Clinical features and factors related to lifetime suicidal ideation and suicide attempts in patients who have had substance-induced psychosis across their lifetime

The World Health Organization (WHO) reports that more than 700,000 people commit suicide every year, which is considered a global concern and a public health problem (World Health Organization, 2021). Although suicide had decreased by around one-third before the COVID-19 pandemic (Turecki et al., 2019; World Health Organization, 2021), it could be expected that the pandemic has had an impact, and thus suicide behaviors may increase (Czeisler et al., 2020; Farooq et al., 2021). Suicide represents a tragedy for the individual, family, and society (Turecki et al., 2019; World Health Organization, 2021). Consequently, studies on suicide behaviors are critical and have grown exponentially in recent years (Turecki et al., 2019). Despite some debate and the difficulty in establishing specific terminology, suicide behaviors may be considered as a continuum (Goodfellow et al., 2018; Klonsky et al., 2016; Turecki et al., 2019). This spectrum includes nonsuicidal self-injury, suicidal ideation (SI), suicide attempts (SA), and completed suicide (Goodfellow et al., 2018; Turecki et al., 2019). Suicide-spectrum behavior research has mainly focused on SI and SA, as they are frequently observed in daily practice, have a high correlation to suicide, and due to the very nature of suicide in which it is not directly possible to study it after the event (Klonsky et al., 2016).

Several models have been proposed to understand the etiopathogenesis of suicidal behaviors from theoretical to empirical approaches (Díaz-Oliván et al., 2021; Klonsky et al., 2018). Most models describe or suggest a complex interaction between diverse factors which would act either as risk/predisposing factors or as precipitants (i.e. from ideation to the action or event) (Díaz-Oliván et al., 2021; Klonsky et al., 2018). Among those elements are included genetic, biological, psychological, clinical, environmental, and social factors (Díaz-Oliván et al., 2021; Klonsky et al., 2016, 2018; May and Klonsky, 2016; Turecki et al., 2019). Substance use disorders (SUDs) are a frequent factor implied in suicidal behaviors (Armoon et al., 2021; Rodríguez-Cintas et al., 2017). In this line, it has been suggested that SUDs may help to distinguish between patients with SI (ideators) and those who actually had SA (attempters) (May and Klonsky, 2016). In any case, a recent meta-analysis reported that 35% of SUD patients presented SI in the last year, while 20% had SA (Armoon et al., 2021). There are several factors that may explain the high prevalence of SI and SA among SUD patients, including concurrent mental disorders (Rodríguez-Cintas et al., 2017). Further, primary and induced psychotic disorders are considered a risk factor for suicide behaviors (Bai et al., 2021; Rodríguez-Cintas et al., 2017; Rognli et al., 2022). However, to the best of our knowledge, the prevalence of SI or SA remains unknown in patients with substance-induced psychosis (SIP). It could be expected that the prevalence is as high as that in SUD patients (35% for SI and 20% for SA) or in patients with schizophrenia (34.5% for SI and 26.8% for SA) (Armoon et al., 2021; Bai et al., 2021; Lu et al., 2019).

SIP is frequently observed in SUD patients, with a prevalence between 0.8% to more than 80% in SUD patients (Fiorentini et al., 2021) and an annual incidence ranging between 9.3 to 14.1 per 100,000 persons in the general population (Rognli et al., 2022). The prevalence varies according to the substance analyzed. For example, cannabis-induced psychosis has a prevalence between 0.8% and 10% (Fiorentini et al., 2021), while the prevalence associated with psychostimulants may rise above 37.5% (Lecomte et al., 2018) and from 55.6% to more than 85% for cocaine-induced psychosis (Roncero et al., 2014; Sabe et al., 2021). SIP is considered to be one of the most serious consequences of SUD. Patients with SIP are at risk of schizophrenia and other mental disorders, have higher mortality rates than the general population, present more concurrent disorders, have higher impulsivity, and have worse addiction severity and an inferior quality of life (Hjorthøj et al., 2021a; Murrie et al., 2020; Rognli et al., 2022; Roncero et al., 2013, Roncero et al., 2014, Roncero et al., 2017).

Compared to SUD patients, the factors related to suicide behaviors among patients who have had SIP across their lifetime have received scant research attention. A recent large Danish cohort study found that SIP was a risk factor for suicide (Hjorthøj et al., 2021b). The study reported a risk mortality pattern, with SIP patients who transition to schizophrenia having the highest risk for suicide, followed by SIP patients who do not convert to schizophrenia, and finally by patients with schizophrenia and no SIP. This tendency was observed for all substances except amphetamines (Hjorthøj et al., 2021b). Similarly, Hajebi et al. (2018) found that the numbers of suicide attempts are similar for patients with methamphetamine-induced psychosis and primary psychosis (Hajebi et al., 2018). Few studies have focused on clinical factors related to suicide behaviors in SIP patients. Zarrabi et al. (2016) reported that SI and SA are prevalent and not related to the duration of psychotic symptoms in patients with methamphetamine-induced psychosis (Zarrabi et al., 2016). The authors proposed that depression could explain the suicide behaviors in methamphetamine users and patients with methamphetamine-induced psychosis (Zarrabi et al., 2016). Other factors, such as gender, impulsivity, trauma, anxiety, personality disorders, and addiction characteristics, are usually related to both SIP and suicide behaviors in SUD patients (Andersson et al., 2022a, 2022b; Fiorentini et al., 2021; López-Goñi et al., 2018; Marino et al., 2020; Masferrer et al., 2018; Rodríguez-Cintas et al., 2017; Sideli et al., 2020). Therefore, it may be theorized that the findings on SUD patients may be extrapolated to SIP patients, as several factors associated with suicide behaviors are also known risk factors for SIP. However, further studies are needed on this issue.

This research aims to explore the prevalence, clinical features, and factors related to lifetime SI and SA in patients who have had SIP across their lifetime.

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