Suicide Assessment and Treatment in Psychotic Disorders

Available with English captions and subtitles in Spanish.

Dost Öngür, MD, PhD, McLean Hospital, presents as part of the 2023 Suicide-Focused Assessment and Treatment: An Update for Professionals course.

Supporting People With Psychotic Disorders

In his talk, Öngür explains how assessment and treatment of suicidal thoughts and behaviors in patients with psychotic disorders can be challenging, and what clinicians should keep in mind when working with this population.

Watch now to learn more about:

  • Which factors to consider when assessing suicide in patients with psychotic disorders
  • Which therapies and treatment plans are most effective for this population
  • How to work with patients and their support networks to decrease suicide risk

Clinicians must be mindful of specific issues when assessing suicide in patients with schizophrenia, schizoaffective disorder, as well as less common psychotic disorders.

“People with psychotic disorders who are at risk for suicide don’t necessarily come in and say, ‘I’m thinking of killing myself,’” Öngür states.

“It’s crucial to assess for psychosis and psychotic symptoms; psychotic experiences and risk factors; as well as suicidal ideation and behavior.”

Öngür explains how the majority of suicides in people with psychotic disorders often happen in the early course of the illness, especially in the first decade.

Patients can experience a sense of loss that their lives will never be the same after the onset of a psychotic disorder. The risk is especially high for people in their late teens to twenties with high educational attainment, who have partial insight, and who were doing well before they developed the illness.

Other risks for suicide in this patient population can include not following treatment plans and experiencing command auditory hallucinations (those that instruct an individual to act).

Delusions that elicit shame and guilt can also increase risk, as can social and environmental factors.

Patients who are unmarried, living alone, or who are unemployed are especially vulnerable, as are those who have recently been discharged from the hospital or whose routines have otherwise been disrupted in any way.

View the Slides

Öngür points out how clinicians should also consider that medication side effects can increase the risk of suicide. For example, akathisia, a side effect of antipsychotic medications, can create restlessness that leads to great psychological pain.

In treating suicidality in patients with psychotic disorders, Öngür emphasizes that collaborative care is important. Multidisciplinary teams, including psychiatrists, psychologists, social workers, and other professionals as needed, should be involved in the assessment of patients.

Evidence-based psychotherapy, such as cognitive behavioral therapy (CBT) and dialectical behavior therapy (DBT), can be effective in addressing psychotic and suicidal symptoms.

Clinicians should also ask patients about their own understanding of their psychosis.

“If you’re not asking about the patient’s understanding of the problems that they’re experiencing, or of suicide, suicidal ideation, and behavior, you may miss important details that are going to be helpful,” he says.

Clinicians should develop a safety plan with patients and families to identify triggers and warning signs and to develop coping strategies. Providers should also make sure that patients know how to access suicide hotlines, crisis centers, and emergency services.

The clinical interview and establishing a rapport with patients are critical to ensuring patients feel heard, validated, and hopeful.

“The interview with a mental health clinician can go a long way to actually restore that hope,” Öngür says.

“You want to be giving people this notion that with good treatment, many people will do well, and you’re not going to stay this way forever. I know you’re feeling very difficult things right now, and it feels intolerable, but there’s light at the end of the tunnel.”


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About Dost Öngür

A native of Istanbul, Turkey, Dr. Dost Öngür is the William P. and Henry B. Test Professor of Psychiatry at Harvard Medical School and chief of the Division of Psychotic Disorders at McLean Hospital.

In addition to his clinical work, Dr. Öngür receives funding from the National Institute of Mental Health and other sources for his research on the clinical manifestations and neurobiology of schizophrenia and bipolar disorder.