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1 Edinburgh Research Explorer Are people at risk of psychosis also at risk of suicide and selfharm? A systematic review and meta-analysis. Citation for published version: Taylor, PJ, Hutton, P & Wood, L 2015, 'Are people at risk of psychosis also at risk of suicide and self-harm? A systematic review and meta-analysis.' Psychological Medicine, vol. 45, no. 5, pp DOI: /S Digital Object Identifier (DOI): /S Link: Link to publication record in Edinburgh Research Explorer Document Version: Peer reviewed version Published In: Psychological Medicine General rights Copyright for the publications made accessible via the Edinburgh Research Explorer is retained by the author(s) and / or other copyright owners and it is a condition of accessing these publications that users recognise and abide by the legal requirements associated with these rights. Take down policy The University of Edinburgh has made every reasonable effort to ensure that Edinburgh Research Explorer content complies with UK legislation. If you believe that the public display of this file breaches copyright please contact openaccess@ed.ac.uk providing details, and we will remove access to the work immediately and investigate your claim. Download date: 06. Jan. 2019
2 1 Table 1 Characteristics of Included Studies Authors, year & country Pyle in press; UK 1 (also Morrison 2012) Design Sample Source UHR sample Longitudinal EDIE2 N = 288 ( (4.3) Comparison sample UHR measure Outcome measure(s) - CAARMS BDI-II suicidal ideation; CAARMS suicidality; Completed suicide Grano Controlled 2013; Finland 1 cross-sectional Hui 2013; UK Nelson 2013; Australia Welsh & Tiffin, 2013; UK Demjaha 2012; UK Controlled cross-sectional JERI CAMEO N = 66 (45 female); Age M = 15.6 (2.1) N = 60 (29 female); Age M = 20.2 (2.9) Longitudinal PACE N = 416 ( (3.4) Longitudinal FARMS research clinic N = 30 (16 female); Age M = 15.8 (1.4) Longitudinal OASIS N = 122 (52 female); Age M = 23.4 (4.9) N = 137 helpseeking non-uhr (65 female); Age M = 15.2 (2.1) N = 45 healthy controls (21 PROD screening tool CAARMS BDI-II suicidal ideation (Finnish version) BDI-II suicidal ideation 21.4 (3.9) - CAARMS or BPRS Completed suicide - CAARMS Non-validated measure of suicidal ideation & attempts - CAARMS CAARMS suicidality
3 2 DeVylder 2012; USA Fusar-Poli 2012a; Australia & UK Fusar-Poli 2012b; UK Kang 2012; South Korea Palmier-Claus et al., 2012; UK Zimbron 2012; UK Grano 2011; Finland Hutton 2011; UK Raballo 2011; Australia Cross-sectional Longitudinal (self-injury data cross-sectional) COPE research program OASIS & PACE clinic N = 20 (8 female); Age M = 20.7 (3.8) N = 509 (256 female); Age median = 20 Longitudinal OASIS clinic N = 290 (127 female 2 ) Controlled Community cross-sectional N = 15 (13 female); Age M = 16.8 (0.4) Cross-sectional EDIE2; EDIT N = 27 (14 female); Age M = 22.6 (4.4) Controlled CAMEO N = 30 (12 female); cross-sectional Age M = 21.7 (4.2) Controlled cross-sectional JERI N = 43 (28 female); Age M = 14.7 (1.7) Cross-sectional EDIT N = 34 (9 female); Age M = 22.0 (4.8) Cross-sectional PACE clinic N = 223 (128 - SIPS/SOPS Chart review; BDI-I suicidal ideation - CAARMS CAARMS suicidality - CAARMS Completed suicide Group 1: N = 125 CAARMS Korean Non-validated non-clinical translation measure of controls (95 suicidal ideation & attempts 16.9 (0.3); Group 2: N = 46 depressed spectrum disorder ( (0.5) - CAARMS (in past CAARMS N = 30 FEP ( (4.2) N = 37 helpseeking non-uhr (16 female); Age year) CAARMS PROD screening tool suicidality Life-time selfharm details not provided BDI-II suicidal ideation (Finnish version) M = 14.7 (1.9) - CAARMS BDI-II suicidal ideation; Case note audit - CAARMS CAARMS suicidality
4 3 Velthorst 2010; Pan- European Phillips 2009; Australia 3 Preti 2009; Italy Niendam 2008; USA Morrison 2004; UK (Also Morrison 2007) 18.7 (3.1) Longitudinal EPOS project N = 239 ( (5.3) Controlled PACE clinic Group 1: N = 43 (28 cross-sectional 17.6 (3.0); Group 2: N = 44 (27 female); Age M = 18.0 (2.7); Group 3: N = 28 ( (3.7); Group 4: N = 78 (47 female); Controlled longitudinal Controlled longitudinal (self-injury data cross-sectional) Programma 2000 CAPPS project Age M = 17.8 (2.6) N = 81 (24 female); N = 22.3 (3.6) N = 64 (25 female); Age M = ( ) Longitudinal EDIE 1 Monitoring group: N = 23 (4 female); Age Median = SIPS Completed suicide - CAARMS Suicide attempts and self-harm derived from CAARMS interview N = 87 FEP ( (3.8) N = 26 non-clinical controls ( (2.3) BPRS, ERLraos-CL SIPS BPRS suicidality; HONOS suicidality BPRS suicidality - PANSS Completed suicide. Adlard & Yung, Controlled 1997; Australia 1 cross-sectional PACE clinic N = 25 (12 female); Age M = 20.9 Group 1: N = 27 FEP (19 female); Age M = 22.4; Group 2: N = 22 non-clinical BPRS Revised Adolescent Suicide Questionnaire; Adolescent
5 4 controls (11 Health Survey 19.9 Note: 1 Unpublished data obtained; 2 Percentages and reported numbers do not match in paper; 3 Characteristics described separately for four randomized UHR groups at baseline but prevalence combined for meta-analyses; BDI = Beck Depression Inventory, BPRS = Brief Psychiatric Rating Scale, CAARMS = Comprehensive Assessment of At-Risk Mental States, ERIroas-CL = Early Recognition Inventory Retrospective Assessment of Symptoms checklist, HONOS = Health Of the Nation Outcome Scale (Wing 1998), PANSS = Positive and Negative Symptoms Scale (Kay 1987), SIPS = Structured Interview for Prodromal Syndromes (Miller 2003), SOPS = Scale of Prodromal Symptoms (Miller 2003), UHR = Ultra High Risk of Psychosis
6 5 Table 2 Overview of Assessment of Study Methodological Quality Authors Pyle et al., in press Grano et al., 2013 Hui 2013; Nelson et al., 2013 Welsh & Tiffin, 2013 Demjaha 2012 DeVylder 2012 Fusar- Poli et al., 2012a Fusar- Poli et al., 2012b Kang et al., 2012 Unbiased selection of cohort Selection minimises baseline differences in prognostic factors* Sample size calcula tion* Adequate description of the cohort Validated method for ascertaining UHR status Validated methods for ascertaini ng outcome Outcome assessments blind to UHR status Adequate followup* 1 Missing data minimal Control of confoun ders* Partial N/A No Yes Yes Partial No Partial Partial Partial Yes Yes Partial No Partial Partial Partial No N/A Yes No Yes Yes Partial No Yes Yes Partial No N/A Yes No Yes Yes N/A N/A Partial Yes Unclear No Yes No N/A N/A Yes N/A N/A Partial Yes Unclear Partial Yes Yes N/A N/A Yes N/A No Partial Yes Partial No Yes Yes No Yes No N/A No Yes Yes Partial No N/A Yes No Yes Yes N/A No Partial Yes Partial No N/A Unclear No Yes Yes N/A N/A Yes Yes Unclear No Yes Unclear N/A N/A Partial No No Yes Yes Unclear No N/A Yes No Yes Analysis appropriate *
7 6 Palmier- Claus et al., 2012 Zimbron 2012 Grano et al., 2011 Hutton et al., 2011 Raballo 2011 Velthorst 2010 Phillips 2009 Preti et al., 2009 Niendam a 2008 Morrison 2004 Adlard & Yung, 1997 Partial N/A No Partial Yes Partial Partial N/A Yes No Yes Yes Partial No Yes Yes Unclear No N/A Yes No Yes Yes Partial No Partial Partial Partial No N/A Yes N/A N/A Yes N/A N/A Yes Yes Partial No N/A No N/A N/A Yes N/A N/A Partial Yes Partial No N/A Yes No N/A Yes N/A N/A Partial Yes Unclear No Yes Partial No N/A Yes N/A No Yes Yes Partial No N/A Yes N/A N/A Yes Partial No Partial Yes Partial No Yes Yes No Yes Partial Yes No Yes Yes Partial No N/A Yes No Yes Yes N/A N/A Yes Yes Unclear No Yes Partial N/A N/A Yes Partial No Yes Yes Yes No N/A Yes No Yes * Criteria only applicable to certain designs; 1 Note that this criteria only applied to those studies with follow-up data on self-harm or suicidality or those undertaking analyses whereby suicidality/self-harm predicted other variables at follow-up.
8 7 Table 3 Overview of Studies Comparing Suicidality and Self-Harm Rates between UHR and Comparison Groups Study Comparison Outcome Descriptive Statistics Finding Grano 2013 UHR vs. help-seeking Suicidal ideation (past UHR: n = 39/66 Significantly higher in UHR, adolescence 2 weeks) Control: n = 38/134 OR = 3.64 ( ) Hui 2013 UHR vs. HC Suicidal ideation (past 2 weeks) Kang 2012 UHR vs. HC Suicidal ideation Suicidal ideation (last six months) Suicide attempt UHR: n = 36/50 Control: n = 4/44 UHR: n = 6/15 Control: n = 15/125 UHR: n = 1/15 Control: n = 6/125 UHR: n = 1/15 Control: n = 1/125 Significantly higher in UHR, OR = ( ) Significantly higher in UHR (p =.01) 1, OR = 4.89 ( ) No difference (p =.56) 1 OR = 1.42 ( ) 2 No difference (p =.20) 1 OR = 8.86 ( ) 2 UHR vs. depressed spectrum disorder Suicidal ideation Suicidal ideation (last six months) Suicide attempt UHR: n = 6/15 Control: n = 31/46 UHR: n = 1/15 Control: n = 9/46 UHR: n = 1/15 Control: n = 3/46 No difference (p =.07) 1, OR = 0.32 ( ) No difference (p =.43) 1, OR = 0.29 ( ) 2 No difference (p =.1.00) 1, OR = 1.02 ( ) 2 Zimbron 2012 UHR vs. FEP Self-harm UHR: n = 12/30 Control: n = 7/30 No difference, OR = 2.19 ( ) Grano 2011 UHR vs. help-seeking adolescence Suicidal ideation (past 2 weeks) UHR: 0.44 Control: 0.16 Significantly higher in UHR Preti 2009 UHR vs. FEP Suicide attempt UHR: n = 7/81 No difference,
9 8 Suicidality (BPRS) Suicidality (HoNOS) Control: n = 6/87 UHR: 1.9 (1.3) Control: 1.8 (1.4) UHR: 0.38 (0.87) Control: 0.42 (0.93) OR = 1.28 ( ) No difference, d = 0.07 No difference, d = Adlard & Yung, 1997 UHR vs. FEP Self-harm Self-harm (last 12 months) Suicidal ideation Suicidal ideation (last six months) Suicide attempt Suicide attempt (last 12 months) UHR: n = 12/25 Control: n = 5/27 UHR: n = 8/25 Control: n = 2/27 UHR: n = 23/25 Control: n = 21/27 UHR: n = 21/25 Control: n = 14/27 UHR: n = 7/25 Control: n = 11/27 UHR: n = 6/25 Control: n = 7/27 Significantly higher in UHR (p =.04) 1, OR = 4.06 ( ) Significantly higher in UHR (p =.04) 1, OR = 5.88 ( ) No difference (p =.25) 1, OR = 3.29 ( ) Significantly higher in UHR (p =.02) 1, OR = 4.88 ( ) No difference (p =.39) 1, OR = 0.57 ( ) No difference (p =.1.00) 1, OR = 0.90 ( ) UHR vs. HC Self-harm Self-harm (last 12 months) Suicidal ideation Suicidal ideation (last six months) Suicide attempt Suicide attempt (last 12 months) UHR: n = 12/25 Control: n = 5/22 UHR: n = 8/25 Control: n = 1/22 UHR: n = 23/25 Control: n = 14/22 UHR: n = 21/25 Control: n = 4/22 UHR: n = 7/25 Control: n = 3/22 UHR: n = 6/25 Control: n = 1/22 No difference (p =.13) 1, OR = 3.14 ( ) Significantly higher in UHR (p =.03) 1, OR = 9.88 ( ) 2 Significantly higher in UHR (p =.03) 1, OR = 6.57 ( ) Significantly higher in UHR (p <.01) 1, OR = ( ) No difference (p =.30) 1, OR = 2.46 ( ) No difference (p =.10) 1, OR = 6.63 ( ) 2
10 Note: Significance = p <.05; Odds Ratio (OR) and associated Confidence Intervals (CI) calculated from study data for purposes of this review. BPRS = Brief Psychiatric Rating Scale; HC = Healthy Controls; HoNOS = Health of the Nation Outcome Scale; FEP = First-Episode Psychosis; UHR = Ultra High Risk of Psychosis, 1 Two-tailed Fisher s exact test calculated from summary data as no comparison made in the paper; 2 Very few cases present, interpret tests and OR with caution. 9
11 10 Figure Captions Figure 1: Flow chart detailing the literature search process Figure 2: Forest plots of meta-analysis of prevalence
12 Electronic database searches 11 (PsycInfo, Embase, Medline) N = 1972 Duplicates removed N = 1430 Number excluded N = 1265 Articles included following screening of title and abstract N = 165 Conference abstracts followed-up N = 8 Reasons for exclusion: No UHR group N = 111 Non-English N = 19 Not empirical papers N = 14 No measure of suicidality/self-harm N = 1 Additional duplicates N = 3 Articles included following screening of full text N = 9 Final list of included articles N = 21 Additional articles added Following contact with corresponding authors N = 2 Following reference searches of selected articles N = 9 Articles included, identified through conference abstracts N = 1
13 12 Figure 2 Study Lifetime Suicidal Ideation Prev (95% CI) % Weight Study Recent Suicidal Ideation Prev (95% CI) % Weight DeVylder et al 0.55 ( 0.33, 0.76) Grano et al 0.55 ( 0.42, 0.66) Kang et al Adlard & Yung 0.40 ( 0.16, 0.66) ( 0.77, 1.00) Hutton et al Hui et al Pyle et al 0.77 ( 0.59, 0.91) ( 0.59, 0.84) ( 0.59, 0.71) Overall 0.66 ( 0.29, 0.96) Overall 0.66 ( 0.58, 0.73) Q=14.76, p=0.00, I2=86% Q=5.63, p=0.13, I2=47% Prev Prev Study Lifetime Self-Harm Prev (95% CI) % Weight Study Lifetime Suicide Attempt Prev (95% CI) % Weight Zimbron et al Hutton et al Phillips et al Adlard & Yung 0.40 ( 0.23, 0.58) ( 0.22, 0.55) ( 0.59, 0.72) ( 0.29, 0.68) Kang et al Hutton et al Preti et al Phillips et al Adlard & Yung 0.07 ( 0.00, 0.26) ( 0.30, 0.64) ( 0.03, 0.16) ( 0.06, 0.14) ( 0.12, 0.47) Overall Q=14.96, p=0.00, I2=80% 0.49 ( 0.33, 0.66) Overall Q=28.27, p=0.00, I2=86% 0.18 ( 0.07, 0.32) Prev Prev
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