Risk Factors for Deliberate Self-harm and Suicide Among Adolescents and Young Adults With First-Episode Psychosis

Aubrey M. Moe; Elyse Llamocca; Heather M. Wastler; Danielle L. Steelesmith; Guy Brock; Jeffrey A. Bridge; Cynthia A. Fontanella


Schizophr Bull. 2022;48(2):414-424. 

In This Article

Abstract and Introduction


Little is known about the risk factors for deliberate self-harm (DSH) and suicide among adolescents and young adults with first episode psychosis (FEP) and the longitudinal course of DSH following the initial onset of illness. This study identifies risk factors for DSH and suicide death among Medicaid-covered adolescents and young adults with FEP along with the periods of greatest risk for DSH after diagnosis. A retrospective longitudinal cohort analysis was performed using Medicaid claims data merged with death certificate data for 19 422 adolescents and young adults (aged 15–24 years) diagnosed with the onset of FEP between 2010 and 2017. DSH per 1000 person-years and standardized mortality rates for suicide were determined. Hazard ratios of DSH and suicide were estimated by Cox proportional hazard models. During follow-up, 2148 (11.1%) individuals had at least one self-harm event and 22 (0.1%) died by suicide. The hazards of DSH were significantly higher for those with a previous DSH, suicidal ideation, child abuse and neglect, comorbid medical and psychiatric diagnoses, and prior mental health care. The median follow-up time for those who had DSH was 208.0 days (SD: 526.5 days) in adolescents and 108.0 days (SD: 340.0 days) in young adults. Risk of DSH was highest in the first 3 months following FEP. Individuals with FEP are at high risk for self-harm and suicidal behavior, and recognition of who among these individuals and when following illness onset they are at greatest risk may guide more precise clinical recognition and intervention.


Psychotic disorders are serious illnesses that emerge during the youth and young adult years, often causing a significant functional impairment[1] and illness-related burden.[2] Individuals with psychosis are at elevated risk for early mortality, dying an estimated 20 years earlier than general-population peers.[3] Suicide is a major contributor to this early mortality; suicide rates in psychosis are approximately 12 times greater than in the general population.[4] An estimated 25–50% of individuals with psychosis attempt suicide during the course of illness,[5] with 5–10% dying by suicide.[6] As suicide is also the second leading cause of death in the United States among young people ages 15–24[7] understanding risk factors for suicide among youth with psychosis is particularly important.

Suicide risk for individuals with psychosis is greatest among young adults[8,9] early in the course of illness,[10,11] with recent data suggesting that suicide is the leading cause of death in the five years following diagnosis[12] and 8–10% of individuals with first-episode psychosis (FEP) attempt suicide during the initial years of treatment.[13,14] Though most existing suicide research has included individuals with more chronic psychosis,[15,16] risk factors for individuals with FEP have been identified (e.g., male sex, depression, substance use, previous suicide attempts).[17,18] As rates of suicide and suicide attempts are elevated among youth with psychosis[17] effective strategies for identifying and addressing risk may benefit from further examination of a continuum of suicidal behavior, including deliberate self-harm (DSH). DSH describes an act of non-fatal self-poisoning or self-injury irrespective of suicidal intent[19] and thus includes non-suicidal self-injury (NSSI) without the intent to die[20] and suicide attempts.[21] DSH is a risk-factor for subsequent suicide[22] and thus examining DSH in a population at elevated risk (i.e., youth with psychosis) may improve intervention and prevention. DSH is a strong predictor of suicide among people with psychosis over the course of illness,[23] and studies indicate that approximately 11% of individuals with FEP engage in DSH.[24,25] Though risk factors for DSH among people with psychosis have been identified (e.g., previous history of self-harm, substance abuse, depressed mood),[26] the course of DSH in the period of time following an initial psychotic disorder diagnosis remains unclear.

Additionally, there is considerable clinical heterogeneity among individuals with psychosis[27] that can hinder the identification of individual risk for DSH and suicide. Notably, the typical age of initial psychosis-onset spans broadly from the adolescent years to the late 20s, leading to significant developmental variation among FEP individuals. Recent attention has been given to the relevance of "emerging adulthood"[28]—an early adulthood developmental phase characterized by transitions and uncertainty—and how the unique developmental tasks and challenges of this phase influence clinical presentation and inform treatment approaches for individuals with FEP.[29,30] Relatedly, specific investigations of how developmental phase when illness begins may influence risk for DSH and suicide are relevant but relatively unexplored.

In summary, longitudinal investigations of who is at greatest risk when will provide a more refined understanding of risk factors among individuals with FEP, allowing for more precise identification and improved clinical management of DSH and suicide. Thus, the present study investigates the emergence of DSH and suicide following an initial diagnosis of psychosis among a population-based sample of adolescents and young adult FEP patients. In addition to assessing known risk factors for DSH and suicide among youth[31] and in psychosis,[26] we extended prior research by assessing developmental stage at the time of diagnosis (i.e., adolescent versus young adult) to determine its influence on risk for DSH and suicide. Given the elevated rates of self-harm and suicide among youth in general, observed rates of DSH and suicide among FEP individuals were also compared to general population controls. Collectively, this approach allowed for a more refined investigation of when and which individuals in the early stage of a psychotic disorder are at greatest risk for DSH. Notably, to the best of our knowledge, the current study is the largest investigation of DSH and suicide among youth following an initial psychosis diagnosis.