Risque suicidaire lors du premier épisode psychotique

Abstract

Suicide is the most common cause of early mortality during the course of schizophrenia. The most recent data in the literature show that the risk of suicide is greater at the beginning of the course of schizophrenia. The risk of suicide during the first year is 12 times higher than that of the general population. Specifically, 2-5 % of people with first-episode psychosis will die by suicide in long-term follow-up studies. Regarding the presence of suicidal ideation that are a major factor of suicide in subjects suffering from psychotic disorders, their prevalence remains extremely worrying, since they are substantial and persistent. Consequently, suicide prevention should be a major and immediate objective in the management of the disease, as soon as the diagnosis has been made. Suicidal ideas are a potential precursor to the evolution towards acting out. Their evolution must be specifically assessed in each individual. Indeed, in the influential Danish OPUS study the authors reported heterogeneity in suicidal ideations in young patients with first episode of psychosis and identified three prototypical trajectories of suicidal ideations over the first 2 years in treatment. Particularly, nearly 40 % of patients with first-episode psychosis have persisting suicidal thoughts over the initial treatment period. Consequently, the authors recommend routine screening for suicidality when providing treatment for first-episode psychosis. The main risk factors for suicidal behavior in patients with a first episode are classical ones. Previous research has suggested that, in addition to young age and early course of illness, other important clinical predictors of suicide in individuals with schizophrenia include presence of depressive symptoms and misuse of substances, which are very common conditions in these patients. Lack of social support, loss, rejection, stigma, insight, fear of future losses, are all negative experiences experienced by patients starting a psychotic disorder. Negative connotations of the diagnosis of psychotic disorders, feelings of being trapped that can be directly related to feeling a burden can lead to suicidal crisis in these individuals. Then, the painful experience of the disease and its consequences associated with self-stigmatization and social rejection may induce hopelessness and suicidal thoughts in these young subjects. The quality of the insight and its evolution may worsen the depressive experience and suicidal risk and they therefore also require to be measured regularly. Thus, the clinical evaluation of patients entering psychosis should focus on those dimensions that are not directly related to the psychotic symptoms. At the precise evaluation of each patient must be associated personalized measures of prevention. It is now proposed that prevention strategies targeting suicidal behaviour in first-episode psychosis should not be universal. On a more general level, evidence-based data to support specific care programs are still lacking, and only few data are in favor of integrated care in patients presenting with first episode. It should also be kept in mind that the risk of suicide is extraordinarily high for all psychiatric patients during the first few months after discharge from hospital. This should encourage caregivers to offer intensive follow-up programs to their patients and to embrace recontact and follow-up initiatives using the tools of e-health. Last, programs for the early detection of schizophrenia seem to be beneficial for the prevention of suicide in these subjects.