Open Access

Differences between subjective experiences and observed behaviors in near-fatal suicide attempters with untreated schizophrenia: a qualitative pilot study

  • Taiju Yamaguchi1,
  • Chiyo Fujii2Email author,
  • Takahiro Nemoto1,
  • Naohisa Tsujino1,
  • Kiyoaki Takeshi1 and
  • Masafumi Mizuno1
Annals of General Psychiatry201514:17

https://doi.org/10.1186/s12991-015-0055-1

Received: 1 August 2014

Accepted: 31 March 2015

Published: 15 April 2015

Abstract

Background

In cases of untreated schizophrenia, the patients’ entourage often does not recognize the psychotic symptoms of the patient and the possibility that the patient may attempt suicide. The aim of this study was to investigate the discrepancies between the subjective experiences and observed behaviors in near-fatal suicide attempters with untreated schizophrenia.

Methods

A semi-structured interview was carried out with seven near-fatal suicide attempters with untreated schizophrenia to examine the subjective experiences at the time of the suicide attempt. The families of the patients were also interviewed to determine their recognition of the patients’ psychotic symptoms and the suicidal ideation. The interview data were analyzed qualitatively.

Results

Six subjects were undergoing exacerbation of the psychotic symptoms at the time of exhibiting the suicide-related ideation. One subject had been in a prolonged depressive state before attempting suicide. Although all the patients experienced severe distress due to psychotic symptoms and depressive mood, they all exhibited only low level or no help-seeking behavior, and six of seven families had not recognized the change in the patient’s mental condition.

Conclusions

Appropriate information about schizophrenia should be provided to the general public so that any help-seeking by the patients with this disease is not overlooked. In addition, accessible early intervention services for psychosis should be established.

Keywords

Untreated schizophrenia Suicide Help-seeking Family Psychoeducation

Background

Suicide is one of the most significant causes of unexpected death among patients with schizophrenia, particularly during the early phase of the illness [1-4]. Given that 10%–28% of patients diagnosed with a first episode of psychosis have already attempted suicide prior to the first treatment [5-7] and that the risk of suicide is high even in the prodromal phase of schizophrenia [8], there is a possibility that a considerable number of patients commit suicide prior to being recognized as suffering from schizophrenia needing appropriate treatment. This suggests that the actual risk of suicide in schizophrenia might be higher than the estimated based on epidemiological studies. Moreover, previous studies indicate that the longer the duration of untreated psychosis (DUP), the higher the risk of suicide-related behaviors [9-11]. Thus, there is no doubt that a clear understanding of the association between the characteristics of the clinical features and suicide-related behaviors in untreated schizophrenia is critical to provide necessary care to those with who are at a high risk of suicide arising from treatable symptoms.

While depressed mood, low self-esteem, hopelessness, and previous suicide attempts are well-established risk factors [12,13], the relationship between the psychiatric symptomatology and suicide in people with schizophrenia is not yet well understood [12,14]. In order to examine the causes and psychological processes of suicide, the psychological autopsy method has been widely used in scientific research [15]. Although psychological autopsy is a well-established method, its efficiency is limited in cases of untreated schizophrenia, because the patient’s entourage had often not recognized the psychotic symptoms of the patient [16,17], and as a result, they may not be able to report on the mental status associated with the suicide-related behavior.

Therefore, instead of psychological autopsy, we conducted semi-structured interviews of persons diagnosed with schizophrenia for the first time in their lives only after they exhibited near-fatal suicide attempts [18] in order to examine the subjective experiences which are potentially relevant to suicide in people with untreated schizophrenia. We also conducted interviews with patients’ family members to investigate the families’ awareness of the mental state of these persons prior to their suicide attempts. A better understanding of the subjective experiences related to suicide and of the discrepancies between the subjective experiences and observed behaviors may be helpful to devise more effective measures for preventing suicide among persons with schizophrenia.

In this article, the terms to describe suicidality were followed the guidelines published by Silverman et al. [19,20].

Methods

Study subjects

Patients were included in the study if they met the following criteria: admission to the emergency care unit of the Toho University Omori Medical Center in Tokyo between January 2007 and June 2011, after a near-fatal suicide attempt [16] and consulting the psychiatric department; aged 18 to 65 years; diagnosis of schizophrenia (F20 according to the ICD-10 research criteria; World Health Organization, 1992); no neurological or endocrine disorders to explain the psychosis; no mental retardation; no substance-induced psychotic disorders; no previous history of psychiatric consultation and/or treatment; willing and able to give informed consent. Seven patients met the criteria during the study period.

Method

Semi-structured interviews of patients fulfilling the above criteria were conducted just after the psychiatrists responsible for the patients decided that the patient’s physical and mental conditions was stable enough to be interviewed. On the same day, semi-structured interviews of the patient’s family members were also conducted separately from the patients. Family members gave written informed consent to participate in the study. The topics covered our semi-structured interviews were as follows.

Interview with the patient:
  • Subjective experience of symptoms,

  • Mental state at the time of the suicide attempt,

  • Psychosocial stressors,

  • History of previous suicide attempts,

  • Timing of appearance of vague suicidal ideation,

  • Timing of appearance of definite suicidal ideation, and

  • Help-seeking behaviors.

Interview with the family:
  • Objective observations,

  • Recognition of the patient’s mental health problems (possibility that the patient has psychosis),

  • Recognition of the patient’s suicidal ideation, and

  • Realization of the patient’s need for psychiatric consultation.

All the interviews were conducted by TY. Using a grounded-theory approach [21], TY, CF, and MM coded the transcriptions of the recorded data and analyzed by a series of discussions to identify the subjects’ clinical characteristics, subjective experiences at the time of the suicide attempt, psychosocial stressors related to suicide-related ideation, psychological processes leading to the suicide attempt, characteristics of the patients’ help-seeking behaviors, and the families’ recognition of the patients’ psychiatric problems before their suicide attempts.

Ethical approval for the research was obtained from the Ethical Research Committee of Toho University Omori Medical Center.

Results

Clinical manifestations and subjective experiences

Cases 1–6 showed rapid exacerbation of psychotic symptoms preceding the suicide attempt. Case 5 recalled that the death of his aunt may have been the trigger of exacerbation of the symptoms. Case 6 said that psychotic symptoms became more pronounced after she was hospitalized for physical illness. Cases 1–4 could not recall any trigger for the exacerbation of the symptoms. Case 7 was in a severe depressed mood but had no acute deterioration of psychotic symptoms preceding the suicide attempt.

The results presented in Table 1 summarize the subjective experiences of the patients. In regard to the contents of the hallucinations, cases 1 and 4 had command hallucinations; case 1 followed a command to exhibit suicide-related behavior; his behavior was not suicide-related in the actual sense, as he did not show suicide-related ideation at any time during the entire process. He simply followed the voices he heard suggesting that said that he would be able to fly if he jumped from the sixth floor of his apartment building, and he had not expected that he would fall to the ground. Case 4 attempted suicide because of the severe distress caused by the powerful hallucination saying ‘drop dead!’ not because he followed the command hallucination.
Table 1

Characteristics of patients and their subjective experiences

Case number

Gender

Age

DUP (months)

Marital status

Length of formal education

Employment status

Dominant clinical symptoms

Timing of the appearance of vague suicide-related ideation

Timing of the appearance of definite suicide-related ideation

1

Male

40

156

Single

16

Unemployed

Command hallucination saying ‘jump off’

(−)

(−)

Delusion of persecution, delusion of reference

       

Thought broadcasting

  
       

Insomnia, social avoidance

  

Male

34

20

Single

12

Unemployed

Delusion of persecution, delusion of reference

4 days before

Just before

       

Acute stress reaction

  
       

Delusion of observation

  
       

Thought broadcasting

  
       

Depressed mood as a reaction to the psychotic episode

  
       

Insomnia, social avoidance

  

3

Male

30

Single

14

Auditory hallucination

Just before

       

Acute stress reaction

  
       

Delusion of persecution, delusion of reference

  
       

Depressed mood as a reaction to the psychotic episode

  
       

Insomnia, Social avoidance

  

4

 

26

3

Single

14

Unemployed

Command hallucination saying ‘drop dead’

10 days before

Just before

       

Acute stress reaction

  
       

Delusion of persecution, delusion of reference

  
       

Thought broadcasting

  
       

Depressed mood as a reaction to the psychotic episode

  
       

Insomnia

  
 

Male

55

300

Single

16

Unemployed

Delusion of persecution, delusion of reference

6 hours before

6 hours before

       

Acute stress reaction

  
       

Depressed mood as a reaction to the psychotic episode

  
       

Social avoidance

  

6

Female

59

 

Married

14

 

Delusion of reference

3 hours before

 
       

Acute stress reaction

  
       

Depressed mood as a reaction to the psychotic episode

  
       

Social avoidance

  

7

Male

 

22

Divorced

 

Unemployed

Depressed mood

 

11 days before

       

Hopelessness

  
       

Insomnia, loss of appetite

  
       

Hypobulia

  
       

Delusion of reference, Thought broadcasting

  
       

Social avoidance

  

Italicized data are the most influential symptoms on each case’s suicidal behavior.

In cases 2–6, the rapid exacerbation of positive symptoms (auditory hallucinations, delusion of persecution, and so forth) inflicted such unbearably painful experiences that they felt a sudden surge of suicide-related ideation. In these cases, the period between the appearance of definite suicide-related ideation and the suicide attempt was very short. None of cases 1–6 had attempted suicide previously.

In case 7, mainly depressed mood and hopelessness were associated with the suicide-related ideation. This patient had experienced a psychosocially stressful life event that had triggered the suicidal ideation. After his apartment building was recognized to be in need of remodeling, his depressed mood deteriorated because he did not have enough money to have the building remodeled. Case 7 had also attempted suicide 11 days prior to the suicide attempt that resulted in hospitalization. In the previous attempt, he had changed his mind about suicide and stopped the behavior of his own will. In this subject, the period from the appearance of definite suicidal ideation to the suicide attempt was longer than in the other cases. He said that he was fluctuating between wanting to die and wanting to live until the near-fatal suicide attempt.

Help-seeking behaviors and recognition by the families

Table 2 shows the patients’ help-seeking behaviors and recognition of the symptoms by the families. All of the patients exhibited only low level or no help-seeking behaviors in response to their psychotic symptoms and distress. Therefore, most family members did not recognize the patients’ need for psychiatric treatment.
Table 2

Observed behaviors: patient’s help-seeking behavior and the families’ recognition

 

Patient’s help-seeking behavior

Families’ recognition of the possibility that the patient has psychosis

Families’ realization that the patient may attempt suicide

Case 1

None

(−)

(−)

Case 2

Not enough

(−)

(−)

Case 3

Not enough

(−)

(−)

Case 4

Not enough

(+)

(−)

Case 5

None

(−)

(−)

Case 6

Not enough

(−)

(−)

Case 7

Not enough

(−)

(−)

Case 2 told his mother only once that he felt like his conversations were wiretapped. His mother took little note of this because he was not talking in a very serious tone. Case 3 handed a note to his mother saying that he had heard something unusual, but the mother had not taken this seriously. Case 7 told his friends, but not his family, that he often felt depressed. In case 4, while the family had recognized that the patient needed to see a psychiatrist because of his restless behavior, they failed to persuade him to seek psychiatric treatment. Although case 4 himself recognized that he had psychiatric problems, he believed that no medical treatment could ameliorate his problems, and his family had no information about whom to consult in such a situation.

Discussion

Most existing reports on the role of psychotic symptoms in suicidality have focused on the quantitative aspects of the symptoms. However, given that the relationships between psychotic symptoms and suicide-related ideation are diverse, the qualitative aspects of the symptoms should also be considered. Since the direct examination of the psychological processes of suicide completers with untreated schizophrenia is impossible, we examined the characteristics of the suicide-related behaviors of near-fatal suicide attempters with untreated schizophrenia in order to obtain a clearer understanding of the psychological processes leading to suicide. We also focused on the discrepancies between the subjective experiences and observed behaviors in people with schizophrenia in an attempt to devise more effective suicide prevention strategies.

Six out of seven patients in this study exhibited a depressed mental status at the time of the suicide attempt. This is to some extent in line with previous research indicating that suicide attempts during untreated psychosis are associated with depressive episodes [22]. However, the present results show that depressed mood itself does not always have a direct relation to suicide. Subjectively, case 7 had severe depressed mood induced by psychosocial factors that was directly related to suicide, whereas cases 2–6 suffered from relatively low-level depressed moods not directly related to the suicidal behavior. In the latter cases (cases 2–6), rapid exacerbation of the psychotic symptoms was associated with an increased risk of suicide.

In cases that experienced rapid exacerbation of the psychotic symptoms, the period between the appearance of definite suicidal ideation and the near-fatal suicide attempt was very short, and these patients attempted suicide without hesitation, unlike case 7, who did not show rapid exacerbation of the psychotic symptoms. In regard to case 1, who followed the direction of the command hallucination, his sudden suicide-related behavior can be interpreted as being a consequence of his thinking being dominated by the hallucination. In the other cases (cases 2–6), patients’ minds were not entirely dominated by the delusions or hallucinations, but the rapid exacerbation of psychotic symptoms caused an acute stress reaction in the patients. For people with psychotic symptoms, delusions of persecution and auditory hallucinations can be challenging or traumatic life events that may cause social avoidance, depression, or PTSD [23-25]. The results of the present study suggest that rapid exacerbation of psychotic symptoms can cause an acute stress reaction leading to fatal suicidal behavior. This suggests that crisis intervention in cases with rapid exacerbation of the psychotic symptoms is vital to prevent suicide, even if the patient does not have suicide-related ideation and/or severe depressed mood at the time.

These findings seem to be inconsistent with the results of previous research showing that suicide-related behavior is not common at the peak of psychosis [26,27]. Whether delusional ideas and/or hallucinations function as protective factors or risk factors for suicide may depend on the contents [28] and/or intensity of such symptoms. In regard to command hallucinations, which have been recognized as risk factors for suicide in patients with psychosis [29], it is important for suicide prevention to consider the contents of the hallucinations and how these symptoms affect each patient. In this study, one case responded to the command hallucination, resulting in self-injurious behavior (case 1), another case developed acute stress reaction due to the contents of the powerful command hallucinations that were quite distressing to the patient (case 4).

The results of the present study demonstrate that there are several obstacles to provide early interventions in response to rapid deterioration of psychotic symptoms: poor public awareness and failure to recognize the symptoms of psychosis, lack of appropriate help-seeking behaviors from the patients for distressing symptoms, and limited social resources for mental health services.

Previous studies suggested that families and caregivers play a principal role in shortening the delays in providing treatment for psychosis [30,31]. However, public knowledge of mental disorders, and in particular, of specific schizophrenia symptoms, is poor [32], and families tend to underestimate patients’ early psychotic symptoms [31]. In cases 2 and 3, despite the families knowing that the patients suffered from delusions of persecution or auditory hallucinations, they never believed that the patients might be in need of psychiatric treatment.

In Japan, local authorities have started setting up educational activities for preventing suicide based on the Suicide Prevention Law enacted in 2006. Most of these are educational programs on depression targeted at gatekeepers [33,34]. Previous studies have shown that educating gatekeepers on depression decreased suicide rate [35,36]. On the other hand, the results of the present study indicate that most family members did not recognize the signs of psychosis in the patients, suggesting that the number of people with untreated schizophrenia committing suicide may be higher than suggested by the statistics. Given the epidemiological data that schizophrenia occurs mostly in adolescents [37,38] and that the mean DUP in Japan is 13.7–20.3 months [39,40], proactive public information campaigns about psychosis and incorporating mental health literacy education in schools as part of the curriculum are necessary for devising more effective suicide prevention strategies, especially for the younger generation.

Considering the results of this study and previous research [41], we acknowledge the fact that appropriate help-seeking is often difficult for people with psychotic symptoms. Recent findings indicate that educating the public about the early signs and symptoms of psychosis and schizophrenia will reduce both the DUP and the suicide-related behaviors [42,43]. These educational activities are expected to foster help-seeking behaviors in people suffering from psychotic symptoms.

In case 4, despite the family recognizing the need for psychiatric treatment for the patient, the lack of a community-based psychiatric crisis intervention system prevented the implementation of a well-timed intervention. Recently, several institutions have made efforts to promote early psychiatric interventions in Japan [44,45]. However, mental health services for those who refuse to see a psychiatrist (case 4) or people with social avoidance (cases 1–3 and 5–7) are still extremely limited. The establishment of a system for early intervention in patients with psychosis, including outreach services, is urgently needed to promote suicide prevention.

This study had several limitations. First, since the sample size was very small, our study sample cannot be considered as representative of ‘suicide in untreated schizophrenia in general’. Second, there was no control group matched with the cases. Finally, the possibility of incomplete and biased information cannot be excluded, because the data were collected retrospectively. Nonetheless, this is the first qualitative study to examine the psychological processes leading to suicide in persons with untreated schizophrenia and the discrepancies between the subjective experiences and observed behaviors of these persons. We expect that our findings will contribute to the development of more effective suicide prevention strategies.

Conclusions

In people with schizophrenia, which is mainly characterized by symptoms of hallucinations and delusions, there is the possibility that suicide ideations rapidly progress to suicide attempts. Therefore, it is essential to establish a psychiatric crisis intervention system in the community for providing timely and appropriate professional intervention to prevent suicide. The general public (including those who impart education) should be given information not only on depression and stress-related disorders but also on schizophrenia so that help-seeking by the patients is not overlooked.

Declarations

Acknowledgements

This study was supported in part by the Health and Labour Sciences Research Grants to Masafumi Mizuno (PI), H20-kokoro-ippan-010, as Comprehensive Research on Disability Health and Welfare, from the Ministry of Health, Labour, and Welfare.

Authors’ Affiliations

(1)
Department of Neuropsychiatry, School of Medicine, Toho University
(2)
Department of Forensic Psychiatry, National Center of Neurology and Psychiatry, National Institute of Mental Health

References

  1. Brown S. Excess mortality of schizophrenia. A meta-analysis. Br J Psychiatry. 1997;171:502–8.View ArticlePubMedGoogle Scholar
  2. Dutta R, Murray RM, Hotopf M, Allardyce J, Jones PB, Boydell J. Reassessing the long-term risk of suicide after a first episode of psychosis. Arch Gen Psychiatry. 2010;67:1230–7.View ArticlePubMedGoogle Scholar
  3. Munk-Jorgensen P, Mortensen PB. Incidence and other aspects of the epidemiology of schizophrenia in Denmark, 1971–87. Br J Psychiatry. 1992;161:489–95.View ArticlePubMedGoogle Scholar
  4. Palmer BA, Pankratz VS, Bostwick JM. The lifetime risk of suicide in schizophrenia: a reexamination. Arch Gen Psychiatry. 2005;62:247–53.View ArticlePubMedGoogle Scholar
  5. Misuno M. Tougoushittyousyou no michiryou-kikan to sono yogo ni kansuru ekigakuteki kennkyuu: Kousei Roudou Kagaku Kenkyuuhi Hojokinn Kokoro no Kenkou Kagaku Kenkyuujigyou Kenkyuu Houkokusyo [Epidemiololgical study on the duration of untreated psychosis of the first episode patients with schizophrenia and their prognosis. In Japanese]. Tokyo Japan: Ministry of Health Labour and Welfare in Japan; 2011.Google Scholar
  6. Bertelsen M, Jeppesen P, Petersen L, Thorup A, Ohlenschlaeger J, le Quach P, et al. Suicidal behaviour and mortality in first-episode psychosis: the OPUS trial. Br J Psychiatry Suppl. 2007;51:s140–6.View ArticlePubMedGoogle Scholar
  7. Robinson J, Cotton S, Conus P, Schimmelmann BG, McGorry P, Lambert M. Prevalence and predictors of suicide attempt in an incidence cohort of 661 young people with first-episode psychosis. Aust N Z J Psychiatry. 2009;43:149–57.View ArticlePubMedGoogle Scholar
  8. Andriopoulos I, Ellul J, Skokou M, Beratis S. Suicidality in the ‘prodromal’ phase of schizophrenia. Compr Psychiatry. 2011;52:479–85.View ArticlePubMedGoogle Scholar
  9. Altamura AC, Bassetti R, Bignotti S, Pioli R, Mundo E. Clinical variables related to suicide attempts in schizophrenic patients: a retrospective study. Schizophr Res. 2003;60:47–55.View ArticlePubMedGoogle Scholar
  10. Clarke M, Whitty P, Browne S, Mc Tigue O, Kinsella A, Waddington JL, et al. Suicidality in first episode psychosis. Schizophr Res. 2006;86:221–5.View ArticlePubMedGoogle Scholar
  11. Harvey SB, Dean K, Morgan C, Walsh E, Demjaha A, Dazzan P, et al. Self-harm in first-episode psychosis. Br J Psychiatry. 2008;192:178–84.View ArticlePubMedGoogle Scholar
  12. Hawton K, Sutton L, Haw C, Sinclair J, Deeks JJ. Schizophrenia and suicide: systematic review of risk factors. Br J Psychiatry. 2005;187:9–20.View ArticlePubMedGoogle Scholar
  13. Siris SG. Suicide and schizophrenia. J Psychopharmacol. 2001;15:127–35.View ArticlePubMedGoogle Scholar
  14. Taylor PJ, Gooding PA, Wood AM, Johnson J, Pratt D, Tarrier N. Defeat and entrapment in schizophrenia: the relationship with suicidal ideation and positive psychotic symptoms. Psychiatry Res. 2010;178:244–8.View ArticlePubMedGoogle Scholar
  15. Hawton K, Appleby L, Platt S, Foster T, Cooper J, Malmberg A, et al. The psychological autopsy approach to studying suicide: a review of methodological issues. J Affect Disord. 1998;50:269–76.View ArticlePubMedGoogle Scholar
  16. Asukai N. Jisatsu no Kiken-inshi toshiteno Seishin-syougai-Seimeiteki-kikennsei no Takai Kito-Shudan wo Mochiita Jisatsu Sippaisya no Shindangakuteki Kentou- [Mental disorder as a risk factor of suicide; a clinical study of failed suicides In Japanese]. Seishin Shinkeigaku Zasshi. 1994;96:415–43.PubMedGoogle Scholar
  17. Knittel D, Munn G, Simmer E. Prodromal psychosis as an etiology of suicide: a case report and review of the literature. Am J Forensic Med Pathol. 2008;29:238–41.View ArticlePubMedGoogle Scholar
  18. Cantor CH, Hill MA, McLachlan EK. Suicide and related behaviour from river bridges. A clinical perspective. Br J Psychiatry. 1989;155:829–35.View ArticlePubMedGoogle Scholar
  19. Silverman MM, Berman AL, Sanddal ND, O’Carroll PW, Joiner TE. Rebuilding the tower of babel: a revised nomenclature for the study of suicide and suicidal behaviors part 1: background, rationale, and methodology. Suicide Life Threat Behav. 2007;37:248–63.View ArticlePubMedGoogle Scholar
  20. Silverman MM, Berman AL, Sanddal ND, O’Carroll PW, Joiner TE. Rebuilding the tower of babel: a revised nomenclature for the study of suicide and suicidal behaviors part 2: suicide-related ideations, communications, and behaviors. Suicide Life Threat Behav. 2007;37:264–77.View ArticlePubMedGoogle Scholar
  21. Strauss A, Corbin J. Basics of qualitative research: grounded theory procedures and techniques. London: Sage Publications; 1990.Google Scholar
  22. Barrett EA, Sundet K, Faerden A, Nesvag R, Agartz I, Fosse R, et al. Suicidality before and in the early phases of first episode psychosis. Schizophr Res. 2010;119:11–7.View ArticlePubMedGoogle Scholar
  23. Birchwood M, Meaden A, Trower P, Gilbert P, Plaistow J. The power and omnipotence of voices: subordination and entrapment by voices and significant others. Psychol Med. 2000;30:337–44.View ArticlePubMedGoogle Scholar
  24. Freeman D, Garety PA, Kuipers E. Persecutory delusions: developing the understanding of belief maintenance and emotional distress. Psychol Med. 2001;31:1293–306.View ArticlePubMedGoogle Scholar
  25. Birchwood M. Pathways to emotional dysfunction in first-episode psychosis. Br J Psychiatry. 2003;182:373–5.View ArticlePubMedGoogle Scholar
  26. Drake RE, Gates C, Whitaker A, Cotton PG. Suicide among schizophrenics: a review. Compr Psychiatry. 1985;26:90–100.View ArticlePubMedGoogle Scholar
  27. Skodlar B, Tomori M, Parnas J. Subjective experience and suicidal ideation in schizophrenia. Compr Psychiatry. 2008;49:482–8.View ArticlePubMedGoogle Scholar
  28. Siris SG, Acosta FJ. Qualitative content of auditory hallucinations and suicidal behavior in schizophrenia. Schizophr Res. 2012;134:298–9.View ArticlePubMedGoogle Scholar
  29. Wong Z, Ongur D, Cohen B, Ravichandran C, Noam G, Murphy B. Command hallucinations and clinical characteristics of suicidality in patients with psychotic spectrum disorders. Compr Psychiatry. 2013;54:611–7.View ArticlePubMedGoogle Scholar
  30. Lincoln C, Harrigan S, McGorry PD. Understanding the topography of the early psychosis pathways. An opportunity to reduce delays in treatment. Br J Psychiatry Suppl. 1998;172:21–5.PubMedGoogle Scholar
  31. Addington J, Van Mastrigt S, Hutchinson J, Addington D. Pathways to care: help seeking behaviour in first episode psychosis. Acta Psychiatr Scand. 2002;106:358–64.View ArticlePubMedGoogle Scholar
  32. Lauber C, Nordt C, Falcato L, Rossler W. Do people recognise mental illness? Factors influencing mental health literacy. Eur Arch Psychiatry Clin Neurosci. 2003;253:248–51.View ArticlePubMedGoogle Scholar
  33. Kato TA, Suzuki Y, Sato R, Fujisawa D, Uehara K, Hashimoto N, et al. Development of 2-hour suicide intervention program among medical residents: first pilot trial. Psychiatry Clin Neurosci. 2010;64:531–40.View ArticlePubMedGoogle Scholar
  34. Kaniwa I, Kawanishi C, Suda A, Hirayasu Y. Effects of educating local government officers and healthcare and welfare professionals in suicide prevention. Int J Environ Res Public Health. 2012;9:712–21.View ArticlePubMed CentralPubMedGoogle Scholar
  35. Rutz W, von Knorring L, Walinder J. Frequency of suicide on Gotland after systematic postgraduate education of general practitioners. Acta Psychiatr Scand. 1989;80:151–4.View ArticlePubMedGoogle Scholar
  36. Rutz W, von Knorring L, Walinder J. Long-term effects of an educational program for general practitioners given by the Swedish Committee for the Prevention and Treatment of Depression. Acta Psychiatr Scand. 1992;85:83–8.View ArticlePubMedGoogle Scholar
  37. Kim-Cohen J, Caspi A, Moffitt TE, Harrington H, Milne BJ, Poulton R. Prior juvenile diagnoses in adults with mental disorder: developmental follow-back of a prospective-longitudinal cohort. Arch Gen Psychiatry. 2003;60:709–17.View ArticlePubMedGoogle Scholar
  38. Kirkbride JB, Errazuriz A, Croudace TJ, Morgan C, Jackson D, Boydell J, et al. Incidence of schizophrenia and other psychoses in England, 1950–2009: a systematic review and meta-analyses. PLoS One. 2012;7, e31660.View ArticlePubMed CentralPubMedGoogle Scholar
  39. Yamazawa R, Mizuno M, Nemoto T, Miura Y, Murakami M, Kashima H. Duration of untreated psychosis and pathways to psychiatric services in first-episode schizophrenia. Psychiatry Clin Neurosci. 2004;58:76–81.View ArticlePubMedGoogle Scholar
  40. Nishii H, Yamazawa R, Shimodera S, Suzuki M, Hasegawa T, Mizuno M. Clinical and social determinants of a longer duration of untreated psychosis of schizophrenia in a Japanese population. Early Interv Psychiatry. 2010;4:182–8.View ArticlePubMedGoogle Scholar
  41. O’Callaghan E, Turner N, Renwick L, Jackson D, Sutton M, Foley SD, et al. First episode psychosis and the trail to secondary care: help-seeking and health-system delays. Soc Psychiatry Psychiatr Epidemiol. 2010;45:381–91.View ArticlePubMedGoogle Scholar
  42. Joa I, Johannessen JO, Auestad B, Friis S, McGlashan T, Melle I, et al. The key to reducing duration of untreated first psychosis: information campaigns. Schizophr Bull. 2008;34:466–72.View ArticlePubMed CentralPubMedGoogle Scholar
  43. Melle I, Johannessen JO, Friis S, Haahr U, Joa I, Larsen TK, et al. Course and predictors of suicidality over the first two years of treatment in first-episode schizophrenia spectrum psychosis. Arch Suicide Res. 2010;14:158–70.View ArticlePubMedGoogle Scholar
  44. Mizuno M, Suzuki M, Matsumoto K, Murakami M, Takeshi K, Miyakoshi T, et al. Clinical practice and research activities for early psychiatric intervention at Japanese leading centres. Early Interv Psychiatry. 2009;3:5–9.View ArticlePubMedGoogle Scholar
  45. Nemoto T, Funatogawa T, Takeshi K, Tobe M, Yamaguchi T, Morita K, et al. Clinical practice at a multi-dimensional treatment centre for individuals with early psychosis in Japan. East Asian Arch Psychiatry. 2012;22:110–3.PubMedGoogle Scholar

Copyright

© Yamaguchi et al.; licensee BioMed Central. 2015

This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/4.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly credited. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated.

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