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Suicidality in Children and adolescents with first episode psychosis
Author's Response
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Tatiana Falcone, Child Psychiatrist Cleveland Clinic, Erin Carlton, Damir Janigro, Kathleen Franco
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falcont1{at}ccf.org Tatiana Falcone, et al.
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Dear Editor We will like to thank Dr Harvey and colleagues for bringing attention to the frequency of self harm during the first episode psychosis. Our data which we are submitting for publication indicates an even greater concern in this population. Retrospective review of all psychotic patients admitted to a child and adolescent psychiatry unit from 2003-2006. Out of 1500 cases reviewed, 102 patients below the age of 18 were identified with first onset psychosis between the ages of 8 years old and 18 years old they carried the following diagnosis Psychosis NOS, schizophreniform disorder, schizoid personality disorder. In our sample 32% of the patients had a recent history of self harm (suicidal attempt) just prior to the admission for their initial psychosis. Contrary to Dr Harvey et al we we did not found male gender was associated with higher incidence of self harm and violence against others, but it was associated with high severity on the attempt. Interestingly enough 28.43 % of our group accessed the legal system first and later the mental health system, secondary to violence against others. Poor insight of psychotic patients may predispose them to make wrong choices and end up in the legal system before entering the mental health arena. Previous non-psychotic psychiatric history was reported by 74 patients. The most frequent commorbidity was ADHD followed by, Intermittent Explosive Disorder, separation anxiety, Oppositional defiant disorder, and emotional instability manifested by depression, explosiveness, or violence against self or others. Labile affect is a key symptom when suspecting an organic brain disorder, as is poor attention and motor abnormalities. When psychosis presents earlier in life are there more physiologic factors at play than later in the 3rd or 4th decade? Future research is needed to detect any differences what triggers psychosis in childhood versus adult cases. Observation that children who are often more disinhibited than adults is consistent with this higher percentage and particularly from an inpatient service. The immature brain continues to develop into young adulthood, when myelination, pruning, and other neuronal maturation remain incomplete. It is understandable then why there maybe a difference in rates of self harm with even higher numbers in children and adolescents. Male gender, negative symptoms and persecutory delusions are clearly linked to greater treatment delay; this could also explain the increased rate in males. The quality of the initial treatment intervention for the first psychotic episode is critical. Each progressive psychotic episode impacts brain development, social and family relationships. Investing efforts in improving the approach to treatment of the first psychotic episode may improve the eventual life outcome. There should be a low threshold for hospitalization of psychotic children, since the suicide attempt was so high in this population. This further supports the importance of a strong psychosocial plan and close follow up for both patient and family. Perhaps the most critical piece in the treatment of psychotic children is engaging the family early enough to enhance their understanding of the role of medication and close follow up and the consequences of inadequate or partial treatment. Tatiana Falcone MD Erin Carlton MDc Damir Janigro PhD Kathleen Franco MD |
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Samuel B Harvey King's College London, Institute of Psychiatry
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s.harvey{at}iop.kcl.ac.uk Samuel B Harvey
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We wish to thank Falcane, Carlton, Janigro and Franco for their interest in our recent paper (1). The results they share from their own review of self harm amongst children and adolescents with first episode psychosis are both interesting and concerning. They report nearly a third of young patients engaged in self harm immediately prior to their first admission to hospital. While this is significantly higher than the 11% we reported in our study, it is difficult to make direct comparisons without knowing more about the comparability of the two services and populations. It should also be noted that our study included all cases presenting to any mental health service, while their study only included admissions, thus focusing on a potentially higher risk group. Despite this, their results did prompt us to re-examine the effect of age within our data. As we initially reported, young age did not seem to confer any increased risk of self harm in our sample. Our sample included 44 adolescents aged between 16 and 18 years of age. Of these, six (13.6%) engaged in some form of self harm during the pre-treatment period of psychosis. We were not able to determine whether adolescents with first episode psychosis presented with a different range of risk factors for self harm. Yours sincerely Dr S B Harvey References 1. Harvey SB, Dean K, Morgan C, Walsh E, Demjaha A, Dazzan P, et al. Self-harm in first-episode psychosis. Br J Psychiatry 2008;192(3):178-84. Declaration of Interests None |
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