Association of Psychotic Experiences With Subsequent Risk of Suicidal Ideation, Suicide Attempts, and Suicide Deaths: A Systematic Review and Meta-analysis of Longitudinal Population Studies

Abstract

Importance: Recent research has highlighted that psychotic experiences are far more prevalent than psychotic disorders and associated with the full range of mental disorders. A particularly strong association between psychotic experiences and suicidal behavior has recently been noted.

Objective: To provide a quantitative synthesis of the literature examining the longitudinal association between psychotic experiences and subsequent suicidal ideation, suicide attempts, and suicide deaths in the general population.

Data sources: We searched PubMed, Excerpta Medica Database, Cumulative Index to Nursing and Allied Health Literature, and PsycINFO from their inception until September 2017 for longitudinal population studies on psychotic experiences and subsequent suicidal ideation, suicide attempts, and suicide death.

Study selection: Two authors searched for original articles that reported a prospective assessment of psychotic experiences and suicidal ideation, suicide attempts, or suicide death in general population samples, with at least 1 follow-up point.

Data extraction and synthesis: Two authors conducted independent data extraction. Authors of included studies were contacted for information where necessary. We assessed study quality using the Newcastle-Ottawa Quality Assessment Scale. We calculated pooled odds ratios using a random-effects model. A secondary analysis assessed the mediating role of co-occurring psychopathology.

Main outcomes and measures: Psychotic experiences and subsequent suicidal ideation, suicide attempts, and suicide death.

Results: Of a total of 2540 studies retrieved, 10 met inclusion criteria. These 10 studies reported on 84 285 participants from 12 different samples and 23 countries. Follow-up periods ranged from 1 month to 27 years. Individuals who reported psychotic experiences had an increase in the odds of future suicidal ideation (5 articles; n = 56 191; odds ratio [OR], 2.39 [95% CI,1.62-3.51]), future suicide attempt (8 articles; n = 66 967; OR, 3.15 [95% CI, 2.23-4.45]), and future suicide death (1 article; n = 15 049; OR, 4.39 [95% CI, 1.63-11.78]). Risk was increased in excess of that explained by co-occurring psychopathology: suicidal ideation (adjusted OR, 1.59 [95% CI, 1.09-2.32]) and suicide attempt (adjusted OR, 2.68 [95% CI, 1.71-4.21]).

Conclusions and relevance: Individuals with psychotic experiences are at increased risk of suicidal ideation, suicide attempts, and suicide death. Psychotic experiences are important clinical markers of risk for future suicidal behavior.

Figure 1.. PRISMA Style Flow Diagram of Included Studies

Figure 2.. Conceptual Model of the Association Between a Range of Risk Factors and Psychotic Experiences and Suicidal Behavior

Because of shared risk factors, psychotic experiences function as a risk marker for suicidal behavior.

Figure 3.. Forest Plot Showing Association Between Psychotic Experiences and Suicidality

Studies are shown for suicide ideation (A), suicide attempt (B), and suicide death (C). Horizontal lines represent 95% CIs. Diamonds show overall pooled estimate for each subset. The vertical line indicates the mean. ES indicates effect size.

Figure 4.. Forest Plot Showing the Association Between Psychotic Experiences and Suicidality, Adjusted for Psychopathology

Studies are shown for suicide ideation (A) and suicide attempt (B). Horizontal lines represent 95% CIs. Diamonds show overall pooled estimate for each subset. The vertical line indicates the mean. ES indicates effect size.