempt was so high in this population. This further supports the importance of a strong psychosocial plan and close follow up for both patient and family. Perhaps the most critical piece in the treatment of psychotic children is engaging the family early enough to enhance their understanding of the role of medication and close follow up and the consequences of inadequate or partial treatment.

Tatiana Falcone MDErin Carlton MDcDamir Janigro PhDKathleen Franco MD
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