The subjective perception of the association between psychotic experiences and suicidal behavior among young adults.

OBJECTIVES: Psychotic experiences such as hallucinations and delusions are reported by approximately 7.2% of the general population, even in the absence of a psychotic disorder. Individuals who report such psychotic experiences are significantly more likely to endorse suicidal ideation and behavior across several large epidemiological samples. This study aimed to determine whether individuals who reported psychotic experiences and suicidal behavior would subjectively endorse a causal relationship between these two clinical phenomena. METHODS: Five open-ended questions were asked via online survey to 12 college students who had previously reported both hallucination-like experiences and suicidal behavior in a quantitative survey. Thematic analysis was used to analyze open-ended responses. RESULTS: The majority of respondents, n (%) = 11 (91.6), did not endorse a notable subjective relationship between psychosis and suicidal ideation or suicide attempts. However, respondents did spontaneously report that stigma and fear may drive suicidal ideation among people who report psychotic experiences and other symptoms of psychological distress. CONCLUSIONS: These findings are generally inconsistent with the hypothesis that psychotic experiences are directly related to suicidal behavior, and are consistent with the alternative hypothesis that both psychotic experiences and suicidal behavior are indicators of common underlying factors such as general psychological distress, potentially exacerbated by stigma.

Physical injury and psychotic experiences in 48 low- and middle-income countries.

BACKGROUND: Psychotic experiences (PEs) may be associated with injuries, but studies focusing specifically on low- and middle-income countries (LAMICs) are scarce. Thus, the current study examined the link between injuries and PEs in a large number of LAMICs. METHOD: Cross-sectional data were used from 242 952 individuals in 48 LAMICs that were collected during the World Health Survey in 2002-2004 to examine the association between traffic-related and other (non-traffic-related) forms of injury and PEs. Multivariable logistic regression analysis and meta-analysis were used to examine associations while controlling for a variety of covariates including depression. RESULTS: In fully adjusted analyses, any injury [odds ratio (OR) 2.07, 95% confidence interval (CI) 1.85-2.31], traffic injury (OR 1.84, 95% CI 1.53-2.21) and other injury (OR 2.09, 95% CI 1.84-2.37) were associated with higher odds for PEs. Results from a country-wise analysis showed that any injury was associated with significantly increased odds for PEs in 39 countries with the overall pooled OR estimated by meta-analysis being 2.46 (95% CI 2.22-2.74) with a moderate level of between-country heterogeneity (I2 = 56.3%). Similar results were observed across all country income levels (low, lower-middle and upper-middle). CONCLUSIONS: Different types of injury are associated with PEs in LAMICs. Improving mental health systems and trauma capacity in LAMICs may be important for preventing injury-related negative mental health outcomes.

Investigating the role of hallucinatory experiences in the transition from suicidal thoughts to attempts.

OBJECTIVE: Psychotic experiences, including auditory hallucinatory experiences (HEs), are strongly associated with both suicidal thoughts and behaviour. This study examined their role in the ideation-to-attempt transition in adolescents, including their direct and indirect effect via potential mediators. METHOD: Participants were from an Australian prospective longitudinal cohort of 1669 adolescents (12-17 years); of which a subsample endorsing baseline suicidal ideation (n = 216) was the focus of most analyses. Suicidal thoughts and behaviours were measured using the Self-Harm Behaviour Questionnaire. The Diagnostic Interview Schedule for Children was used to assess auditory HEs. Potential mediators of interest were psychological distress and Interpersonal Theory of Suicide (IPTS) constructs. RESULTS: Among adolescents reporting suicidal ideation at baseline (n = 216), 6.5% had attempted suicide during follow-up. The size of auditory HEs' univariate effect suggests a possible strong relationship with increased risk of incident suicide attempts (OR = 2.40; 95%CI = 0.76-7.56); however, there was inadequate statistical power to produce a precise estimate. When HEs were accompanied by distress there was a nine-fold increased risk of acting on suicidal thoughts. Distress was independently associated with risk of attempt transition (OR = 4.09), whereas IPTS constructs were poor explanatory variables in most models. CONCLUSION: Adolescents with psychological distress and auditory HEs are at high risk of incident suicide attempts. Further investigations on the role of negative/distressing content of hallucinations in the ideation-to-attempt transition are warranted.

Psychotic experiences and physical health conditions in the United States.

AIMS: Psychotic experiences are associated with physical health conditions, though the associations have not always been consistent in the literature. The current study examines the associations between psychotic experiences and several physical health conditions across four racial groups in the United States. METHODS: We analyzed data from the Collaborative Psychiatric Epidemiology Surveys to examine the associations between psychotic experiences and physical health conditions across four racial groups (White, Black, Asian, Latino). We used multivariable logistic regression to calculated adjusted odds ratios and 95% Confidence Intervals. RESULTS: Psychotic experiences were significantly associated with several physical health conditions depending on the condition and the racial group being examined. Further, the number of physical health conditions was associated with increasingly greater risk for psychotic experiences in a linear fashion. CONCLUSIONS: Psychotic experiences may serve as useful markers for physical health conditions and overall physical health status. Future studies should examine the underlying mechanisms between psychotic experiences and health, and explore the clinical utility of psychotic experiences for preventive interventions.

Psychotic experiences and subjective cognitive complaints among 224 842 people in 48 low- and middle-income countries.

AIMS: Cognitive deficits are an important factor in the pathogenesis of psychosis. Subjective cognitive complaints (SCCs) are often considered to be a precursor of objective cognitive deficits, but there are no studies specifically on SCC and psychotic experiences (PE). Thus, we assessed the association between SCC and PE using data from 48 low- and middle-income countries. METHODS: Community-based cross-sectional data of the World Health Survey were analysed. Two questions on subjective memory and learning complaints in the past 30 days were used to create a SCC scale ranging from 0 to 10 with higher scores representing more severe SCC. The Composite International Diagnostic Interview was used to identify past 12-month PE. Multivariable logistic regression and mediation analyses were performed. RESULTS: The final sample consisted of 224 842 adults aged ⩾18 years [mean (SD) age 38.3 (16.0) years; 49.3% males]. After adjustment for sociodemographic factors, a one-unit increase in the SCC scale was associated with a 1.17 (95% CI 1.16-1.18) times higher odds for PE in the overall sample, with this association being more pronounced in younger individuals: age 18-44 years OR = 1.19 (95% CI 1.17-1.20); 45-64 years OR = 1.15 (95% CI 1.12-1.17); ⩾65 years OR = 1.14 (95% CI 1.09-1.19). Collectively, other mental health conditions (perceived stress, depression, anxiety, sleep problems) explained 43.4% of this association, and chronic physical conditions partially explained the association but to a lesser extent (11.8%). CONCLUSIONS: SCC were associated with PE. Future longitudinal studies are needed to understand temporal associations and causal inferences, while the utility of SCC as a risk marker for psychosis especially for young adults should be scrutinised.

Criminal victimization and psychotic experiences: cross-sectional associations in 35 low- and middle-income countries.

OBJECTIVE: Criminal victimization has been associated with elevated risk for psychotic symptoms in the United Kingdom, but has not been studied in low- and middle-income countries (LMICs). Understanding whether crime exposure may play a role in the social etiology of psychosis could help guide prevention and intervention efforts. METHOD: We tested the hypothesis that criminal victimization would be associated with elevated odds of psychotic experiences in 35 LMICs (N = 146 999) using cross-sectional data from the World Health Organization World Health Survey. Multivariable logistic regression analyses were used to test for associations between criminal victimization and psychotic experiences. RESULTS: Victimization was associated with greater odds of psychotic experiences, OR (95% CI) = 1.72 (1.50-1.98), and was significantly more strongly associated with psychotic experiences in non-urban, OR (95% CI) = 1.93 (1.60-2.33), compared to urban settings, OR (95% CI) = 1.48 (1.21-1.81). The association between victimization and psychosis did not change across countries with varying aggregated levels of criminal victimization. CONCLUSIONS: In the largest ever study of victimization and psychosis, the association between criminal victimization and psychosis appears to generalize across a range of LMICs and, therefore, across nations with a broad range of crime rates, degree of urban development, average per capita income, and racial/ethnic make-up.

Why are psychotic experiences associated with self-injurious thoughts and behaviours? A systematic review and critical appraisal of potential confounding and mediating factors.

Psychotic experiences (PEs), including hallucination- and delusion-like experiences, are robustly associated with self-injurious thoughts and behaviours (SITB) in the general population. However, it remains unclear as to why there is an association. The purpose of this systematic review was to elucidate the role of other factors that influence the association between PEs and SITB and, in doing so, highlight potential mechanisms underlying the relationship. A search of electronic international databases was undertaken, including PubMed, PsycINFO and EMBASE, and eligible studies were grouped according to seven confounder categories: sociodemographics, mental disorders, alcohol and substance use, environmental, psychological, intervention and family history/genetic factors. The systematic search strategy identified 41 publications reporting on 1 39 427 participants from 16 different countries. In the majority of studies, where adjustment for other variables occurred, the association between PEs and SITB persisted, suggesting PEs have an independent role. Common mental disorders, psychological distress and negative environmental exposures explained a substantial amount of the variance and therefore need to be considered as potential underlying mechanisms. There was high variability in the variables adjusted for in these studies, and so the question still remains as to whether the association between PEs and self-harm/suicidality can be attributed (fully or in part) to confounding and mediating factors or directly causal mechanisms. Regardless of causality, the now extensive literature reporting an association between these two clinical phenomena supports the broad usefulness of PEs as an indicator of risk for SITB.

Psychotic experiences and suicide attempt risk in common mental disorders and borderline personality disorder.

OBJECTIVE: Recent research has demonstrated a strong relationship between psychotic experiences and suicidal behaviour. No research to date, however, has investigated the role of borderline personality disorder (BPD) in this relationship, despite the fact that BPD is highly comorbid with common mental disorders and is associated with both recurrent suicidal behaviour and psychotic experiences. This paper examined the relationship between psychotic experiences and suicide attempts, including interrelationships with BPD and common mental disorders. METHOD: We used the 2007 Adult Psychiatric Morbidity Study, a stratified, multistage probability sample of households in England, which recruited a nationally representative sample aged 16 years and older. Participants were assessed for common mental disorders, BPD (clinical and subclinical), suicidal behaviour, and psychotic experiences. RESULTS: Approximately 4% of the total sample (n = 323) reported psychotic experiences. Psychotic experiences were associated with increased odds of suicide attempts in individuals with BPD (OR = 2.23, 95% CI = 1.03-4.85), individuals with a common mental disorder (OR = 2.47, 95% CI = 1.37-4.43), individuals without a common mental disorder (OR = 3.99, 95% CI = 2.47-6.43), and individuals with neither a common mental disorder nor BPD (OR = 3.20, 95% CI = 1.71-5.98). CONCLUSION: Psychotic experiences are associated with high odds of suicidal behaviour in individuals with and without psychopathology. This relationship is not explained by clinical or subclinical BPD.

Prevalence, demographic variation and psychological correlates of exposure to police victimisation in four US cities.

Aims Victimisation by the police is purported to be widespread in cities in the USA, but there is limited data on police-public encounters from community samples. This is partly due to an absence of measures for assessing police violence exposure from the standpoint of civilians. As such, the demographic distribution and mental health correlates of police victimisation are poorly understood. The aims of this study were to present community-based prevalence estimates of positive policing and police victimisation based on assessment with two novel measures, and to test the hypotheses that (1) exposure to police victimisation would vary across demographic groups and (2) would be associated with depression and psychological distress. METHODS: The Survey of Police-Public Encounters study surveyed adults residing in four US cities to examine the prevalence, demographic distribution and psychological correlates of police victimisation. Participants (N = 1615) completed measures of psychological distress (K-6 scale), depression (Patient Health Questionnaire 9) and two newly constructed measures of civilian-reported police-public encounters. Both measures were developed to assess police victimisation based on the WHO domains of violence, which include physical violence (with and without a weapon, assessed separately), sexual violence (inappropriate sexual contact, including public strip searches), psychological violence (e.g., threatening, intimidating, stopping without cause, or using discriminatory slurs) and neglect (police not responding when called or responding too late). The Police Practices Inventory assesses lifetime history of exposure to positive policing and police victimisation, and the Expectations of Police Practices Scale assesses the perceived likelihood of future incidents of police victimisation. Linear regression models were used to test for associations between police-public encounters and psychological distress and depression. RESULTS: Psychological violence (18.6%) and police neglect (18.8%) were commonly reported in this sample and a substantial minority of respondents also reported more severe forms of violence, specifically physical (6.1%), sexual (2.8%) and physical with a weapon (3.3%). Police victimisation was more frequently reported by racial/ethnic minorities, males, transgender respondents and younger adults. Nearly all forms of victimisation (but not positive policing) were associated with psychological distress and depression in adjusted linear regression models. CONCLUSIONS: Victimisation by police appears to be widespread, inequitably distributed across demographic groups and psychologically impactful. These findings suggest that public health efforts to both reduce the prevalence of police violence and to alleviate its psychological impact may be needed, particularly in disadvantaged urban communities.

Epidemiology of depression with psychotic experiences and its association with chronic physical conditions in 47 low- and middle-income countries.

BACKGROUND: The co-existence of depression and psychotic experiences (PEs) is associated with more pronounced adverse health outcomes compared to depression alone. However, data on its prevalence and correlates are lacking in the general adult population, and there is no published data on its association with chronic physical conditions. METHOD: Cross-sectional, community-based data from 201 337 adults aged ⩾18 years from 47 low- and middle-income countries from the World Health Survey were analyzed. The presence of past 12-month PE and DSM-IV depression was assessed with the Composite International Diagnostic Interview (CIDI). Information on six chronic medical conditions (chronic back pain, edentulism, arthritis, angina, asthma, diabetes) were obtained by self-report. Multivariable logistic regression analysis was performed. RESULTS: The crude overall prevalence of co-morbid depression/PEs was 2.5% [95% confidence interval (CI) 2.3-2.7%], with the age- and sex-adjusted prevalence ranging from 0.1% (Sri Lanka, Vietnam) to 9.03% (Brazil). Younger age, urban setting, current smoking, alcohol consumption, and anxiety were significant correlates of co-existing depression/PEs. Co-occurring depression/PEs was associated with significantly higher odds for arthritis, angina, and diabetes beyond that of depression alone after adjusting for sociodemographics, anxiety, and country, with odds ratios (depression/PEs v. depression only) being: arthritis 1.30 (95% CI 1.07-1.59, p = 0.0086); angina 1.40 (95% CI 1.18-1.67, p = 0.0002); diabetes 1.65 (95% CI 1.21-2.26, p = 0.0017). CONCLUSIONS: The prevalence of co-existing depression/PEs was non-negligible in most countries. Our study suggests that when depression/PE or a chronic condition (e.g. arthritis, angina, diabetes) is detected, screening for the other may be important to improve clinical outcomes.

Risk and functional significance of psychotic experiences among individuals with depression in 44 low- and middle-income countries.

BACKGROUND: Studies on whether the co-occurrence of psychotic experiences (PEs) and depression confers a more pronounced decrement in health status and function compared with depression alone are scarce in the general adult population. METHOD: Data on 195 479 adults aged ⩾18 years from the World Health Survey were analysed. Using the World Mental Health Survey version of the Composite International Diagnostic Interview (CIDI), depression in the past 12 months was categorized into four groups: depressive episode, brief depressive episode, subsyndromal depression, and no depression. Past 12-month psychotic symptoms were assessed using four questions on positive symptoms from the CIDI. Health status across seven domains (cognition, interpersonal activities, sleep/energy, self-care, mobility, pain/discomfort, vision) and interviewer-rated presence of a mental health problem were assessed. Multivariable logistic and linear regression analyses were performed to assess the associations. RESULTS: When compared with those with no depression, individuals with depression had higher odds of reporting at least one PE, and this was seen across all levels of depression severity: subsyndromal depression [odds ratio (OR) 2.38, 95% confidence interval (CI) 2.02-2.81], brief depressive episode (OR 3.84, 95% CI 3.31-4.46) and depressive episode (OR 3.75, 95% CI 3.24-4.33). Having coexisting PEs and depression was associated with a higher risk for observable illness behavior and a significant decline in health status in the cognition, interpersonal activities and sleep/energy domains, compared with those with depression alone. CONCLUSIONS: This coexistence of depression and PEs is associated with more severe social, cognitive and sleep disturbances, and more outwardly apparent illness behavior. Detecting this co-occurrence may be important for treatment planning.

Clinical significance of psychotic experiences in the context of sleep disturbance or substance use.

BACKGROUND: Psychotic experiences (PE) are commonly reported in the general population, where they are associated with elevated clinical need and functional impairment. Research studies typically exclude PE that occur in the context of sleep or substance use (PE-SS), based on the assumption that they are normative within these contexts. This is the first study to formally test clinical and functional outcomes associated with PE that occur in the context of sleep or substance use. METHOD: Data from the Collaborative Psychiatric Epidemiology Surveys (n = 11 776) were used to assess the associations between both PE and PE-SS and a broad range of outcomes, including psychiatric co-morbidity, suicidal behavior, mental health treatment utilization and World Health Organization (WHO) domains of function, using logistic regression analyses. Lifetime PE and PE-SS were mutually exclusive categories, assessed using the WHO Composite International Diagnostic Interview psychosis screen. RESULTS: PE were associated with all 10 clinical and functional outcomes. Similarly, respondents reporting PE-SS had greater clinical need and impaired function relative to controls, which was significant for seven of the 10 outcome variables. When directly compared, the PE and PE-SS groups differed only in their associations with role function (greater impairment for PE) and self-care (greater impairment for PE-SS). CONCLUSIONS: PE-SS were associated with a broad range of clinical and functional outcomes in this large general population sample. These associations were similar to those found for PE. Future studies should investigate relative differences between sleep- and substance-induced PE.

Changing perceptions of illness in the early course of psychosis: psychological pathways to self-determination and self-management of treatment.

Treatment early in the course of psychosis can improve prognostic outcomes, facilitate adaptive functioning, and reduce familial and societal burden. However, little is known about the pathway of first episode psychosis (FEP) from the perspective of highly adherent adolescents and young adults. This study sought to understand the pathways in youth self-determination and self-management of treatment by investigating youth and parents' changing perceptions of illness in the early course of psychosis. Twenty-eight (n = 28) interviews were conducted using a semistructured interview guide on 12 adolescents following their FEP hospitalization and 16 parents. Standardized self-report forms and hospital inpatient records were used to collect and confirm demographic and clinical data. On average, three years had passed from initial hospitalization (age 16.2 years, SD = 1.2) to time of interview (age 19.3 years, SD = 2.3), thus allowing for a range of experiences across the early period of illness. Highly adherent adolescents experienced identifiable temporal phases of early psychosis, comprised of emergent and specific themes. Parents described a parallel pathway toward supporting their child's self-determination and self-management of treatments, with some distinct experiential differences. Five dominant themes that emerged across time were symptom recognition, awareness of change, negative appraisals, positive appraisals, and treatment self-management. Examining how these themes evolve over the early course of psychosis can help guide interventions that are compatible with the parent and adolescent's perceptions of illness at that point in time, and can therefore work in concert with the family's existing efforts to understand and manage their emerging condition and progress toward recovery.

Co-occurrence of psychotic experiences and common mental health conditions across four racially and ethnically diverse population samples.

BACKGROUND: Prior research with racially/ethnically homogeneous samples has demonstrated widespread co-occurrence of psychotic experiences (PEs) and common mental health conditions, particularly multi-morbidity, suggesting that psychosis may be related to the overall severity of psychiatric disorder rather than any specific subtype. In this study we aimed to examine whether PEs are associated with the presence of specific disorders or multi-morbidity of co-occurring disorders across four large racially/ethnically diverse samples of adults in the USA. METHOD: Data were drawn from the National Comorbidity Survey Replication (NCS-R), the National Survey of American Life (NSAL) and separately from the Asian and Latino subsamples of the National Latino and Asian American Study (NLAAS). Logistic regression models were used to examine the relationship between PEs and individual subtypes of DSM-IV disorder, and to test for a linear dose-response relationship between the number of subtypes and PEs. RESULTS: Prevalence of PEs was moderately greater among individuals with each subtype of disorder in each data set [odds ratios (ORs) 1.8-3.8], although associations were only variably significant when controlling for clinical and demographic variables. However, the sum of disorder subtypes was related to odds for PEs in a linear dose-response fashion across all four samples. CONCLUSIONS: PEs are related primarily to the extent or severity of psychiatric illness, as indicated by the presence of multiple psychiatric disorders, rather than to any particular subtype of disorder in these data. This relationship applies to the general population and across diverse racial/ethnic groups.

Declining social support in adolescents prior to first episode psychosis: associations with negative and affective symptoms.

Social support for individuals with psychosis is associated with decreased symptom severity, improved outcomes, and recovery. In adolescents, declining social support prior to the first hospitalization has been shown to predict time to relapse, which may have implications for early intervention. Data were collected on adolescents (n=84) following a first hospitalization for a psychotic episode in order to examine how change in social support relates to the duration and type of untreated symptoms. Most adolescents experienced a decline in social support (n=46) prior to index hospitalization. Chi-square analyses showed that declining social support was related to negative symptoms and longer duration of untreated psychosis, whereas stable social support was associated with manic symptoms and diagnosis of Bipolar disorder. When entered together into a logistic regression model, the decline in social support was primarily explained by the type of symptoms, rather than by the duration of untreated symptoms. These findings are relevant for targeting psychosocial treatments toward adolescents who may have particular deficits in social support during the prodromal phase and first episode of psychosis.

Temporal association of stress sensitivity and symptoms in individuals at clinical high risk for psychosis.

BACKGROUND: Increased sensitivity and exposure to stress are associated with psychotic symptoms in schizophrenia and its risk states, but little is known about the co-evolution of stress sensitivity and exposure with positive and other symptoms in a clinical high-risk (CHR) cohort. METHOD: A combined cross-sectional and longitudinal design was used to examine the associations over time of stress sensitivity and exposure (i.e. life events) with 'prodromal' symptoms in a cohort of 65 CHR patients assessed quarterly for up to 4 years, and at baseline in 24 healthy controls similar in age and gender. RESULTS: Impaired stress tolerance was greater in patients, in whom it was associated over time with positive and negative symptoms, in addition to depression, anxiety and poor function. By contrast, life events were comparable in patients and controls, and bore no association with symptoms. In this treated cohort, there was a trajectory of improvement in stress tolerance, symptoms and function over time. CONCLUSIONS: Impaired stress tolerance was associated with a wide range of 'prodromal' symptoms, consistent with it being a core feature of the psychosis risk state. Self-reported life events were not relevant as a correlate of clinical status. As in other treated CHR cohorts, most patients improved over time across symptom domains.

Early recognition and treatment of the traumatically transected parotid duct: report of case.

The immediate treatment of a transected parotid duct has been presented along with a brief review of the literature. The importance of exploration of wounds in the facial area cannot be overemphasized, as early repair of a severed duct is of utmost importance for establishing its patency.