Bipolar and Schizophrenia May be Key Indicators of Suicide Risk, According to Study

Background:

Suicide is a growing public health crisis in the United States, especially for people experiencing severe mental illness (SMI), specifically bipolar disorder and schizophrenia-spectrum disorders. Approximately 10% of people who visit an emergency department (ED) each year have experienced suicidality in the two weeks before their visit, and over 40% of patients who died by suicide had visited an ED in the year leading up to their death. Individuals with SMI-related symptoms, such as psychosis, are more likely to have repeated ED visits over six months than those who do not experience SMI-related symptoms. Despite this elevated risk, individuals with SMI are often left out of the suicide prevention research.

This study examined differences in suicide outcomes among individuals with bipolar disorder or schizophrenia compared to those with other psychiatric diagnoses (other psychotic disorders; e.g., unipolar depression, anxiety disorder, substance use disorder, eating disorder, attention deficit disorder, other) following discharge from the ED. The researchers also conducted a secondary analysis to determine the effectiveness of the CLASP (Coping Long Term with Active Suicide Program) intervention in reducing suicidal behaviors. CLASP is a comprehensive, suicide prevention intervention that integrates case management, individual psychotherapy, and optional involvement of a significant other. It has been adapted for EDs and includes seven follow-ups with the patient and four with the identified significant other, with the aim of reducing suicide risk by addressing risk factors, setting goals, creating safety plans, and encouraging treatment engagement.

“Some ways we can enhance and personalize suicide treatment for people with schizophrenia could be by addressing specific stressors that people with schizophrenia face at higher rates than other groups, such as stigma or social isolation,” says Dr. Ana Rabasco, lead author and a postdoctoral fellow at Butler Hospital’s Research Program. “Ultimately, we hope that the clinical implications from this work will help to reduce the high rates of suicide among people with serious mental illness.”

“This study fills a critical gap in suicide prevention research by focusing on individuals with serious mental illnesses, who are often excluded from these types of studies despite facing significantly elevated risk,” says Dr. Sarah Arias, Assistant Professor at Butler Hospital and Brown University.

This year-long, nationwide study evaluated 1,235 adults who visited eight diverse EDs across seven U.S. states for recent suicide attempts or active suicidal ideation. All participants self-reported a diagnosis of bipolar disorder, schizophrenia spectrum disorder, or other psychotic disorders. The study was conducted in three sequential phases across participating ED sites. In Phase 1, patients received treatment as usual with no additional suicide prevention measures. Phase 2 introduced universal suicide screening, identifying individuals at risk. Phase 3 combined universal and secondary suicide risk screening, a safety plan and resources by nursing staff, and the delivery of the CLASP intervention. Across each phase, all patients were followed for 52 weeks after their ED visit, with follow-up calls occurring at weeks 6, 12, 24, 36, and 52, and medical record reviews at 6 and 12 months. A total of 448 participants were enrolled in the CLASP intervention phase of the study.

Key Takeaways:

• Individuals with bipolar disorder and schizophrenia reported higher rates of lifetime suicide attempts compared to those with other psychiatric disorders.
• Individuals with bipolar disorder and schizophrenia who did not receive the CLASP intervention were more likely to experience suicide-related events and did so more quickly after being seen in the ED for suicidality, compared to those with other psychiatric disorders.
• Among participants with bipolar disorders, those who received the CLASP intervention had a significantly longer time to suicide outcome and lower overall risk compared to those in the non-intervention phases, demonstrating CLASP’s effectiveness for this subgroup.
• Participants with schizophrenia showed no significant improvement in time to or rate of suicide outcomes when receiving CLASP, suggesting that individuals with SSD may require more intensive or tailored interventions.

The study underscores that psychiatric diagnoses, particularly schizophrenia and bipolar disorder, could be a key indicator of suicide risk. In addition, it reinforces the need for improved risk assessment tools in emergency settings and interventions to reduce the heightened risk of suicide following discharge.

“It was encouraging to see that tailored interventions like CLASP can meaningfully reduce suicide risk for individuals with bipolar disorder,” explains Dr. Arias. “However, the lack of improvement for those with schizophrenia suggests that more work is needed to further examine how to enhance the effectiveness of interventions like CLASP using diagnosis-specific strategies. Findings like these are such an important step for informing suicide risk assessment and post-discharge care protocols in emergency settings.”

This study was published in the Journal of Affective Disorders and conducted by Drs. Ana Rabasco (First author), Sarah Arias, Madeline B. Benz, Ivan Miller, and Brandon A. Gaudiano, from Warren Alpert Medical School of Brown University and Butler Hospital, Drs. Lauren M. Weinstock and Zachary J. Kunicki from Warren Alpert Medical School of Brown University, Dr. Edwin D. Boudreaux from the University of Massachusetts Medical School, and Dr. Carlos A. Camargo Jr. from Massachusetts General Hospital and Harvard Medical School.

Read the article here

This Article:

Rabasco, A., Arias, S., Benz, M. B., Weinstock, L. M., Miller, I., Boudreaux, E. D., Camargo, C. A., Jr, Kunicki, Z. J., & Gaudiano, B. A. (2024). Longitudinal risk of suicide outcomes in people with severe mental illness following an emergency department visit and the effects of suicide prevention treatment. Journal of affective disorders, 347, 477–485. https://doi.org/10.1016/j.jad.2023.12.019

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