Risk assessment for violence and self-harm in first episode psychosis and the need for early psychosis intervention services

To the Editor

The Australian and New Zealand Journal of Psychiatry has become an important forum for the sometimes heated debate about the value of early intervention in psychosis services (Amos, 2012; Castle, 2012; McGorry, 2012; Mihalopoulos et al., 2012; Nielssen et al., 2012; Yung, 2012). To date, much of the argument has related to cost effectiveness and the impact of early intervention on the long-term prognosis of schizophrenia. Here, we draw on the results of two recently published systematic meta-analyses to consider the potential for early intervention services to reduce the incidence of both violence and suicidal behaviour in first episode psychosis.

The first meta-analysis estimated that 35.4% of patients with first episode psychosis commit any act of violence, 16.6% commit an act of serious violence and 0.6% commit an act of severe violence (Large and Nielssen, 2011). The second meta-analysis estimated that 18.4% of patients with first episode psychosis attempt suicide at some stage prior to treatment and that 9.8% make a suicide attempt after the onset of psychosis but before initial treatment (Challis et al., 2013). The two meta-analyses combined the results of all of the available research in order to establish the risk factors for violence and self-harm in a way that minimises the possibility of both type I and type II errors.

An examination of the risk factors for self-harm and violence determined by meta-analyses reveals that some risk factors for one form of harm are protective against the other, and vice versa (Table 1). For example, depressed mood and insight are risk factors for self-harm but protective against violence, whereas a history of involuntary treatment and male sex are risk factors for violence but protect against self-harm. There are a number of shared risk factors for violence and self-harm, including young age, substance use, failure to complete school and the duration of untreated psychosis. A notable finding was a lack of an association between positive symptoms and either violence or self-harm.

Table 1.

Effect size and relative effect size directions of factors associated with violence and self-harm in first episode psychosis as determined by meta-analysis.

	Odds ratios		Effect size direction
	Violence	Self-harm
Age	0.54 a	0.57 a	Same
Alcohol use	1.43	1.68 a	Same
Depressed mood	0.57 a	2.61 a	Opposite b
Drug use	2.33 a	1.46 a	Same
Duration of untreated psychosis	1.56 a	1.45 a	Same
Involuntary treatment	3.84 a	0.79	Opposite b
Less education	1.99 a	1.38 a	Same
Less insight	1.31	0.61 a	Opposite b
Male	1.61 a	0.85	Opposite b
Negative symptoms	0.82	1.20	Opposite
Positive symptoms	1.20	1.05	Same
Schizophrenia	1.02	0.92	Opposite
Self-harm	1.22	3.94 a	Same

a

Statistically significant with a p-value > 0.05 as determined by meta-analysis.

b

Statistically significant opposite effect sizes as determined by confidence intervals.

The combined results of these meta-analyses have four implications. First, the high incidence of self-harm and violence in first episode psychosis suggests that the reduction in these harms should be a priority for mental health services. Second, the complex and contradictory nature of risk factors for self-harm and violence means that efforts to categorise people with first episode psychosis into meaningful overall risk groups are fundamentally flawed. Third, the most effective way to reduce harm is likely to be via interventions that mitigate shared risk factors for self-harm and violence. These interventions would be based more on the principle of universal clinical precautions than on risk assessment and should include efforts to reduce the duration of untreated psychosis and treat co-morbid substance use. Fourth, the treatment of substance abuse in early psychosis appears to be of importance because it holds out more hope of preventing harm than the treatment of positive symptoms. Further, it is now known that first episode psychosis presents a window of opportunity during which patients can cease using substances and can experience real benefits in terms of improvement in mood, positive symptoms and social function (Mullin et al., 2012).

The debate about the need for specialist first episode psychosis services is likely to continue. However, these findings emphasise the need to design mental health services that can provide prompt treatment for psychosis, are acceptable to young people, and can concentrate on co-morbid substance use.