Brief psychotic disorder and suicidal behavior

To the Editor

The central characteristic of brief psychotic disorder (BPD) is a disturbance that involves the sudden onset of at least one of the following psychotic symptoms: delusions, hallucinations, disorganized speech, or grossly abnormal psychomotor behavior, including catatonia (American Psychiatric Association, 2013). Duration of an episode of BPD is at least 1 day but less than 1 month, with eventual full return to premorbid level of functioning. BPD is a DSM-V diagnosis which is similar to the ICD-10 diagnosis of acute transient psychotic disorder (ATPD). The annual incidence of BPD ranges from 4 to 10 per 100,000. The average age at onset is in the mid 30s but onset can occur across the lifespan. Severe psychological stressors may precipitate BPD. Individuals with BPD typically experience emotional turmoil, anxiety or confusion.

Because the disturbance is brief and the prognosis is very good some clinicians may underestimate a suicide risk in patients with BPD/ATPD. The level of impairment during an acute episode may be very significant. Observation of all psychotic patients is necessary to ensure that the patient is protected from acting on the basis of delusions or rapid mood changes. Several lines of evidence suggest that BPD/ATPD is associated with an increased risk of suicidal behavior (Pillmann et al., 2003; Castagnini and Bertelsen, 2011). In one study, suicidal behavior was examined in the index episode of ATPD and during a 5-year prospective follow-up (Pillmann et al., 2003). This study showed that 26.1% of subjects with ATPD had suicidal symptoms (suicide ideation and suicide attempt) during the index acute episode. During the follow up period 35.7% of patients with ATPD made suicide attempts. 14.3% of individuals with ATPD made one suicide attempt and 21.4% of ATPD patients attempted suicide more than once. Another study suggested that ATPD is associated with excess mortality from both natural and unnatural causes, particularly from suicide in younger subjects (Castagnini and Bertelsen, 2011). Data from all subjects aged over 15 years who were enrolled in 1996 in the Danish psychiatric register with a first-admission diagnosis of ATPD were linked to the national register of causes of death. Over the period 1996–2001, the standardised mortality ratio for suicide was 30.9. These studies suggest that all health professionals should be educated that BPD/ATPD is associated with an elevated risk of suicidal behavior and that BPD/ATPD patients need follow-up and during that time careful evaluation of suicidality should take place.