Suicidal Ideation in People With Psychosis Not Taking Antipsychotic Medication: Do Negative Appraisals and Negative Metacognitive Beliefs Mediate the Effect of Symptoms?

Abstract

Between 5% and 10% of people with psychosis will die by suicide, a rate which is 20-75 times higher than the general population. This risk is even greater in those not taking antipsychotic medication. We examined whether negative appraisals of psychotic experiences and negative metacognitive beliefs about losing mental control mediated a relationship between psychotic symptoms and suicidal ideation in this group. Participants were diagnosed with schizophrenia spectrum disorders, antipsychotic-free for 6 months at baseline, and were participating in an 18-month randomized controlled trial of cognitive therapy vs treatment as usual. We conducted a series of mediation analyses with bootstrapping on baseline (N = 68), follow-up data (9-18 mo; n = 49), and longitudinal data (n = 47). Concurrent general symptoms were directly associated with suicidal ideation at baseline, and concurrent negative symptoms were directly associated with suicidal ideation at 9-18 months. Concurrent positive, negative, general, and overall symptoms were each indirectly associated with suicidal ideation via negative appraisals and/or negative metacognitive beliefs, at baseline and 9-18 months, except for negative symptoms at baseline. Controlling for baseline suicidal ideation and treatment allocation, baseline general symptoms were indirectly associated with later suicidal ideation, via baseline negative appraisals and negative metacognitive beliefs. Baseline negative metacognitive beliefs also had a direct association with later suicidal ideation. These findings suggest the clinical assessment of suicidal ideation in psychosis may be enhanced by considering metacognitive beliefs about the probability and consequences of losing mental control.

Levels of Structural Integration Mediate the Impact of Metacognition on Functioning in Non-affective Psychosis: Adding a Psychodynamic Perspective to the Metacognitive Approach

“…Therefore, findings of the present study must be considered as preliminary and replicated in independent samples, including healthy controls as well as other clinical populations with different levels of structural integration. Future clinical studies might include comparisons between psychodynamic and synthetic metacognitive approaches in terms of specific interventions, as well as multi-method designs, relative vs. absolute measures of psychosocial functioning and further relevant outcome measures like suicidality (Hutton et al, 2019).…”

Are negative beliefs about psychosis associated with emotional distress in adults and young people with such experiences? A meta‐analysis

“…(2015) and Pyle, Stewart, et al (2015) found that baseline scores on the ‘negative appraisals of experience’ and ‘expectations’ subscales were predictive of depression at 3‐ and 6‐month follow‐up, respectively. Three studies investigated the association between negative beliefs and suicidal ideation or risk over periods between 6 and 18 months, but no significant relationships were reported (Hutton et al , 2019; Pyle, Stewart, et al , 2015; Stip, et al , 2017). However, small samples in two of these studies likely limited power ( n = 45–68).…”

“…A small number of studies controlled for psychosis symptoms (Birchwood et al , 2007; Hutton et al , 2019; Karatzias, Gumley, Power, & O’Grady, 2007; Rooke & Birchwood, 1998; Shahar, Weinberg, McGlashan, & Davidson, 2010; Upthegrove et al , 2014). These publications reported that when controlling for psychosis symptoms, cognitive appraisals (e.g., entrapment, loss) remained significantly associated with depression, anxiety, and (in one study; cross‐sectional association in Hutton et al, 2019) suicidal ideation, whilst psychosis symptoms (e.g., positive symptoms) were not found to significantly predict emotional distress.…”

“…respectively. Three studies investigated the association between negative beliefs and suicidal ideation or risk over periods between 6 and 18 months, but no significant relationships were reported (Hutton et al, 2019;Pyle, Stewart, et al, 2015;Stip, et al, 2017). However, small samples in two of these studies likely limited power (n = 45-68).…”

Metacognition Research in Psychosis: Uncovering and Adjusting the Prisms That Distort Subjective Reality

“…Paul Lysaker et al 11 demonstrate the link between meta-cognition and disturbances in awareness of illness regardless of any accompanying symptom configuration, and Kelsey Bonfils et al 12 present novel findings linking metacognition with empathy, one of the foundations of human relatedness; these 2 articles rely on Paul Lysaker's approach. Finally, Paul Hutton et al 13 build upon Wells' model and describe how both negative appraisals of psychotic experiences and negative metacognitive beliefs about worry may mediate the relationship between psychotic symptoms and suicidal ideation.…”