A systematic review of longitudinal studies of suicidal thoughts and behaviors in first-episode psychosis: course and associated factors

Soc Psychiatry Psychiatr Epidemiol. 2021 Dec;56(12):2117-2154. doi: 10.1007/s00127-021-02153-2. Epub 2021 Aug 25.


Purposes: To better assess and reduce suicidal risk in first-episode psychosis (FEP), we aimed to investigate the evolution of suicidal thoughts and behaviors (STBs) and associated factors in FEP.

Method: This systematic review (PROSPERO-CRD42020168050) meets PRISMA guidelines. PubMed, Medline, PsycINFO, Embase, EBM Reviews and references lists of relevant articles were searched (February 2020) to identify longitudinal studies, published in English or in French, that assessed the prevalence of STBs at entry to services and over follow-up, and examined factors associated with STBs among all persons with affective and non-affective FEP from a defined catchment area. Screening, data extraction and quality assessment using the adapted Newcastle Ottawa Scale were done independently by two reviewers. Results on prevalence and associated factors are presented by type of STB.

Results: Of 3,177 references, 17 studies of 11 non-overlapping samples (n = 14,907) with varying lengths of follow-up (1-41.7 years) were included. The prevalence of STBs decreased over follow-up. Up to 21.6% made at least one suicide attempt, 27% had suicidal ideation, and 1-4.3% died by suicide during follow-up. Of 53 factors assessed across studies, only male sex, depressive symptoms, and STBs occurring early during follow-up were associated with subsequent STBs. Early intervention for psychosis decreased STBs in the first three years. Other factors were assessed in a single study, yielded conflicting results, or were not associated with STBs.

Conclusions: The high prevalence of STBs following onset of psychosis highlights the need for early detection and intervention and ongoing assessment of suicidal risk throughout follow-up, with attention to identified risk factors. The heterogeneity of the studies precluded a meta-analysis and several factors were each assessed by a single study. Additional well-designed longitudinal studies of STBs and associated factors are warranted.

Keywords: First-episode psychosis; Suicidal thoughts and behaviors; Suicide; Systematic review.

Publication types

  • Review
  • Systematic Review

MeSH terms

  • Humans
  • Longitudinal Studies
  • Male
  • Psychotic Disorders* / diagnosis
  • Psychotic Disorders* / epidemiology
  • Risk Factors
  • Suicidal Ideation*
  • Suicide, Attempted