IMPORTANCE: Up to 1 million persons die by suicide annually. However, a lack of risk markers makes suicide risk assessment one of the most difficult areas of clinical practice. OBJECTIVE: To assess psychotic symptoms (attenuated or frank) as a clinical marker of risk for suicide attempt. DESIGN, SETTING, AND PARTICIPANTS: Prospective cohort study of 1112 school-based adolescents (aged 13-16 years), assessed at baseline and at 3 and 12 months for self-reported psychopathology, psychotic symptoms, and suicide attempts. MAIN OUTCOMES AND MEASURES: Suicide attempts at the 3- and 12-month follow-up and acute suicide attempts (defined as those occurring in the 2 weeks before an assessment). RESULTS: Of the total sample, 7% reported psychotic symptoms at baseline. Of that subsample, 7% reported a suicide attempt by the 3-month follow-up compared with 1% of the rest of the sample (odds ratio [OR], 10.01; 95% CI, 2.24-45.49), and 20% reported a suicide attempt by the 12-month follow-up compared with 2.5% of the rest of the sample (OR, 11.27; 95% CI, 4.44-28.62). Among adolescents with baseline psychopathology who reported psychotic symptoms, 14% reported a suicide attempt by 3 months (OR, 17.91; 95% CI, 3.61-88.82) and 34% reported a suicide attempt by 12 months (OR, 32.67; 95% CI, 10.42-102.41). Adolescents with psychopathology who reported psychotic symptoms had a nearly 70-fold increased odds of acute suicide attempts (OR, 67.50; 95%CI, 11.41-399.21). Differences were not explained by nonpsychotic psychiatric symptom burden, multimorbidity, or substance use. In a causative model, the population-attributable fraction of suicide attempts would be 56% to 75% for psychotic symptoms. CONCLUSIONS AND RELEVANCE: Adolescents with psychopathology who report psychotic symptoms are at clinical high risk for suicide attempts. More careful clinical assessment of psychotic symptoms (attenuated or frank) in mental health services and better understanding of their pathological significance are urgently needed.
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