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

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.