SCHRES-06872; No of Pages 6

Schizophrenia Research xxx (2016) xxx–xxx

Contents lists available at ScienceDirect

Schizophrenia Research

journal homepage: www.elsevier.com/locate/schres

Hallucinations in adolescents and risk for mental disorders and suicidal

behaviour in adulthood: Prospective evidence from the MUSP birth
cohort study
Melissa Connell a, Kim Betts b, John J. McGrath c,d, Rosa Alati b,g, Jake Najman b,f, Alexandra Clavarino b,h,
Abdullah Mamun b, Gail Williams b, James G. Scott a,d,e,⁎
a
The University of Queensland Centre for Clinical Research, Herston, QLD 4029, Australia
b
School of Public Health, University of Queensland, Herston, QLD 4029, Australia
c
Queensland Brain Institute, University of Queensland, St Lucia, QLD 4076, Australia
d
Queensland Centre for Mental Health Research, The Park Centre for Mental Health, Wacol, QLD 4076, Australia
e
Royal Brisbane and Women's Hospital, Herston, QLD 4029, Australia
f
School of Social Science, University of Queensland, St Lucia. QLD 4076, Australia
g
Centre for Youth Substance Abuse Research, University of Queensland, Royal Brisbane and Women's Hospital, Herston, QLD 4006, Australia
h
School of Pharmacy, The University of Queensland, 20 Cornwall Street, Woolloongabba, 4102, Queensland, Australia

a r t i c l e i n f o a b s t r a c t

Article history: Background: Hallucinations, once equated with serious mental disorders, are common in adolescents. Given the
Received 16 February 2016 high prevalence of hallucinations, it is important to determine if they are associated with adverse mental health
Received in revised form 7 May 2016 outcomes in adulthood. This study compared the mental health outcomes of participants (aged 30–33 years) in
Accepted 9 June 2016 the Mater-University of Queensland Study of Pregnancy (MUSP) who reported hallucinations at (a) 14 years only
Available online xxxx
and (b) 14 and 21 years versus cohort members without hallucinations.
Method: Participants (n = 333) were aged between 30 and 33 years and (a) reported hallucinations on the Youth
Keywords:
Hallucinations
Self-Report Questionnaire at 14 and/or the Young Adult Self-Report Questionnaire at 21 years and (b) controls
Birth cohort (n = 321) who did not report hallucinations. Lifetime diagnoses of mental disorders were ascertained by the
Mental disorders Structured Clinical Interview for DSM Disorders (DSM IV-TR) administered by clinical psychologists. Suicidal be-
Psychotic disorders haviour was measured by self report.
Suicide Results: Hallucinations at 14 years only were not associated with an increased risk of mental disorders in adult-
hood. Hallucinations reported at both 14 and 21 years were associated with lifetime diagnoses of psychotic dis-
orders (OR, 8.84; 95% CI: 1.61–48.43 and substance use disorders (OR, 2.34; 95% CI: 1.36–4.07) and also strongly
associated with lifetime suicide attempts (OR, 7.11; 95% CI: 2.68–18.83).
Conclusions: Most adolescents who experience hallucinations do not have an increased rate of mental disorder in
adulthood; however, those with hallucinations that are experienced at more than one point in time are at in-
creased risk of suicidal behaviour and both psychotic and non-psychotic psychopathology.
© 2016 Elsevier B.V. All rights reserved.

1. Introduction 2012a). Studies exploring the outcomes of hallucinations in adolescents

Hallucinations, cardinal symptoms of psychotic disorders, also occur
in other mental disorders and in otherwise well individuals. For exam-
ple, a large community-based study reported the lifetime prevalence
of hallucinations as 5.2% (McGrath et al., 2015) whilst studies of adoles-
cents have found a higher prevalence of almost 15% (Kelleher et al.,
⁎ Corresponding author at: The University of Queensland Centre for Clinical Research,
Herston, QLD 4029, Australia.
E-mail address: james.scott@health.qld.gov.au (J.G. Scott).
have found an increased risk of subsequent psychotic disorder (Poulton
et al., 2000; Welham et al., 2009) and other psychopathology (Dhossche
et al., 2002; Fisher et al., 2013; Kelleher et al., 2012b). However, these
studies have their limitations and the utility of hallucinations as a pre-
dictor of future mental health disorders is in debate.
Five population studies have examined adult mental health out-
comes of children and adolescents who hallucinate. Two studies based
on the Dunedin birth cohort assessed diagnostic outcomes of partici-
pants who experienced psychotic symptoms measured at 11 years
(based on the Diagnostic Interview Schedule for Children) (Fisher et

http://dx.doi.org/10.1016/j.schres.2016.06.009
0920-9964/© 2016 Elsevier B.V. All rights reserved.

Please cite this article as: Connell, M., et al., Hallucinations in adolescents and risk for mental disorders and suicidal behaviour in adulthood:
Prospective evidence from the MUS..., Schizophr. Res. (2016), http://dx.doi.org/10.1016/j.schres.2016.06.009
2 M. Connell et al. / Schizophrenia Research xxx (2016) xxx–xxx
al., 2013; Poulton et al., 2000). Participants who were interviewed by
child psychiatrists and identified as having psychotic symptoms had a
16-fold greater risk of adult schizophreniform disorder (odds ratio
[OR], 16.4; 95% confidence interval [CI], 3.9–67.8) at 26 years (Poulton
et al., 2000). In a subsequent study of the same cohort, outcomes were
extended to 38 years, where it was found that hallucinations were asso-
ciated with an increased likelihood of schizophrenia (relative risk [RR],
7.24; 95% CI, 2.17–24.13) and posttraumatic stress disorder (RR, 3.03;
95% CI, 1.33–6.89) (Fisher et al., 2013), suggesting childhood psychotic
symptoms may be a useful predictor of future mental health problems.
In a longitudinal study of youth aged 14–17 years, Dominguez and col-
leagues measured psychotic experiences at three time points over an 8-
year period. They found that those who reported hallucinations and
other psychotic experiences at only one time did not have an increased
risk of subsequent psychosis (compared with those who never halluci-
nated). However, adolescents with hallucinations at all three time
points had 10 times the odds of future psychosis (OR, 9.9; 95% CI, 2.5–
39.8) (Dominguez et al., 2011).
Two studies have reported the diagnostic outcomes of adolescents
who experienced auditory or visual hallucinations measured by the
Youth Self-Report (Dhossche et al., 2002; Welham et al., 2009). Welham
and colleagues reported that participants of the Mater Hospital Univer-
sity of Queensland Study of Pregnancy (MUSP) who experienced hallu-
cinations at 14 years were at increased risk of non-affective psychosis at
age 21 (OR, 5.09; 95% CI, 2.18–11.8 [males]; 2.27; 1.01–5.12 [females])
(Welham et al., 2009). However, this study did not examine non-psy-
chotic disorders as an outcome. By contrast, Dhossche and colleagues
assessed both psychotic and non-psychotic outcomes in adulthood of
hallucinations in a community sample of adolescents (Dhossche et al.,
2002). Those reporting hallucinations were at increased risk of a depres-
sive disorder (OR, 3.0; 95% CI, 1.1–8.8) or substance use disorder (OR,
7.8; 95% CI, 2.5–24.6) at 8-year follow-up but none had transitioned to
psychotic disorder.
Collectively, these studies suggest children and adolescents who hal-
lucinate are at increased risk of psychotic and non-psychotic disorders
in adulthood. However, all studies assessed diagnostic outcomes using
lay interviewers rather than clinicians, few examined a range of both
psychotic and non-psychotic outcomes, and only one (Dominguez et
al., 2011) examined hallucinations in adolescents at more than one
time point showing that persistence of hallucinations was important
in predicting future psychosis. There is a need for studies that examine
a range of outcomes associated with hallucinations, which are mea-
sured at more than one time point, and that follow participants into
adulthood after they have transitioned through the period of highest
risk for psychosis (Dhossche et al., 2002; Welham et al., 2009).
Another outcome associated with hallucinations in adolescents and
adults is suicidality. A cross-sectional study of a large representative
sample of adults showed those respondents with psychotic experiences
(PE) were more likely to report current suicidal ideation (OR, 5.24; 95%
CI, 2.85–9.62) and suicide attempts (OR, 9.48; 95% CI, 3.98–22.62)
(DeVylder et al., 2015a). Prospective studies have also reported that
PE in adolescents elevate the risk for suicidal behaviours at follow-up.
A prospective cohort study of school-based adolescents with baseline
psychopathology and psychotic symptoms found 14% had 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) (Kelleher et al., 2013). Another longitudinal cohort study of ad-
olescents found that PE at one time point only without psychological
distress was not associated with an increased risk of suicidality at
12 months (Martin et al., 2015). However, persistent psychotic experi-
ences (i.e. those present at both baseline and one year follow-up) and
those PE accompanied by psychological distress were associated with
increased odds of suicide attempts (OR, 4.63: 95% CI, 1.21–17.72 and
12.81; 4.02–40.88, respectively). Both studies have follow-up times lim-
ited to 12 months and did not report associations with adult suicidal
behaviour.
Please cite this article as: Connell, M., et al., Hallucinations in adolescents and risk for mental disorders and suicidal behaviour in adulthood:
Prospective evidence from the MUS..., Schizophr. Res. (2016), http://dx.doi.org/10.1016/j.schres.2016.06.009
The current study examined a broad range of mental health out-
comes in adulthood for those who reported experiencing hallucinations
at (i) 14 years and (ii) both 14 and 21 years. Based on previous findings
(van Os et al., 2009), it was hypothesised that those experiencing hallu-
cinations at 14 years would be at increased risk of adult psychotic and
non-psychotic disorders as well as suicidality. Additionally, those ado-
lescents who experienced hallucinations at both 14 and 21 years
would have the highest risk of psychotic and non-psychotic disorder
and suicidality at 30–33 years.
2. Method
2.1. Participants
Participants were from the Mater-University of Queensland Study of
Pregnancy (MUSP), a prospective birth cohort study of mothers and
their offspring who received antenatal care at the Mater Misericordiae
Mothers' Hospital, a major public hospital in Brisbane, Australia, be-
tween 1981 and 1984. Baseline data were collected on 7223 mothers
and their singleton live-birth offspring who have since been prospec-
tively followed-up over thirty years. Further information describing
the MUSP cohort study can be found elsewhere (Najman et al., 2005).
At the 14- and 21-year data collections, the Youth Self-Report
(Achenbach, 1991) and the Young Adult Self-Report (Achenbach,
1997) were used to identify those offspring experiencing auditory and
visual hallucinations (Fig. 1). Only participants who provided data at
both 14- and 21-year follow-ups were eligible for recruitment. In
total, 3535 participants completed the hallucination questions at both
time points, of which 822 (23.3%) endorsed experiencing auditory or vi-
sual hallucinations at 14 and/or 21 years. This group consisted of 455
participants (12.9%) with hallucinations only at 14 years old, 227
(6.4%) with hallucinations only at 21 years old and 140 (4%) with hallu-
cinations at both 14 and 21 years old.
2.2. Sampling protocol
The target sample included all 822 MUSP participants who endorsed
experiencing hallucinations at ages 14 and/or 21 and 490 randomly se-
lected MUSP participants who did not report hallucinations at either
time point. The intended ratio of participants endorsing hallucinations
to those not endorsing hallucinations (roughly 2:1), was chosen to
oversample individuals who were at a potentially greater risk of having
a psychotic disorder by age 30. Four hundred and forty-five (54%) of
those who had experienced hallucinations (56.7% male, M age = 31.6,
SD = 0.88) and 321 (65%) of those who had not experienced hallucina-
tions were interviewed (42.2% male, M age = 31.1, SD = 0.95). This re-
sulted in a total sample of 766 participants. The current study restricted
cases to (a) 250 (54.9%) participants who reported hallucinations at age
14 alone and (b) 83 (59.2%) participants who reported hallucinations at
age 14 and age 21. One hundred and twelve cohort members reported
hallucinations at 21 years only but were not included in the present
study as it could not be determined if they had already developed a psy-
chotic disorder prior to this age (we intend to follow these individuals in
future studies). Methods to assess potential bias resulting from the re-
sponse rates are outlined below.
2.3. Interview procedure
Interviews were conducted face to face when possible, and phone
interviews were used when participants were unable to attend the
study location. Interviews involved completion of self-report question-
naires and participation in a semi-structured interview. Interviewers
were ‘blind’ to age 14 and age 21 hallucination group status.
 M. Connell et al. / Schizophrenia Research xxx (2016) xxx–xxx 3

Fig. 1. Sampling procedure used in participant selection.

2.4. Structured clinical interview for DSM-IV Axis I disorders (SCID I) 2.5. Suicidality

The SCID I is a semi-structured interview used for making DSM-IV
Axis I diagnoses and covers key diagnostic groups including mood disor-
ders, psychotic disorders, anxiety disorders, substance use disorders,
somatoform disorders, eating disorders and adjustment disorders
(First et al., 2002). It requires administration by a clinician or trained
mental health professional familiar with DSM classification and diagno-
sis. It assesses both lifetime and current diagnoses and can be used to
provide symptom ratings as either absent, subthreshold or threshold.
The research version of the SCID was administered using netSCID, a
computerized program designed in collaboration with the SCID authors
and found to improve accuracy and reliability of administration. Inter-
views were administered by clinical psychologists and clinical psychol-
ogy registrars with experience and training in interviewing those with
psychotic disorders. Raters undertook training in administration of the
SCID and were required to meet criteria of 95% diagnostic agreement
with SCID training interviews before interviewing the MUSP partici-
pants. Interviewers were required to participate in regular group meet-
ings with J.S. and M.C. in which ratings were reviewed and complex
presentations discussed. All interviews were audio recorded and ran-
dom audits were undertaken by M.C. to ensure adherence to the proto-
col and accuracy of ratings made.
To avoid the limitations of single item measures of suicidality, suicid-
al ideation, suicide plans and suicide attempts over the person's lifetime
were measured using three items which asked if the person had ever se-
riously thought about committing suicide, had they ever made a plan
and had they ever had an attempt.
2.6. Outcome variables
For the main analyses, we used the major categories of Axis 1 diag-
noses from the SCID, including any DSM-IV mood (i.e. major depressive
disorder, bipolar disorders and substance-induced mood disorders),
anxiety (i.e. panic disorder, agoraphobia, posttraumatic stress disorder,
generalized anxiety disorder, obsessive compulsive disorder, social pho-
bia and specific phobia), psychotic (i.e. schizophrenia, schizoaffective
disorder, psychotic disorder NOS, substance induced psychotic disorder
and brief psychotic disorder), substance use (i.e. disorders of abuse and
dependence including alcohol, cannabis, cocaine, opiate, hallucinogen,
amphetamine, sedative and polysubstance dependence) and eating dis-
order (i.e. anorexia nervosa, bulimia nervosa and eating disorder NOS).
A secondary analysis was also conducted based on selected mental dis-
orders (major depressive disorder [MDD], social phobia, specific phobia,

Please cite this article as: Connell, M., et al., Hallucinations in adolescents and risk for mental disorders and suicidal behaviour in adulthood:
Prospective evidence from the MUS..., Schizophr. Res. (2016), http://dx.doi.org/10.1016/j.schres.2016.06.009
4 M. Connell et al. / Schizophrenia Research xxx (2016) xxx–xxx

posttraumatic stress disorder [PTSD], generalized anxiety disorder Table 2

[GAD], panic disorder, obsessive compulsive disorder [OCD], alcohol
abuse and/or dependence [combined as alcohol use disorder], cannabis
abuse and/or dependence [combined as cannabis use disorder] and
polysubstance dependence disorders). Suicidality was measured using
Multivariable associations between hallucinations at age 14 only and hallucinations at
both 14 and 21 with DSM-IV mental disorder categories, adjusted for potential
confoundersa [expressed in OR with 95% confidence intervals (CI)] (n = 650).
Hallucinations

three categorical variables of suicidal thoughts, suicidal plans and suicide
attempts.
2.7. Predictor variables
Hallucinations were measured at age 14 using the YSR (Achenbach,
1991) and at age 21 using the YASR. (Achenbach, 1997) Hallucinations
were assessed at 14 and 21 years with the YSR/YASR questionnaires
which included two questions: (i) “I hear sounds or voices which
other people think aren't there”; (ii) “I see things that other people
think aren't there”. Respondents answered with very true or often true,
somewhat or sometimes true, or not true, which were then reclassified
into three discrete hallucinations categories: (1) did not experience hal-
lucinations, (2) experienced hallucinations sometimes or often at age
14, (3) experienced hallucinations sometimes or often at ages 14 and
21.The reliability of self-report measures for assessing hallucinations
in adolescents has been established (Kelleher et al., 2011). Of all psy-
chotic experiences, self-report assessment of hearing voices or sounds
that others don't hear was found to be the strongest predictor of a clin-
ically verifiable history of auditory hallucinations (positive predictive
value [PPV] = 71.4% and negative predictive value [NPV] = 90.4%),
with visual hallucinations also showing moderately successful predic-
tive power (PPV = 81.8% and NPV = 80%) (Kelleher et al., 2011). Hallu-
cination items from the YSR have been used in previous longitudinal
studies (Dhossche et al., 2002; Welham et al., 2009).
2.8. Statistical analyses
Chi-square tests were used to examine the associations between the
different categories of hallucinations with the major groups of mental
disorders at age 30. Univariate and multivariate logistic regressions
were then used to examine the associations between hallucinations ad-
justed for potential covariates with the mental disorder groups and with
suicidal behaviour. Covariates used in the adjusted models were partic-
ipant age, sex, substance use at age 14 and maternal education at base-
line. Secondary analyses were then conducted examining the
associations between hallucinations with specific mental disorders.
The final sample in all analyses consisted of 650 participants with values
for all variables of interest.
2.9. Response rates analyses
Two separate attrition analyses were conducted using multivariate
logistic regression to compare differences among baseline measures
(i.e., pre-pregnancy) between (1) MUSP participants who reported hal-
lucinations at 14 and/or 21 years of age who participated in the current
study versus those who did not participate and (2) MUSP participants
who did not report hallucinations at 14 or 21 years of age (controls)
and participated in the current study versus those who did not partici-
pate These analyses were further limited to participants with all data
on baseline variables of interest.
None Age 14 only Ages 14 and 21
Disorder category OR (95% CI) OR (95% CI) OR (95% CI)
Mood 1.00 1.04 (0.74–1.48) 1.47 (0.89–2.43)
Anxiety 1.00 0.92 (0.63–1.33) 1.52 (0.91–2.54)
Psychotic 1.00 1.09 (0.16–7.60) 8.84 (1.61–48.43)
Substance use 1.00 1.08 (0.71–1.62) 2.34 (1.36–4.07)
Eating 1.00 1.23 (0.35–4.30) 3.60 (0.99–13.07)
a
Adjusted confounding factors were age, sex, maternal education at baseline and sub-
stance use at 14 years.
3. Results
After adjusting for age, sex, maternal education at baseline and sub-
stance use at 14 years, hallucinations at 14 years only were not associat-
ed with any groups of mental disorder in adulthood (Table 2). Those
participants who reported hallucinations at both 14 and 21 years had
increased odds of being diagnosed with a psychotic disorder (OR,
8.84; 95% CI, 1.61–48.43) or substance use disorder (OR, 2.34; 95% CI,
1.36–4.07) at 30–33 years (See Tables 1 and 2).
Pertaining to specific mental disorders, there were no associations
with hallucinations at 14 years. Those with hallucinations at 14 and
21 years had increased risk of alcohol use disorder (OR, 2.41; 95% CI,
1.35–4.30), cannabis use disorder (OR, 2.71; 95% CI, 1.36–5.41), panic
disorder (OR, 3.30; 95% CI, 1.35–8.08), polysubstance dependence (OR,
3.83; 95% CI, 1.13–13.04) and specific phobia (OR, 2.43; 95% CI, 1.11–
5.29) (Supplementary Table 1). There was no association between hal-
lucinations at both 14 and 21 years and major depressive disorder, gen-
eralized anxiety disorder, obsessive compulsive disorder, posttraumatic
stress disorder and social phobia.
Those reporting hallucinations in both adolescence and young adult-
hood were more likely to report lifetime suicidal ideas and behaviours
at 30–33 years. Suicide attempts were almost three times more likely
to occur in those who had hallucinations at 14 years only (OR, 2.63;
95% CI, 1.04–6.63) and seven-fold more likely in those with hallucina-
tions at both follow-ups (OR, 7.11; 95% CI, 2.68–18.83) (Table 3).
Lastly, the attrition analyses showed that among participants who
reported hallucinations, those included in the sample were more likely
to be female and their mothers were more likely to have completed ter-
tiary education (Supplementary Table 2). Among participants who did
report hallucinations, those included in the study were more likely to
be female, have a higher family income and an older maternal age at
birth.
4. Discussion
Adolescents who reported experiencing hallucinations at both 14
and 21 years were at increased risk of both adult psychopathology and
lifetime suicidal ideas and behaviours. Those who reported experienc-
ing hallucinations at 14 years only did not have an increased risk of
mental disorders in the main analysis although they were more likely
to have attempted suicide. Together, these findings suggest that

Table 1
Univariable associations between hallucinations at age 14 only and hallucinations at both 14 and 21 with lifetime DSM-IV mental disorder categories (n = 650).

Hallucinations, %(n)

Disorder category None Age 14 only Ages 14 and 21 Chi-square (df) P value

Mood 42.3 (134) 48.8 (112) 53.0 (44) 3.08 (2) 0.22
Anxiety 33.1 (105) 33.6 (84) 47.0 (39) 5.94 (2) 0.05
Psychotic 0.6 (2) 1.2 (3) 07.2 (6) 17.80 (2) b0.001
Substance use 23.7 (75) 30.0 (75) 44.6 (37) 14.35 (2) 0.001

Please cite this article as: Connell, M., et al., Hallucinations in adolescents and risk for mental disorders and suicidal behaviour in adulthood:
Prospective evidence from the MUS..., Schizophr. Res. (2016), http://dx.doi.org/10.1016/j.schres.2016.06.009
 M. Connell et al. / Schizophrenia Research xxx (2016) xxx–xxx
Table 3
Multivariable associations between hallucinations at age 14 only and hallucinations at both 14 and 21 with suicidal behaviours at age 30, Adjusted for potential confoundersa [expressed in
OR with 95% confidence intervals (CI)] (n = 644).
Hallucinations
None
Suicidal behaviour % yes (n) OR (95% CI)
Ideation 16.8 (53) 1.00
Plans 6.0 (19) 1.00
Attempts 2.2 (7) 1.00
a
Adjusted confounding factors were age, sex, maternal education at baseline and substance use at 14 years.
adolescents whose hallucinations remit before adulthood are at no
greater risk of future mental disorders than individuals who do not ex-
perience hallucinations. However, those who experience hallucinations
in adolescence and adulthood are more likely to develop a mental disor-
der in adulthood.
Those with hallucinations present at 14 and 21 years had an almost
nine-fold risk of developing a psychotic disorder and a three-fold risk of
a substance use disorder. When examining for specific diagnostic out-
comes, hallucinations experienced in both adolescence and adulthood
were associated with a wide range of non-psychotic illness as assessed
by clinicians including alcohol and cannabis use disorders, panic disor-
der, polysubstance dependence and specific phobia.
This study supports and extends previous research. Dominguez and
colleagues (Dominguez et al., 2011) previously reported that hallucina-
tions that were present on more than one follow-up were associated
with later psychotic disorders. Other studies have shown that hallucina-
tions in adolescents are associated with both psychotic and non-psy-
chotic disorders (Fisher et al., 2013). There is now consistent evidence
of an association between hallucinations and suicidal behaviour
(DeVylder et al., 2015b; Kelleher et al., 2013; Link et al., 2015; Martin
et al., 2015). The risk of suicidal ideation and plans and of suicide at-
tempt was greater in those who had hallucinations at both 14 and
21 years compared with those who reported hallucinations at 14 years
only. Persistent hallucinations in adolescents have been shown to be as-
sociated with suicidality in a study where the follow-up was limited to
12 months (Martin et al., 2015). This study is consistent with the find-
ings of Fisher and colleagues (Fisher et al., 2013) who reported psychot-
ic experiences in childhood were associated with suicide attempts at
38 years.
These findings demonstrate that hallucinations occurring at more
than one point in time are predictive of a range of adult mental disor-
ders (Kelleher et al., 2012b). The relationship found with anxiety and
substance use disorders suggests that hallucinations in adolescents
may be indicative of a shared vulnerability for broader psychopatholo-
gy. It may be that affective dysregulation is the core deficit that under-
lies both the experience of hallucinations in adolescents and the risk
of developing a mental disorder in adulthood. Affective dysregulation
is a key feature of affective, anxiety, suicidality (Cisler et al., 2010) and
substance use (Cheetham et al., 2010) difficulties and has been pro-
posed as forming a reciprocal relationship with reality distortion (Van
Rossum et al., 2011; Wigman et al., 2012). Further research is needed
to establish whether psychosis and affective dysregulation are part of
the same continuum or constitute separate but interacting continua
(Taylor et al., 2014; van Os, 2014).
4.1. Clinical implications
In this study, hallucinations that are experienced in early adoles-
cence and remit were found not to be associated with increased risk
for adult psychopathology. However, those whose hallucinations were
present in both adolescence and young adulthood had an increased
risk of mental disorders and suicidal ideation and behaviours at
30 years. It is important to take into account the natural history of hal-
lucinations in young people to avoid unnecessary interventions based
Please cite this article as: Connell, M., et al., Hallucinations in adolescents and risk for mental disorders and suicidal behaviour in adulthood:
Prospective evidence from the MUS..., Schizophr. Res. (2016), http://dx.doi.org/10.1016/j.schres.2016.06.009
5
Age 14 only Ages 14 and 21
% yes (n) OR (95% CI) % yes (n) OR (95% CI)
24.8 (61) 1.44 (0.93–2.23) 39.0 (32) 2.89 (1.66–5.02)
11.0 (27) 1.30 (0.67–2.52) 20.7 (17) 2.89 (1.37–6.09)
7.7 (19) 2.63 (1.04–6.63) 18.3 (15) 7.11 (2.68–18.83)
on the assumption that these experiences are forerunners of psychosis.
However, previous studies have shown that hallucinations in adoles-
cents are associated with serious psychopathology in the short term,
in particular, increased risk of suicidal behaviours (Kelleher et al.,
2013; Martin et al., 2015) which are also linked to distress and affective
dysregulation (Yen et al., 2013). Interventions aimed at improving dis-
tress tolerance and affect regulation may ameliorate psychopathological
processes which perpetuate these difficulties and result in mental disor-
der diagnoses in adulthood (Taylor et al., 2014). Adolescents and their
families can be reassured that most who experience hallucinations
will not develop psychosis or other mental disorders later in life.
4.2. Limitations
The use of lifetime assessments of mental disorders and suicidality
made it difficult to confidently ascribe the temporal sequence of the
onset of the disorders assessed at age 30, and it is feasible that onset
may have preceded the assessments at 14 and 21 years. However, it
would be unlikely that a clinical psychotic disorder would be present
prior to 14 years and there is a tendency for respondents to favour re-
cent experiences in reports of lifetime symptoms and behaviours
(Kelleher et al., 2012c). There are additional confounding factors
which may have been associated with outcomes that were not mea-
sured such as experiences of trauma and adversity. Amongst MUSP par-
ticipants experiencing hallucinations at age 14 and/or 21, the response
rate was 54% which may have impacted the generalisability of our find-
ings. However, the attrition analysis found that aside from gender and
maternal education, those included in the sample did not differ by base-
line variables, and also did not differ by the severity of the reported hal-
lucinations. However, those with mental disorders in adulthood are
more likely to drop out of the MUSP study, thus our estimates may be
conservative.
Finally, whilst a strength of this study was the measurement of hal-
lucinations at two time points encompassing the transition from adoles-
cence to young adulthood, these were seven years apart, which
precludes assumptions as to whether the hallucinations were persistent
or recurrent. Furthermore, there was no information regarding the fre-
quency or emotional valence of the content of the hallucinations, two
characteristics reported of hallucinations in need of treatment
(Daalman et al., 2011; Johns et al., 2014). Ideally, more measurements
of hallucinations at closer time points would better inform the course
of hallucinations in adolescents and their associated adult outcomes.
5. Conclusions
Hallucinations in adolescents are common. When mental health out-
comes were assessed by clinicians using a standardised diagnostic clin-
ical instrument, those experiencing hallucinations at both 14 and
21 years had increased odds of adult mental disorders and suicidal be-
haviours. In most adolescents, the hallucinations resolved and were
not associated with increased odds of adult psychopathology.
Conflict of interest
All authors declare no conflicts of interest.
6 M. Connell et al. / Schizophrenia Research xxx (2016) xxx–xxx
Funding/Support
This study was funded by the National Health and Medical Research
Council (NHMRC #1046216). JGS is supported by a National Health and
Medical Research Council Practitioner Fellowship Grant #1105807.
AAM was funded by the NHMRC CDF Level 2 (ID 1026598). John
McGrath received John Cade Fellowship #1056929 from the National
Health and Medical Research Council.
Funders' roles
The sponsors of the study (the NHMRC) had no role in the design
and conduct of the study; collection, management, analysis and inter-
pretation of the data; and preparation, review or approval of the
manuscript.
Contributors' statement
JGS and JMM planned the study. MC and JGS supervised the data col-
lection. JGS, MC and KB planned the statistical analysis which was con-
ducted by KB. MC and JGS wrote the initial drafts of the manuscript. All
authors were involved in later revisions and all authors approved the
final manuscript.
Access to data
MC, JS and KB had full access to the data used in the study and take
responsibility for the integrity of the data and the accuracy of the data
analysis.
Acknowledgements
The authors thank the MUSP team, MUSP participants, the Mater Misericordiae Hos-
pital, and the Schools of Social Science, Population Health and Medicine (University of
Queensland).
Appendix A. Supplementary data
Supplementary data to this article can be found online at http://dx.
doi.org/10.1016/j.schres.2016.06.009.
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