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Published Online: 28 February 2023

Impact of Treatment Initiation and Engagement on Deliberate Self-Harm Among Individuals With First-Episode Psychosis

Heather M. Wastler, Ph.D. [email protected], Elyse Llamocca, Ph.D., Aubrey M. Moe, Ph.D., Danielle L. Steelsmith, Ph.D., Guy Brock, Ph.D., Jeffrey A. Bridge, Ph.D., John V. Campo, M.D., and Cynthia A. Fontanella, Ph.D.Authors Info & Affiliations
Publication: Psychiatric Services
Volume 74, Number 9
https://doi.org/10.1176/appi.ps.20220372
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Abstract

Objective:

Individuals with psychosis are at increased risk for suicide, with the greatest risk being present during the first few months after diagnosis. The authors aimed to examine whether treatment initiation within 14 days of diagnosis and treatment engagement within 90 days of initiation reduce the risk for deliberate self-harm (DSH) among individuals with first-episode psychosis (FEP).

Methods:

A retrospective longitudinal cohort design was adopted by using Ohio Medicaid claims for 6,349 adolescents and young adults ages 15–24 years with FEP. Logistic regression was used to examine factors associated with treatment initiation and engagement. Cox proportional hazard models were used to estimate the impact of treatment initiation and engagement on DSH. Propensity score weighting was used to control for sociodemographic and clinical covariates.

Results:

Approximately 70% of the sample initiated treatment, 55% of whom engaged in treatment. Treatment initiation and engagement were associated with both demographic and clinical variables. Treatment initiation significantly reduced the hazard of DSH (average treatment effect in the entire population: hazard ratio [HR]=0.62, 95% CI=0.47–0.81; average treatment effect among those treated: HR=0.64, 95% CI=0.52–0.80). In contrast, treatment engagement was not significantly associated with DSH.

Conclusions:

These results suggest that the initial treatment contact is essential for reducing DSH among adolescents and young adults with FEP. Additionally, the finding that treatment engagement did not reduce DSH suggests that standard clinical care may not be sufficient for reducing DSH in this population. These findings highlight the need for suicide-specific interventions for individuals with FEP.

HIGHLIGHTS

•
Treatment initiation reduced the hazard of deliberate self-harm (DSH) among Medicaid-enrolled adolescents and young adults with first-episode psychosis.
•
Treatment engagement was not significantly associated with DSH hazard in this population, suggesting that standard clinical care may not be sufficient for reducing DSH.
•
Given the high rates of DSH in this population, these findings indicate a great need for suicide-specific interventions for individuals with first-episode psychosis.
Psychotic disorders are serious illnesses that lead to significant global disease burden (1) and functional impairment (2). Although evidence-based interventions exist for individuals with psychosis (3, 4), up to 50% of these individuals report that they did not receive any mental health care in the past year (5–7). Treatment delays are associated with greater symptom severity, lower rates of remission, and poor functional outcomes (8). Among those who initiate treatment, disengagement is common, with up to 53% of individuals with early psychosis ending treatment prematurely (9, 10). Common predictors of treatment disengagement include poor family support, isolation, poor medication adherence, substance use, and low symptom severity (9, 10). Because the benefits of early intervention are most pronounced during the first 6 months of treatment (11), individuals who disengage are likely at risk for long-term negative outcomes (e.g., relapse, rehospitalization, poor functional outcome, and suicide). However, studies examining the consequences of treatment disengagement are limited, potentially because of difficulties in tracking outcomes among individuals who are no longer engaged in care.
Early death is one of the most devastating outcomes for individuals with psychosis, with estimated early death rates approximately two to three times greater than in the general population (12). Suicide is a major contributor to early death among individuals with psychosis, with approximately half of these premature deaths being attributable to suicide or other types of injury or poisoning (12). Furthermore, research has shown that suicide rates are 13 times greater among individuals with psychosis relative to the general population (13).
Deliberate self-harm (DSH), including both nonsuicidal self-injury and suicidal behavior (14), is a significant risk factor for suicide, both in the general population (15) and among individuals with psychosis (16). It is estimated that approximately 11% of individuals with psychosis engage in DSH (17, 18), with the greatest risk occurring during the first 3–6 months after diagnosis (17). Given this critical period of heightened risk, early intervention might be key to reducing DSH in this population. Consistent with this notion, studies have shown that greater duration of untreated psychosis is associated with elevated risk for DSH (19), although much less is known about whether prompt treatment initiation and ongoing engagement can reduce DSH risk among individuals with first-episode psychosis (FEP). With the present study, we sought to address this gap by examining the prospective associations of treatment initiation and treatment engagement with DSH after an initial diagnosis of a psychotic disorder, using a population-based sample of adolescents and young adults enrolled in Medicaid. We hypothesized that treatment initiation within 14 days of diagnosis and treatment engagement within 90 days of initiation would be associated with reduced DSH among individuals with FEP.

Methods

Study Design and Sample

This study used a retrospective longitudinal cohort design conducted with Ohio Medicaid claims. Participants included adolescents and young adults ages 15–24 years with FEP who were continuously enrolled in Ohio Medicaid for 180 days before the index diagnosis date and were enrolled for the full period needed to observe treatment initiation and engagement. Consistent with previous research (17), we defined FEP as having at least one inpatient claim or two outpatient claims on different days with a psychosis diagnosis code (see Table S1 in the online supplement to this article) between June 30, 2010, and December 31, 2017, and having no claim with a psychosis diagnosis code in the 180 days before the index diagnosis. Earlier research supports the validity of using claims data to identify psychotic disorders and FEP (20, 21). Given our interest in treatment initiation, we excluded individuals with outpatient mental health care in the 180 days before the index diagnosis. Our final sample consisted of 6,349 Medicaid-enrolled individuals with FEP. All procedures were approved by the Ohio State University Institutional Review Board.

Measures

Our independent variables were treatment initiation and engagement. Given the lack of consensus regarding definitions for treatment initiation and engagement in the psychosis literature (9), we relied on definitions provided in the initiation and engagement in treatment performance measure from the Healthcare Effectiveness Data and Information Set of the National Committee for Quality Assurance (22, 23).
Treatment initiation was defined as an inpatient admission or at least one psychotherapy (individual, family, or group), medication management, or partial hospitalization visit (see Table S2 in the online supplement) with a psychosis diagnosis code (see Table S1 in the online supplement) on or within 14 days of the index date. Engagement was defined as at least two psychiatric hospitalizations or outpatient visits for psychotherapy, medication management, or partial hospitalization within 90 days of initiation. The engagement period focused on the 90 days after treatment initiation, given that our previous work has demonstrated that the risk for DSH is greatest during the first 3–6 months after an index diagnosis (17). Our primary outcome was the first nonfatal DSH claim during the follow-up period (see Table S3 in the online supplement) (15, 24). The follow-up period was up to 365 days from the end of the initiation or engagement period, with follow-up ending at the earliest of the first DSH claim, the end of Medicaid enrollment, death, or the end of the study period (December 31, 2017), if any occurred before the end of the full 365 days. We included age, gender, race-ethnicity, Medicaid eligibility status, and metropolitan status as sociodemographic covariates in our analyses. Clinical covariates included comorbid psychiatric conditions (i.e., attention-deficit hyperactivity disorder, anxiety disorders, substance use disorders, or other psychiatric disorders), chronic medical conditions, and previous mental health emergency department visits or inpatient hospitalizations. Assessment of comorbid psychiatric conditions was based on the presence of one inpatient or two outpatient claims with a relevant diagnosis code (see Table S1 in the online supplement), and assessment of chronic medical conditions was based on the presence of at least one claim with a relevant diagnosis code (25–27).

Statistical Methods

Logistic regression was used to examine the association of treatment initiation and engagement with sociodemographic and clinical characteristics. Cox proportional hazards regression was used to examine the associations of treatment initiation and treatment engagement with DSH. We verified that the proportional hazards assumption was met for each variable of interest by confirming that no significant interaction existed between each variable and the log of time in an unweighted Cox proportional hazards model. Propensity score weighting controlled for sociodemographic and clinical covariates. We estimated propensity scores by using logistic regression models, controlling for all covariates. Propensity score models for treatment initiation and engagement also controlled for DSH occurring between the index date and the end of the initiation and engagement periods, respectively. For each exposure, we estimated both the average treatment effect in the total population (ATE), by using stabilized ATE weights, and the average treatment effect among the treated (ATT), by using ATT weights. All assumptions were tested and met before we ran analyses (see the online supplement) (28–34). Statistical analyses were conducted with SAS, version 9.4 (28), and R, version 4.0.3 (29).

Results

Sample Characteristics

The demographic characteristics of the sample are presented in Table 1. The sample included 49.6% females and 47.1% adolescents ages 15–19 years and consisted predominantly of individuals who were non-Hispanic White (45.5%) and enrolled in Medicaid because of poverty (78.7%). Most participants had an index diagnosis of a schizophrenia spectrum disorder (69.3%).
TABLE 1. Characteristics of Medicaid-enrolled adolescents and young adults with first-episode psychosis (N=6,349)
CharacteristicN%
Age at index diagnosis (years)  
 15–192,99047.1
 20–243,35952.9
Gender  
 Male3,20050.4
 Female3,14949.6
Race-ethnicity  
 Non-Hispanic White2,89145.5
 Non-Hispanic Black2,65841.9
 Hispanic1782.8
 Othera6229.8
Medicaid eligibility status at index diagnosis  
 Poverty4,99778.7
 Disability1,17018.4
 Foster care1021.6
 Otherb801.3
Area of residence  
 Metropolitan5,42185.4
 Nonmetropolitan92814.6
Comorbid psychiatric conditionc  
 Attention-deficit hyperactivity disorder851.3
 Anxiety2223.5
 Substance use disorder68810.8
 Other psychiatric disorderd2944.6
Chronic medical conditionc  
 None3,73058.8
 Noncomplex1,87629.6
 Complex74311.7
History of self-harmc2644.2
Index psychosis category  
 Affective disorder1,94930.7
 Schizophrenia spectrum disorder4,40069.3
Previous inpatient mental health carec2624.1
Previous emergency department mental health carec71611.3
a
Other race-ethnicity included Asian American, Native American or Alaska Native, Native Hawaiian or other Pacific Islander, more than one race, and unknown.
b
Other eligibility included incarceration and unknown Medicaid eligibility categories.
c
Included all claims in the 180 days before the index diagnosis.
d
Excluded diagnosis codes for bipolar disorder and depression.

Factors Associated With Treatment Initiation and Engagement

Factors associated with treatment initiation are summarized in Table 2. Most (N=4,419, 69.6%) of the participants initiated treatment within 14 days after the index diagnosis. Of those who initiated treatment, 59.0% (N=2,607) initiated treatment in an inpatient setting, and 41.0% (N=1,812) initiated treatment in an outpatient setting. Females (vs. males) and individuals with index diagnoses of schizophrenia spectrum disorders (vs. affective disorder with psychosis) had significantly lower odds of initiating treatment, whereas individuals with previous emergency department mental health visits had significantly higher odds of initiating treatment, compared with individuals with no previous visits. Factors associated with increased treatment engagement are summarized in Table 3. More than half (N=2,431, 55.0%) of individuals who initiated treatment engaged in treatment during the 90-day engagement period. Individuals who were older (20–24 years), were non-Hispanic Black, were eligible for Medicaid because of disability, had comorbid substance use disorders, or had index diagnoses of schizophrenia spectrum disorders had significantly lower odds than their peers of engaging in treatment. Individuals residing in a nonmetropolitan area had significantly higher odds of treatment engagement than those in a metropolitan area.
TABLE 2. Characteristics associated with treatment initiation within 14 days of diagnosis among Medicaid-enrolled adolescents and young adults (N=4,419) with first-episode psychosis
   Unadjusted analysisAdjusted analysisa
CharacteristicN%OR95% CIpAOR95% CIp
Ages 20–24 years at index diagnosis (reference: 15–19)2,32452.6.96.86–1.07.450.99.89–1.11.880
Female gender (reference: male)2,13348.3.84.75–.93.001.79.70–.88<.001
Race-ethnicity (reference: Non-Hispanic White)        
 Non-Hispanic Black1,86042.11.03.92–1.16.5801.10.97–1.24.140
 Hispanic1192.7.89.65–1.24.500.88.64–1.22.430
 Otherb4379.91.05.87–1.27.6301.07.88–1.30.490
Medicaid eligibility status at index diagnosis (reference: poverty)        
 Disability79418.0.90.79–1.03.130.94.81–1.08.390
 Foster care661.5.78.52–1.19.240.74.49–1.13.150
 Otherc561.31.00.62–1.64.9801.05.65–1.74.860
Nonmetropolitan area of residence (reference: metropolitan)66014.91.09.94–1.27.2801.11.94–1.31.230
Comorbid psychiatric conditiond        
 Attention-deficit hyperactivity disorder641.51.34.83–2.24.2501.52.92–2.60.110
 Anxiety1413.2.75.57–1.00e.050e.75.55–1.02.070
 Substance use disorder46610.6.91.77–1.08.260.90.74–1.08.250
 Other psychiatric disorderf1944.4.84.66–1.08.170.74.53–1.06.100
Chronic medical condition (reference: none)d        
 Noncomplex1,28029.0.89.79–1.01.070.91.80–1.04.170
 Complex50611.5.89.75–1.06.180.95.79–1.13.560
History of self-harm (reference: no history)d1914.31.15.88–1.52.3201.12.85–1.49.430
Schizophrenia spectrum disorder at index date (reference: affective disorder)2,94566.6.65.58–.74<.001.62.54–.70<.001
Previous inpatient mental health care (reference: no such previous care)d1794.1.94.72–1.23.6501.06.73–1.55.770
Previous emergency department mental health care (reference: no such previous care)d54112.21.401.17–1.68<.0011.521.26–1.85<.001
a
The adjusted model included all covariates. AOR, adjusted OR.
b
Other race-ethnicity included Asian American, Native American or Alaska Native, Native Hawaiian or other Pacific Islander, more than one race, and unknown.
c
Other eligibility included incarceration and unknown Medicaid eligibility categories.
d
Included all claims in the 180 days before the index diagnosis.
e
Statistically significant at α=0.05.
f
Excludes diagnosis codes for bipolar disorder and depression.
TABLE 3. Characteristics associated with treatment engagement within 90 days of initiation among Medicaid-enrolled adolescents and young adults (N=2,431) with first-episode psychosis
   Unadjusted analysisAdjusted analysisa
CharacteristicN%OR95% CIpAOR95% CIp
Ages 20–24 years at index diagnosis (reference: 15–19)1,19449.1.73.65–.83<.001.77.68–.87<.001
Female gender (reference: male)1,21149.81.151.02–1.29.0201.06.93–1.20.390
Race-ethnicity (reference: Non-Hispanic White)        
 Non-Hispanic Black94939.0.76.67–.86<.001.84.73–.97.020
 Hispanic712.91.08.74–1.58.7001.13.77–1.66.540
 Otherb25210.4.99.80–1.22.9401.07.86–1.33.550
Medicaid eligibility status at index diagnosis (reference: poverty)        
 Disability38415.8.72.62–.84<.001.81.69–.96.010
 Foster care381.61.05.64–1.73.8601.02.62–1.69.950
 Otherc311.3.96.56–1.64.8701.12.65–1.93.690
Nonmetropolitan area of residence (reference: metropolitan)41217.01.431.21–1.70<.0011.321.10–1.59.003
Comorbid psychiatric conditiond        
 Attention-deficit hyperactivity disorder291.2.67.41–1.10.120.69.41–1.18.180
 Anxiety733.0.87.62–1.22.430.94.65–1.36.740
 Substance use disorder2138.8.66.54–.80<.001.63.50–.78<.001
 Other psychiatric disordere1054.3.96.72–1.29.8001.02.68–1.52.920
Chronic medical condition (reference: none)d        
 Noncomplex71229.31.02.89–1.17.7801.01.88–1.17.880
 Complex26711.0.91.75–1.10.330.96.78–1.17.660
History of self-harm (reference: no history)d994.1.87.65–1.17.370.74.55–1.00.050
Schizophrenia spectrum disorder at index date (reference: affective disorder)1,52362.7.67.59–.76<.001.70.62–.81<.001
Previous inpatient mental health care (reference: no such previous care)d1014.21.06.79–1.44.7001.36.89–2.07.150
Previous emergency department mental health care (reference: no such previous care)d29512.1.98.82–1.17.8101.01.83–1.23.900
a
The adjusted model included all covariates. AOR, adjusted OR.
b
Other race-ethnicity included Asian American, Native American or Alaska Native, Native Hawaiian or other Pacific Islander, more than one race, and unknown.
c
Other eligibility included incarceration and unknown Medicaid eligibility categories.
d
Included all claims in the 180 days before the index diagnosis.
e
Excludes diagnosis codes for bipolar disorder and depression.

Association of Initiation and Engagement With DSH

In the total sample, 3.6% (N=229) of individuals had at least one DSH event during the follow-up period, which began at the end of the initiation period. In the subsample of 4,419 individuals who initiated treatment, 3.0% (N=134) had at least one DSH event during follow-up; among the 1,930 youths who did not initiate treatment, 4.9% (N=95) had at least one DSH event. Treatment initiation was associated with a significantly decreased DSH hazard (ATE: hazard ratio [HR]=0.62; ATT: HR=0.64) (Table 4). Among the 2,431 individuals who engaged in treatment, 2.6% (N=64) had at least one DSH event during follow-up; among the 1,988 individuals who did not engage in treatment, 2.1% (N=42) had at least one DSH event. No significant association was detected between treatment engagement and DSH hazard (Table 4).
TABLE 4. Hazard ratios (HRs) of deliberate self-harm with treatment initiation and treatment engagement
 UnweightedWeighted ATEaWeighted ATTb
TreatmentHR95% CIpHR95% CIpHR95% CIp
Initiation.63.48–.81<.001.62.47–.81<.001.64.52–.80<.001
Engagementc1.20.82–1.78.3501.03.70–1.50.9001.01.71–1.43.960
a
To estimate the average treatment effect in the total population (ATE), stabilized ATE weights were applied.
b
To estimate the average treatment effect among persons treated (ATT), ATT weights were applied.
c
The analysis was limited to adolescents and young adults who initiated treatment (N=4,419).

Discussion

Our previous research has shown that individuals with FEP are at greatest risk for DSH during the first 3 months after their initial diagnosis (17). Given this critical period of heightened risk, the present study examined whether treatment initiation within 14 days of diagnosis and treatment engagement within 90 days of initiation reduce DSH. Of Medicaid-enrolled adolescents and young adults with FEP, 69.6% initiated treatment, 55.0% of whom engaged in treatment. Importantly, treatment initiation was associated with a significantly reduced likelihood of engaging in DSH (ATE: HR=0.62 and ATT: HR=0.64). In contrast, treatment engagement had no impact on DSH among individuals with FEP. These findings have significant clinical implications, highlighting the need for interventions that enhance treatment initiation and interventions that directly target DSH in this vulnerable population.
Our findings are consistent with the broader literature in raising concerns about treatment disengagement among individuals with FEP (9, 10). Although much of this work has focused on early intervention services or coordinated specialty care programs, this study extends the literature by also demonstrating that disengagement is common among individuals participating in standard clinical care. This is an important extension, because up to 50% of individuals with FEP do not have access to specialized early intervention services (30). Consistent with the literature on early intervention (6, 9, 10), we found that both demographic and clinical variables were significantly associated with treatment initiation and engagement. Specifically, females and individuals with index diagnoses of schizophrenia spectrum disorders were less likely than their peers to initiate treatment. Among those who initiated treatment, lower engagement was associated with age, race-ethnicity, Medicaid eligibility status, substance use disorders, and index diagnoses of schizophrenia spectrum disorders. Consistent with the broader literature (9, 10, 31), we observed that minoritized groups were less likely to engage in treatment. Although much of the existing literature focuses on individual factors associated with treatment initiation and engagement, additional research is needed to examine potential systemic factors that might contribute to inequities in access to care. Additionally, we note that comorbid substance use was one of the most robust factors associated with decreased treatment engagement. Given the well-established association between substance use and DSH (16, 32), future research is needed to better understand how substance use contributes to both treatment engagement and DSH in this population.
Of note, we found that treatment initiation significantly reduced the hazard of DSH among individuals with FEP (ATE: HR=0.62 and ATT: HR=0.64). This finding suggests that, even if an individual with FEP decides not to engage in treatment, initiating some form of treatment within 14 days of a diagnosis is essential for reducing DSH. Additional research is needed to determine the mechanisms by which treatment initiation reduces DSH among individuals with FEP. Given the growing body of literature indicating a relationship between positive symptoms of psychosis and suicidal thoughts and behaviors (33), it is possible that the initial treatment contact reduces DSH by reducing positive symptoms. Additionally, it is possible that suicide risk is identified during this initial treatment contact and that providers then offer brief, evidence-based suicide interventions, such as crisis response planning (34, 35), safety planning (36, 37), or lethal means counseling (38), which are commonly used in standard clinical care settings (39). Despite growing evidence that these brief interventions effectively reduce DSH in the general population, it remains unclear how often they are utilized to help individuals with psychosis manage suicide risk; this area is particularly important because individuals with psychosis are often excluded from clinical trials focused on suicide interventions (40). If crisis response planning, safety planning, and lethal means counseling are underused in this population, the dissemination of these interventions could further enhance the positive impact of the initial treatment contact, reducing DSH in this vulnerable population. Additional research is needed to examine whether reduction of positive symptoms, the use of brief evidence-based interventions, or both can account for the impact of treatment initiation on DSH among individuals with FEP.
Contrary to our hypothesis, we found that treatment engagement had no significant impact on DSH. This finding suggests that standard clinical care may not sufficiently reduce DSH among individuals with FEP. Many randomized controlled trials for specialty early intervention programs do not examine suicidal behavior as a primary outcome (41), and the few studies that have done so have yielded mixed results (42–47). Importantly, one recent study reported that the number of individual psychotherapy sessions attended significantly predicted reductions in suicidal ideation during the first year of specialized coordinated care (45). Furthermore, recent efforts to develop suicide interventions for individuals with psychosis have been promising. Specifically, a recent meta-analysis found that suicide-specific interventions significantly reduce suicidal ideation and suicide among individuals with psychosis (48). Nonetheless, this research is still in its infancy, with ongoing trials testing cognitive-behavioral interventions for suicide prevention in psychosis (49). Taken together with our finding that engagement in standard clinical care is not sufficient for reducing DSH, this literature suggests that specialized care might be key for reducing suicide risk in this population. Given the promise of these suicide-specific interventions, further research is needed to determine whether adding these interventions to coordinated specialty care models, such as NAVIGATE, could further reduce the high rates of suicide in this vulnerable population (50).
This study had several strengths. We examined a large population-based sample of individuals with FEP. Moreover, to the best of our knowledge, this was the first study to examine the association of treatment initiation and engagement with DSH in this vulnerable population. However, the following limitations should be considered when interpreting our results. First, the sample in this study had a low rate of DSH (3.6%) compared with samples in previous studies (17, 18). It is possible that the DSH rates we observed were low because we specifically focused on individuals without previous outpatient mental health treatment. Furthermore, DSH is sometimes underrepresented in Medicaid claims data; thus, our findings might underestimate DSH among individuals with psychosis (51–53). Second, consensus is lacking regarding definitions of treatment initiation and engagement among individuals with FEP (9). Therefore, the present study relied on definitions provided by the substance use literature (22, 23). Given NAVIGATE’s recommendations for monthly medication management visits (54), our criteria for treatment engagement might have been more lenient than what is recommended for FEP. Future research should reexamine the relationship between treatment initiation, engagement, and DSH after consensus definitions for this specific population have been developed. Relatedly, our definitions of initiation and engagement included medication management, psychotherapy, and partial hospitalization; therefore, additional research is needed to examine whether the specific type of treatment is related to DSH.
Third, we used Medicaid data from a single state, potentially limiting the generalizability of our findings to the broader population and to non-Medicaid users. Fourth, our sample was predominantly non-Hispanic. Given research showing disparities in treatment access among Hispanic adults (31), further research is needed to examine the relationship of treatment initiation and engagement with DSH among minoritized groups. Fifth, although our use of claims data allowed us to examine a large, population-based sample, this retrospective approach prevented us from determining when participants first started experiencing symptoms and whether they received their first diagnosis before Medicaid enrollment. Additionally, the use of claims data prevented us from differentiating between nonsuicidal self-injury and suicide attempts. Given research indicating that distinct risk factors exist for various aspects of suicide risk (32, 55), further research is needed to determine whether treatment initiation and engagement differentially affect nonsuicidal self-injury and suicide attempts. Additional research is also needed to examine the impact of treatment initiation and engagement on suicidal ideation and suicide. Sixth, although we controlled for a wide range of demographic and clinical factors associated with treatment initiation and engagement, our use of claims data limited our ability to include other important factors that might influence the relationship of DSH with initiation and engagement, such as family support, isolation, treatment motivation, poor medication adherence, duration of untreated psychosis, depression, and symptom severity (9, 10). More research is also needed to determine whether the observed patterns of treatment initiation and engagement generalize to adolescents and young adults with other mental health conditions or whether they are specific to individuals with FEP.

Conclusions

The findings of this study indicate that treatment initiation within 14 days of diagnosis can reduce the hazard of DSH among individuals with FEP. Importantly, treatment engagement did not reduce DSH rates, suggesting that standard clinical care may not be sufficient for reducing DSH among adolescents and young adults with FEP. Given the high rates of suicide in this population (12, 13, 15), our findings suggest a great need for suicide-specific interventions for individuals in the early course of a psychotic disorder. Further research that focuses on identifying effective strategies for reducing DSH among individuals with psychosis is warranted.

Supplementary Material

File (appi.ps.20220372.ds001.pdf)

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Information & Authors

Information

Published In

Go to Psychiatric Services
Go to Psychiatric Services
Psychiatric Services
Volume 74 • Number 9 • September 01, 2023
Pages: 921 - 928
PubMed: 36852553

History

Received: 19 July 2022
Revision received: 7 December 2022
Accepted: 4 January 2023
Published online: 28 February 2023
Published in print: September 01, 2023

Keywords

  1. Epidemiology
  2. Psychosis
  3. Schizophrenia
  4. Suicide
  5. Treatment
  6. Self-destructive behavior

Authors

Details

Heather M. Wastler, Ph.D. [email protected]
Departments of Psychiatry and Behavioral Health (Wastler, Llamocca, Moe, Fontanella), Psychology (Moe), Biomedical Informatics (Brock), and Pediatrics (Bridge), Ohio State University, Columbus; Center for Health Policy and Health Services Research, Henry Ford Health System, Detroit (Llamocca); Center for Suicide Prevention and Research, Abigail Wexner Research Institute, Nationwide Children’s Hospital, Columbus, Ohio (Steelsmith, Bridge, Fontanella); Department of Psychiatry and Behavioral Sciences, Johns Hopkins University School of Medicine, Baltimore (Campo).
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Elyse Llamocca, Ph.D.
Departments of Psychiatry and Behavioral Health (Wastler, Llamocca, Moe, Fontanella), Psychology (Moe), Biomedical Informatics (Brock), and Pediatrics (Bridge), Ohio State University, Columbus; Center for Health Policy and Health Services Research, Henry Ford Health System, Detroit (Llamocca); Center for Suicide Prevention and Research, Abigail Wexner Research Institute, Nationwide Children’s Hospital, Columbus, Ohio (Steelsmith, Bridge, Fontanella); Department of Psychiatry and Behavioral Sciences, Johns Hopkins University School of Medicine, Baltimore (Campo).
View all articles by this author
Aubrey M. Moe, Ph.D.
Departments of Psychiatry and Behavioral Health (Wastler, Llamocca, Moe, Fontanella), Psychology (Moe), Biomedical Informatics (Brock), and Pediatrics (Bridge), Ohio State University, Columbus; Center for Health Policy and Health Services Research, Henry Ford Health System, Detroit (Llamocca); Center for Suicide Prevention and Research, Abigail Wexner Research Institute, Nationwide Children’s Hospital, Columbus, Ohio (Steelsmith, Bridge, Fontanella); Department of Psychiatry and Behavioral Sciences, Johns Hopkins University School of Medicine, Baltimore (Campo).
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Danielle L. Steelsmith, Ph.D.
Departments of Psychiatry and Behavioral Health (Wastler, Llamocca, Moe, Fontanella), Psychology (Moe), Biomedical Informatics (Brock), and Pediatrics (Bridge), Ohio State University, Columbus; Center for Health Policy and Health Services Research, Henry Ford Health System, Detroit (Llamocca); Center for Suicide Prevention and Research, Abigail Wexner Research Institute, Nationwide Children’s Hospital, Columbus, Ohio (Steelsmith, Bridge, Fontanella); Department of Psychiatry and Behavioral Sciences, Johns Hopkins University School of Medicine, Baltimore (Campo).
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Guy Brock, Ph.D.
Departments of Psychiatry and Behavioral Health (Wastler, Llamocca, Moe, Fontanella), Psychology (Moe), Biomedical Informatics (Brock), and Pediatrics (Bridge), Ohio State University, Columbus; Center for Health Policy and Health Services Research, Henry Ford Health System, Detroit (Llamocca); Center for Suicide Prevention and Research, Abigail Wexner Research Institute, Nationwide Children’s Hospital, Columbus, Ohio (Steelsmith, Bridge, Fontanella); Department of Psychiatry and Behavioral Sciences, Johns Hopkins University School of Medicine, Baltimore (Campo).
View all articles by this author
Jeffrey A. Bridge, Ph.D.
Departments of Psychiatry and Behavioral Health (Wastler, Llamocca, Moe, Fontanella), Psychology (Moe), Biomedical Informatics (Brock), and Pediatrics (Bridge), Ohio State University, Columbus; Center for Health Policy and Health Services Research, Henry Ford Health System, Detroit (Llamocca); Center for Suicide Prevention and Research, Abigail Wexner Research Institute, Nationwide Children’s Hospital, Columbus, Ohio (Steelsmith, Bridge, Fontanella); Department of Psychiatry and Behavioral Sciences, Johns Hopkins University School of Medicine, Baltimore (Campo).
View all articles by this author
John V. Campo, M.D.
Departments of Psychiatry and Behavioral Health (Wastler, Llamocca, Moe, Fontanella), Psychology (Moe), Biomedical Informatics (Brock), and Pediatrics (Bridge), Ohio State University, Columbus; Center for Health Policy and Health Services Research, Henry Ford Health System, Detroit (Llamocca); Center for Suicide Prevention and Research, Abigail Wexner Research Institute, Nationwide Children’s Hospital, Columbus, Ohio (Steelsmith, Bridge, Fontanella); Department of Psychiatry and Behavioral Sciences, Johns Hopkins University School of Medicine, Baltimore (Campo).
View all articles by this author
Cynthia A. Fontanella, Ph.D.
Departments of Psychiatry and Behavioral Health (Wastler, Llamocca, Moe, Fontanella), Psychology (Moe), Biomedical Informatics (Brock), and Pediatrics (Bridge), Ohio State University, Columbus; Center for Health Policy and Health Services Research, Henry Ford Health System, Detroit (Llamocca); Center for Suicide Prevention and Research, Abigail Wexner Research Institute, Nationwide Children’s Hospital, Columbus, Ohio (Steelsmith, Bridge, Fontanella); Department of Psychiatry and Behavioral Sciences, Johns Hopkins University School of Medicine, Baltimore (Campo).
View all articles by this author

Notes

Send correspondence to Dr. Wastler ([email protected]).

Competing Interests

Dr. Campo serves on the editorial board of JAMA Pediatrics. Dr. Bridge serves on the scientific advisory board of Clarigent Health. The other authors report no financial relationships with commercial interests.

Funding Information

Dr. Wastler received support from the American Foundation for Suicide Prevention (YIG-0-184-20). Dr. Moe received support from the National Center for Advancing Translational Sciences (KL2TR002734) and a Research Innovation Career Development Award (RICDA) from the Ohio State University College of Medicine. Dr. Brock received support from the Clinical and Translational Science Award (UL1TR002733). Dr. Campo received support from the NIH and Patient-Centered Outcomes Research Institute. Drs. Bridge and Fontanella received support from NIMH (R01 MH-117594-01).The content of this article is solely the responsibility of the authors and does not necessarily represent the official views of the American Foundation for Suicide Prevention or NIMH.

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