Suicide among schizophrenics. Who is at risk?

Social class of origin, lost potential, and hopelessness in schizophrenia

Among schizophrenia patients, young (under 35 years of age), men within the first 5 years of illness onset are a particularly vulnerable group for suicide. It has been hypothesized that suicide in this group is related to the experience of the loss of functioning from pre- to post-morbid state and/or to the discrepancy between high expectations and actual achievements. The purpose of this study is to initiate the deconstruction of the sociocultural context of family of origin among schizophrenia patients as a means of better understanding "lost potential" and its relationship to indices of suicide risk such as hopelessness. Eighteen young, White, unemployed male schizophrenia patients were asked to indicate what job they thought they would have before the onset of schizophrenia and completed depression and hopelessness questionnaires. The results suggest that job expectation was significantly positively correlated with socioeconomic status of family of origin and patients' depression and hopelessness. The theoretical and treatment (especially with respect to vocational services) implications are discussed. Finally, this study formally introduces the concept that "advantaged" socioeconomic status may confer paradoxical disadvantage in coping with the vocational losses consequent to schizophrenia.

Schizophrenia and suicide: systematic review of risk factors

BACKGROUND

Suicide risk is greatly increased in schizophrenia. Detection of those at risk is clinically important.

AIMS

To identify risk factors for suicide in schizophrenia.

METHOD

The international literature on case-control and cohort studies of patients with schizophrenia or related conditions in which suicide was reported as an outcome was systematically reviewed. Studies were identified through searching electronic databases and reference lists, and by consulting experts.

RESULTS

Twenty-nine eligible studies were identified. Factors with robust evidence of increased risk of suicide were previous depressive disorders (OR=3.03, 95% CI 2.06-4.46), previous suicide attempts (OR=4.09, 95% CI 2.79-6.01), drug misuse (OR=3.21, 95% CI 1.99-5.17), agitation or motor restlessness (OR=2.61, 95% CI 1.54-4.41), fear of mental disintegration (OR=12.1, 95% CI 1.89-81.3), poor adherence to treatment (OR=3.75, 95% CI 2.20-6.37) and recent loss (OR=4.03, 95% CI 1.37-11.8). Reduced risk was associated with hallucinations (OR=0.50, 95% CI 0.35-0.71).

CONCLUSIONS

Prevention of suicide in schizophrenia is likely to result from treatment of affective symptoms, improving adherence to treatment, and maintaining special vigilance in patients with risk factors, especially after losses.

Suicide and awareness of illness in schizophrenia: an overview

Suicide is the first cause of premature death in patients with schizophrenia. Numerous studies have identified risk factors for suicide among these patients. This study reviews available literature focusing on awareness of illness in patients with schizophrenia. Insight, or awareness of illness, has been considered a risk factor for suicide in schizophrenic patients. In assessing insight, many issues have to be taken into account, because a high degree of insight is not desirable in some conditions.

Suicide attempts in an African schizophrenia population: an assessment of demographic risk factors

This study investigated demographic variables, including affected sibling pair status, as risk factors for suicidal behavior in schizophrenia patients of African (Xhosa) descent. Xhosa subjects with schizophrenia were interviewed with the Diagnostic Interview for Genetic Studies (DIGS) and then stratified into two groups: those with ( n = 90) and those without ( n = 364) a history of previous suicide attempts. Demographic parameters (including gender, age, and social circumstances, sib ship) were then compared across these groups. Demographic predictors of suicide included sib ship status ( p = 0.038; OR = 1.7) and age of onset of illness ( p = 0.008; OR = 2.5). On further analysis of suicide in siblings, only a minority of sib pairs was found to be concordant for a lifetime history of suicide attempts (3%). These findings raise the possibility that affected sib pair status may be protective in nature. Given the counter-intuitive nature of this finding, further work is needed to replicate it, and to explore possible underlying mechanisms.

No association between akathisia or Parkinsonism and suicidality in treatment-resistant Schizophrenia

Akathisia and drug-induced Parkinsonism have traditionally been associated with depression and suicidality based on case study evidence. In this subanalysis, patients with treatment resistant schizophrenia were rated on the Comprehensive Psychopathological Rating Scale, Barnes Akathisia Scale and Simpson-Angus extrapyramidal side-effect scale at two time points (n=86 at first assessment; n=67 at second assessment). At no time point was there any significant relationship between akathisia and depression/suicidality or distress associated with akathisia and Parkinsonism with suicidality. These preliminary findings warrant further investigation.

Suicidal behavior in schizophrenia and schizoaffective disorder: examining the role of depression

Understanding the relationship between depression and suicidal behavior among individuals with schizophrenia and schizoaffective disorder can aid assessment and treatment. In this study, 86 individuals with schizophrenia and schizoaffective disorder were assessed for past and current suicidal behavior, depression, hopelessness, and reasons for living. Thirty-four percent reported a history of suicide attempts. Suicidal behavior typically occurred 4.5 years after the onset of psychosis and 7.5 years after the onset of the first major depressive episode for those who had a history of major depression. Depression was frequent among both attempters and non-attempters, but only half of the attempters reported a suicide attempt during an episode of major depression. And almost half of those with depression never made a suicide attempt despite a long history of illness. Although depression is a potential stressor for triggering suicidal behavior in a vulnerable subset of individuals with schizophrenia, schizophrenia research must identify other risk factors for suicidal behavior. Clinicians should remember that even without a depressive episode there is still a significant risk for suicidal behavior in schizophrenia.

Suicidality and psychosis: beyond depression and hopelessness

The present study examined recent suicide attempters with and without psychotic disorders in order to understand factors that contribute to suicide ideation during and following the suicide attempt. Patients with psychotic disorders endorsed higher levels of suicide ideation than patients without psychotic disorders. Even when depression, hopelessness, substance abuse, and social problem solving were controlled for, there was a significant association between psychotic disorder and suicide ideation. During the follow-up period, patients with psychotic disorders subsequently attempted suicide at a significantly higher rate than patients without psychotic disorders. The clinical relevance of these findings is discussed.

Hopelessness, neurocognitive function, and insight in schizophrenia: relationship to suicidal behavior

Insight and hopelessness have been reported to be associated with suicidality in schizophrenia. In addition, there is evidence that diminished insight is correlated with impairment in some domains of cognitive function in schizophrenia. The purpose of this study was to clarify the relative importance for suicidality in patients with schizophrenia of hopelessness, cognitive dysfunction, and insight. This study included 333 patients with chronic schizophrenia who were prospectively studied. Insight was rated by the insight items from the Schedule for Affective Disorders and Schizophrenia (SADS) and the Hamilton Depression Rating Scale (HDRS). Positive, negative, and anxiety-depression symptoms were measured with the Brief Psychiatric Rating Scale (BPRS). Cognition was assessed with a neurocognitive battery, which included measures of attention and psychomotor speed, verbal fluency, verbal memory, working memory, and executive function. Current and lifetime suicidality was prospectively assessed. Hopelessness, substance abuse, and greater insight were associated with attempted suicide and suicidal ideation. Those with a history of lifetime, but not current, suicidality had better function on tests of psychomotor speed and attention, verbal working memory, verbal fluency, verbal memory, and executive function. Neurocognitive measures were not significantly correlated with hopelessness and insight. Hopelessness was more severe in those with current and lifetime suicidality. A multiple regression analysis was used to predict current and lifetime suicidality from hopelessness, substance abuse, insight, and cognitive factor scores. The regression models predicting current and lifetime suicidality indicated that hopelessness was the most important predictor of both (beta=0.41, p=0.0001; and beta=0.35, p=0.01, respectively). These findings suggest that hopelessness, substance abuse, greater insight into illness, and higher cognitive function are associated with greater suicidality in chronic schizophrenia, but that among these, hopelessness may be the principal predictor of suicidality.

Depressive episodes in stable schizophrenia: critical evaluation of the DSM-IV and ICD-10 diagnostic criteria

Depressive episodes are a common and potentially severe occurrence in schizophrenia but are poorly recognised by psychiatrists. Coherent diagnostic criteria are necessary to improve diagnosis and treatment of these conditions. To evaluate the usefulness of the ICD-10 category of post-schizophrenic depression (PSD) and the DSM-IV category of postpsychotic depressive disorder of schizophrenia (PDDS), 80 clinically stable schizophrenic outpatients were evaluated with two independent measures of depression, a dimensional measure and a categorical measure. One rater applied the DSM-IV criteria for major depressive episodes (MDE), and the other applied the Calgary Depression Scale for Schizophrenia, the Positive and Negative Syndrome Scale, and the Extrapyramidal Symptoms Rating Scale. Thirteen patients (16.3%) met criteria for MDE. All of them met the DSM-IV PDDS research criteria, but only two patients matched the ICD-10 PSD criteria, which require that the episode occurred in the 12 months after the last psychotic episode. There was no significant difference in the incidence of depressive episodes within 12 months after an acute psychotic episode and outside this time period. The data suggest that depressive episodes in schizophrenia are not restricted to the first year following the psychotic episode. Useful criteria for depressive episodes in schizophrenia should avoid a temporal relation with the psychotic episode.

Suicidal behaviour of psychiatric in-patients

OBJECTIVE

The study aimed to examine suicidal behaviour before and during in-patient care in a psychiatric state hospital.

METHOD

Based upon a psychiatric basic documentation system prevalence and risk factors of in-patient suicides, suicide attempts and suicidal thoughts were investigated over an 11-year period from 1989 until 1999.

RESULTS

A total of 30 in-patient suicides were found among 21 062 patients. According to the multivariate logistic regression analysis the risk of hospital suicide increases for patients with schizophrenia, higher cumulative length of stay, previous suicide attempt, part-time employment and training/retraining. Predictors of suicide attempt during hospitalization are suicide attempt on admission, personality disorder, suicidal thoughts on admission, schizophrenia and affective disorder.

CONCLUSION

As Schizophrenics represent the high-risk group of in-patient suicide, suicide prevention should be a major goal in their treatment. More frequent suicide risk assessment is recommended particularly before granting a leave or an outing.

Suicide and schizophrenia

Suicide and suicide attempts occur at a significantly greater rate in schizophrenia than in the general population. Common estimates are that 10% of people with schizophrenia will eventually have a completed suicide, and that attempts are made at two to five times that rate. Demographically associated with suicidality in schizophrenia are being young, being early in the course of the illness, being male, coming from a high socioeconomic family background, having high intelligence, having high expectations, not being married, lacking social supports, having awareness of symptoms, and being recently discharged from the hospital. Also associated are reduced self-esteem, stigma, recent loss or stress, hopelessness, isolation, treatment non-compliance and substance abuse. Clinically, the most common correlates of suicidality in schizophrenia are depressive symptoms and the depressive syndrome, although severe psychotic and panic-like symptoms may contribute as well. This review specifically explores the issue of depression in schizophrenia, in relation to suicide, by organizing the differential diagnosis of this state and highlighting their potentially treatable or correctable causes. This differential diagnosis includes both acute and chronic disappointment reactions, the prodrome of an acute psychotic episode, neuroleptic induced akinesia and akathisia, the possibility of direct neuroleptic-induced depression, negative symptoms of schizophrenia, and the possible co-occurrence of an independent depressive diathesis. The potential beneficial roles of 'atypical' antipsychotic agents, including both clozapine and more novel agents, and adjunctive treatment with other psychopharmacological medications are considered, and the important roles of psychosocial factors and interventions are recognized.

A randomized, controlled trial of a brief interventional package for schizophrenic out-patients

OBJECTIVE

To evaluate the impact on outcome of a simple educational intervention in schizophrenic patients at risk of relapse.

METHOD

At discharge, 114 schizophrenic patients with at least one previous episode were assigned randomly to a simple educational intervention which had no resource implications, or standard care.

RESULTS

The intervention failed to improve outcome. While insight and treatment attitudes improved, suicidal ideation increased. Systematic management of treatment-emergent adverse effects offered no benefits, although incapacitation from extrapyramidal side-effects at discharge predicted relapse.

CONCLUSION

There are limits to which psychoeducational interventions can be simplified without loss of effectiveness in terms of relapse prevention in schizophrenia. Enhanced insight may be associated with increased suicidal ideation.

The Schizophrenia Suicide Risk Scale (SSRS): development and initial validation

BACKGROUND

Estimations about the lifetime risk of suicide in schizophrenia vary between 4 and 10%. At present, there does not exist a suicide risk scale developed particularly for schizophrenic patients. The aims of the present study were to: (1) develop a clinically useful semi-structured scale for the estimation of short-term suicide risk among schizophrenic patients, and (2) to carry out an initial validation of the scale.

METHODS

A 25-item Schizophrenia Suicide Risk Scale (SSRS) was constructed on the base of the literature. The SSRS scores of 69 living schizophrenic patients (LS group) were compared with the scores of 69 schizophrenic suicides (SS group) whose data had been collected previously from The Finnish nationwide and representative psychological autopsy study. Internal consistency of the SSRS was evaluated with Cronbach alpha. The most important SSRS items predicting suicide were identified with a logistic regression analysis. Sensitivity, specificity, positive predictive value, and negative predictive value of the SSRS in predicting suicide with various cut-off scores were calculated.

RESULTS

In the final logistic regression model, the following SSRS items significantly predicted suicide: suicide plans communicated to someone during the past 3 months; one or more previous suicide attempts; loss of professional skills demanding job; depression observed during an interview; and suicide plans communicated during an interview. With high cut-off scores the specificity of the SSRS became satisfactory, but the sensitivity dropped below 32%. Internal consistency of the anamnestic history of the SSRS was low, which suggests that anamnestic risk factors for suicide in schizophrenia are multifactorial. Internal consistency of the interview-based items was high, and present state risk factors seemed to consist of two separate factors, depression-anxiety and irritability.

CONCLUSIONS

The SSRS may be clinically useful in identifying schizophrenic patients with a particularly high risk for suicide. However, the SSRS seems not to be a practical screening instrument for suicide risk in schizophrenia, and it is probably impossible to construct a suicide risk scale with both high sensitivity and high specificity in this disorder.

Risk factors for suicide in young people suffering from schizophrenia: a long-term follow-up study

Ten per cent of patients with schizophrenia commit suicide, but assessment of risk is difficult. Large case-control studies with a long follow-up period are needed. These should focus on patients from one age group to give clinicians the details required to identify those at highest risk.We present a case-control study of 63 patients who committed suicide and 63 controls from a consecutive admission series of patients with a diagnosis of schizophrenia. All patients were under the age of 30 at admission.Risk factors for suicide were male gender, chronic illness with frequent relapses (OR 6.0), frequent short hospitalisation, a negative attitude towards treatment (OR non-compliance 7.0), impulsive behaviour (OR acting out 6.4, OR involuntary commitment 17), parasuicide (OR suicide attempt 4.8, OR highly lethal suicide attempt 11), high pre-morbid IQ (OR 4.3), psychosis (OR 7.0) and depression (OR 36). However, early onset of a defect state (OR 6.3) and a daily activity (OR 4.2) were protective factors. Identified risk factors could help clinicians to target high-risk patients and form the basis for interventions aimed at reducing suicide.

Atypical Antipsychotic Use in the Treatment of Psychosis in Primary Care

Atypical antipsychotics are a class of novel agents increasingly employed for the treatment of psychotic disorders. The pharmacodynamic properties of the atypicals appear to impact a broader spectrum of psychotic symptoms than had been appreciated with older generation antipsychotics. In addition, the atypical agents appear to have a reduced risk of neurologic side effects compared with conventional antipsychotic use. Both of these features enhance the appeal of the atypical antipsychotics and may be associated with enhanced patient compliance. The atypical antipsychotics appear to be effective for schizophrenia as well as other psychotic disorders, including schizoaffective disorder and mood disorders with psychotic features. Consequently, atypical antipsychotics are now considered to be the first-line treatment for schizophrenia, with the exception of clozapine, which is considered a second-line agent because of risks associated with its use. This review will discuss the literature on atypical antipsychotic efficacy in psychotic disorders. Issues related to antipsychotic use, dosing, adverse effects, and drug interactions are also discussed.

Insight and symptom change in schizophrenia and other disorders

OBJECTIVE

This study sought to evaluate levels of insight and change in insight in subjects with schizophrenia and other major psychiatric disorders. This study also evaluated the relationship of insight to acute psychopathology.

METHOD

One-hundred and eighty-seven subjects consecutively admitted to an acute care psychiatric unit and who met DSM-III-R criteria were evaluated by the Insight and Treatment Attitudes Questionnaire and Brief Psychiatric Rating Scale on admission and discharge. Relationships of insight to diagnosis, involuntary commitment status and change in insight were evaluated with analysis of variance and post hoc Tukey's Standardized Range test. Relationships of change in insight and symptoms were evaluated with analysis of covariance (ANCOVA) and correlation.

RESULTS

Insight deficits were more prevalent in schizophrenia, a mixed group of other psychosis and bipolar disorder as compared with major depressive and schizoaffective disorder. Committed patients had lower insight. Insight improved across diagnoses during hospital care in both voluntary and committed patients. Significant relationships between improved symptoms and improved insight were obtained in the bipolar, schizophrenia and major depressive groups.

CONCLUSION

Insight deficits are prevalent in schizophrenia and bipolar disorder. Many patients show improved insight as their acute symptoms improve. Some aspects of insight are state related during exacerbation of illness in patients with schizophrenia and bipolar disorder.

The ultimate resignation: suicide and search activity

This paper presents an integrative approach to suicidal behavior in terms of search activity concept. Search activity concept displays a broad and holistic approach to behavior, adaptation to environment, body resistance, brain amine metabolism, and REM-sleep functions. Search activity is defined as activity that is oriented to change the situation (or at least the subject's attitude to it) in the absence of a precise prediction of the outcome of such activity, but taking into consideration outcomes at all previous stages of activity. According to the proposed hypothesis, renunciation of search (a state opposed to search activity) leads to a feeling of helplessness, problem-solution deficits, inefficient coping, dreams that represent renunciation of search, and a drop in the activity of amines. All these factors further exacerbate the state of renunciation of search and elevate suicidal risk. In addition, the remnants of search activity are misdirected to self-defeating behaviors that increase mental pain and contribute to renunciation of search. This hypothesis integrates findings from a number of fields of study of suicidal behavior, resolves some paradoxes, suggests new lines of research, and raises suggestions for assessment and treatment of suicidal behavior.

A clinical study on suicide among schizophrenics

We conducted a clinical investigation of 80 suicides who met the DSM-III-R criteria for schizophrenia. The results using this approach showed no significant difference with those of preceding studies, and general features regarding the phenomenology of suicide among schizophrenics worldwide were recognized. The present study, however, served to underscore the following points: (i) suicide of schizophrenics must be considered a concern at all stages of the disease; (ii) the subjective strength of the will to die may be more important for the committing suicides than the lethality of the methods employed; and (iii) a change in the environment, for example, a hospital admission or discharge, may trigger suicide. A control group of 80 living schizophrenics with no past attempted suicide was then matched to the suicide group with respect to sex and illness duration, in order to identify the predictors of suicide. In a logistic regression analysis, the presence of suicidal ideation, degree of anxiety estimated by positive and negative syndrome scale, and birth order were revealed as predictors of suicide. As to the birth order, the risk is higher in middle children.

Predictors of suicide in psychiatric hospital

OBJECTIVE

About 5% of all suicides occur in psychiatric hospitals. The aim of this study was to look for potential characteristics common to patients who committed suicide in psychiatric hospital.

METHOD

All patients who committed suicide in University Psychiatric Hospital in Ljubljana, Slovenia, in the period 1984-1993 were included. The suicidal patients (SP) with schizophrenia (SCH) and affective psychoses (AP) were compared to an age-, sex- and diagnosis-matched control group. Data from files and (in control patients) patient interviews were gathered. Multivariate logistic regression analysis was used.

RESULTS

A total of 79 patients (34 males and 45 females) committed suicide. The majority of them had SCH (n = 36) and AP (n = 23). The predictors of suicide among patients with AP and SCH were depression and lack of insight and, in addition in patients with SCH, past suicidal behaviour and poor relationships with family members.

CONCLUSION

This study provides the clinician with information on risk factors for in-patient suicide.

Suicidal behavior in schizophrenia: characteristics of individuals who had and had not attempted suicide

OBJECTIVE

This study compares demographic and clinical characteristics of 52 individuals with schizophrenia or schizoaffective disorder who had attempted suicide with those of 104 individuals with schizophrenia or schizoaffective disorder who had not made a suicide attempt.

METHOD

Participants were interviewed with the Diagnostic Interview for Genetic Studies.

RESULTS

Most suicide attempts were of moderate to severe lethality, required medical attention, and involved significant suicidal intent. Individuals who had and had not attempted suicide did not differ with respect to demographic variables, duration of illness, rate of depression, or substance abuse. The two groups are affected differentially when depressed.

CONCLUSIONS

Biopsychosocial assessments and interventions are essential for reducing the risk for suicidal behavior in individuals with schizophrenia.

Suicide among psychiatric in-patients with schizophrenia in an Australian mental hospital

Psychiatric in-patient suicides are associated with schizophrenia. In this paper, 62 suicides in patients with schizophrenia, over a 21-year period in a large psychiatric hospital in Melbourne, Australia, were examined. The characteristics, including demographic and clinical data, for the suicides were compared with a comparison group of 22 'alive' in-patients with schizophrenia. Suicide among in-patients with schizophrenia was associated with previous deliberate self-harm, a greater number of episodes of previous deliberate self-harm, pre-admission and intra-admission suicidal thoughts, intra-admission suicidal attempts, fluctuating suicidal ideation, longer length of stay, a greater number of ward transfers, and prescription of a greater number of neuroleptics and antidepressants. Over 40% of suicides occurred after absconding from hospital and a similar number during periods of approved leave. Violent methods (including jumping in front of trains, trams and road traffic, jumping off buildings, hanging and drowning) were most frequently used. It is concluded that psychiatric units should be developed away from readily available methods of suicide. In-patients at high risk should be observed carefully to avoid absconding and suicide. Suicide risk should be examined carefully in patients prior to approving leave, particularly if they have fluctuating suicidal ideation.

Correlates of insight and insight change in schizophrenia

Various theories have been proposed to account for poor insight in schizophrenia. This study examined the relationships between insight, mood, schizophrenic symptoms and cognitive functioning. The relationship between longitudinal changes in insight and changes in symptoms and mood was also investigated. One-hundred patients with DSM-III-R schizophrenia, recently recovered from a relapse of their illness, were rated on the Insight and Treatment Attitudes Questionnaire (ITAQ), the Positive and Negative Syndrome Scale (PANSS), the Montgomery Asberg Depression Rating Scale (MADRS), the Rivermead Behavioural Memory Test and tests of current and premorbid IQ. A random sample of 53 were then given an educational package (video and booklets) designed to improve their insight. Follow-up ratings on the ITAQ, PANSS and MADRS were subsequently obtained. At baseline, better insight was significantly correlated with lower mood and fewer positive symptoms. It was not related to cognitive functioning. Improvement in insight at follow up was related to worsening of mood, but not to change in positive symptoms. The results are consistent with the concept that poor insight, at least in part, results from the psychotic disease process itself. In addition, they suggest that poor insight may protect against depression in the early stages of recovery from schizophrenia.

Suicide in patients hospitalized for schizophrenia: 1913-1940

From a sample of 1357 schizophrenic patients hospitalized between 1913 and 1940 at the Phipps Clinic, we have follow-up data on 1212 (89%) cases, with a mean length of follow-up of 11 years. Of these 1212 patients, 28 (2%) are known to have committed suicide. Suicide was significantly correlated with 1) previous suicide attempts, 2) depressive symptoms, 3) preoccupation with suicide, 4) affective illness in close relatives, 5) poor premorbid social and work history, 6) sexual worries, and 7) psychomotor agitation. Marital status, gender, age at onset, age at admission, number of previous admissions, condition at discharge from Phipps, length of hospitalization, the presence of any type of delusions or hallucinations, alcohol problems, paranoid or catatonic features, and utilization of shock therapies were not significantly correlated with subsequent suicide. The seven variables significantly correlated with suicide enumerated above were chosen to construct a scale suggesting which patients were at high risk for suicide.

Antecedents of suicide in people with schizophrenia

BACKGROUND

Suicides among people with schizophrenia are commonly believed to be impulsive and to occur unexpectedly.

METHOD

As part of the National Suicide Prevention Project in Finland, a nationwide psychological autopsy study, suicide victims with DSM-III-R schizophrenia (n = 86; n = 64 in the active illness phase) and others (n = 1109; n = 666 without any evidence for psychosis) were compared for communication of suicidal intent (CSI), as well as previous suicide attempts known by the next of kin and/or an attending health care professional during the latest treatment relationship.

RESULTS

More victims with schizophrenia (84%) had a history of previous CSI, and/or had made previous suicide attempt(s) than others (70%). Also, victims with active illness schizophrenia (56%) had more CSI and/or had made suicide attempts during their last three months than victims with no psychosis (41%).

CONCLUSIONS

CSI and/or suicide attempts occur at least as often in people with schizophrenia as in those without schizophrenia, even in the active phase of the illness.

Validity study of the Brazilian version of the Calgary Depression Scale for Schizophrenia

INTRODUCTION

Although depression is a well-established feature of schizophrenia, it is difficult to measure, because it overlaps with negative symptoms and extrapyramidal symptoms (EPS). Routinely adopted depression scales were not designed to be used in--cases of schizophrenia, and are known to perform poorly when trying to distinguish depression from other symptoms.

OBJECTIVE

The aim of this study was to evaluate the validity of the Brazilian version of the Calgary Depression Rating Scale for Schizophrenia (CDSS).

METHOD

Outpatients from four mental health units in the city of São Paulo, diagnosed as having schizophrenia by DSM-IV criteria, were evaluated by two independent raters who applied the DSM-IV depression criteria. All patients were assessed by means of the CDSS, the Positive and Negative Syndrome Scale (PANSS), and the Extrapyramidal Symptom Rating Scale (ESRS).

RESULTS

Eighty patients were recruited for the study. The analysis was carried out by comparing the DSM-IV criteria of depression with the CDSS scores, by means of the receiver operating characteristic (ROC) curves. The area under the ROC curve for major depression was 0.95 (SD = 0.02), and at a cut-off point of 6/7 the validity coefficients were as follows: sensibility 77%, specificity 92%, positive predictive value 67% and negative predictive value 95%. The area under the ROC curve for minor depression was 0.95 (SD = 0.02), and at a cut-off point of 4/5 the validity coefficients were as follows: sensibility 95%, specificity 88%, positive predictive value 75% and negative predictive value 98%. The correlation coefficients between the CDSS scores, the PANSS negative and positive subscale scores, and the ESRS scores were all below 0.50.

CONCLUSION

It can be concluded that the Brazilian version of the CDSS is a valid research tool to assess depressive episodes for stabilized patients with schizophrenia.

Guidelines for depot antipsychotic treatment in schizophrenia. European Neuropsychopharmacology Consensus Conference in Siena, Italy

These guidelines for depot antipsychotic treatment in schizophrenia were developed during a two-day consensus conference held on July 29 and 30, 1995 in Siena, Italy. Depot antipsychotic medications were developed in the 1960s as an attempt to improve the long-term treatment of schizophrenia (and potentially other disorders benefiting from long-term antipsychotic medication). Depot drugs as distinguishable from shorter acting intramuscularly administered agents can provide a therapeutic concentration of at least a seven day duration in one parenteral dose. The prevention of relapse in schizophrenia remains an enormous public health challenge worldwide and improvements in this area can have tremendous impact on morbidity, mortality and quality of life, as well as direct and indirect health care costs. Though there has been debate as to what extent depot (long-acting injectable) antipsychotics are associated with significantly fewer relapses and rehospitalizations, in our view when all of the data from individual trials and metaanalyses are taken together, the findings are extremely compelling in favor of depot drugs. However in many countries throughout the world fewer than 20% of individuals with schizophrenia receive these medications. The major advantage of depot antipsychotics over oral medication is facilitation of compliance in medication taking. Non-compliance is very common among patients with schizophrenia and is a frequent cause of relapse. In terms of adverse effects, there are not convincing data that depot drugs are associated with a significantly higher incidence of adverse effects than oral drugs. Therefore in our opinion any patient for whom long-term antipsychotic treatment is indicated should be considered for depot drugs. In choosing which drug the clinician should consider previous experience, personal patient preference, patients history of response (both therapeutic and adverse effects) and pharmacokinetic properties. In conclusion the use of depot antipsychotics has important advantages in facilitating relapse prevention. Certainly pharmacotherapy must be combined with other treatment modalities as needed, but the consistent administration of the former is often what enables the latter.

Complications of severe mental illness related to alcohol and drug use disorders

In this chapter we review research on the relationships between substance use disorder and 11 domains of adjustment for people with severe mental illness. Studies are divided into correlational research and prospective, longitudinal research, with greater weight given to those in the latter category. The weight of the evidence indicates that substance abuse severely complicates severe mental illness in the following domains: relapse of psychiatric illness, hospitalization, disruptive behavior, familial problems, residential instability, decreased functional status, HIV infection, and medication noncompliance. We discuss the limits of causal inference in these studies and the possible mechanisms that relate substance abuse to various complications.

Management of the suicidal patient with schizophrenia

No matter what the course of treatment determined to be most appropriate, suicidal behavior must be considered thoroughly, and it must be conveyed to the patient that the clinician can assist him or her through this period of increased distress. Hopelessness must be viewed as a symptom with the assumption that a more meaningful sense of purpose will emerge despite the chronic and potentially limiting nature of schizophrenia. Most people with schizophrenia are not suicidal, and most who are suicidal can be offered interventions that will reduce their symptomatology and thereby dissipate their suicidal behavior.

Hopelessness and first-episode psychosis: a longitudinal study

Hopelessness has not been adequately studied in first-episode psychotic patients, although it is already present at the early stages, especially in schizophrenic patients. We have studied 96 neuroleptic-naive psychotic patients (49 schizophrenic patients and 47 other non-affective psychotic patients) over a period of 12 months after their first admission. The total score on the Hopelessness Scale (HS) at first admission was higher in the schizophrenic patients, and correlated with younger age and with negative symptoms. High HS scores at baseline predicted poor short-term outcome in schizophrenic patients, as evidenced by worse global functioning at the 12-month follow-up. These correlations were not observed in the other psychoses group. Our results suggest that young, severely affected schizophrenic patients who experience hopelessness might be at higher risk of poor outcome.

Assessment and intervention for the suicidal patient with schizophrenia

The risk for suicidal behavior in schizophrenia is high with 10-15% committing suicide and 20-40% making suicide attempts. Due to the chronicity and complexity of schizophrenia and the multi-determined nature of suicidal behavior, the clinician must utilize a biopsychosocial approach to assessment and intervention. Clinical factors such as psychosis, depression and substance abuse increase the risk for suicidal behavior in schizophrenia. Social factors such as social adjustment and social supports also play a critical role. Ongoing assessment and intervention of suicidal behavior, clinical symptomatology, social environment and treatment issues are essential. Prediction and prevention of suicidal behavior are not always possible however. Treatment focused on the reduction of symptomatology and maintenance of an effective social environment may attenuate the risk for suicidal behavior in schizophrenia.

Calculated risk taking in the treatment of suicidal patients: ethical and legal problems

The ethical rationale by which the law permits suicidal patients to be involuntarily confined to institutions, their suicides prevented, and treatment imposed has been much discussed. Economic factors have now made prolonged hospital care almost impossible in the United States. Psychiatrists feel great pressure to discharge suicidal patients from inpatient care. While discharge is therapeutically desirable for some suicidal patients, for others it is not. In the event of postdischarge suicide, the risk of a lawsuit is considerable.

Clinical management of parasuicides: critical issues in the 1990s

In view of recent rises in suicide rates of males aged 15-29 years, the literature on the specialised clinical management of parasuicides presenting at hospital is reviewed. Few studies demonstrate reduction in suicidal behaviour with such services, although substantial psychosocial benefits have been shown. These negative results with respect to suicidal behaviour partly relate to methodological problems such as small sample sizes, the exclusion of high risk subjects, short follow-up and confusing outcome measures. We cannot be confident that existing clinical practices have been effective in reducing suicide. Hence this paper focuses on selected issues of critical importance. Clinically, risk assessment is a problematic area worthy of clear understanding. There is a continuing confusion over the nature of affective disturbance associated with parasuicide and whether it might benefit from pharmacotherapy. Recent studies on the prevalence of psychological disorder in suicidal youth are discussed. Child abuse might usefully be screened for in parasuicidal patients, although this may be overlooked because of unfamiliarity with the association. New developments in cognitive and pharmacotherapies offer hope for suicidal rate reduction. There is a pressing need for further intervention studies. In particular, community and inpatient care of high risk patients require urgent evaluation. Further study of the role of depression and its appropriate management is needed. Although depression seems a significant factor, the recent rise in youth suicide remain largely unexplained.

Early intervention in schizophrenia

The management of schizophrenia may be characterised by two paradigms. The first approaches the schizophrenias as episodic relapsing disorders, where treatment is provided through both acute (crisis) care and to achieve prophylaxis. The second paradigm, sometimes arising from a failure of the first, is of "rehabilitation", involving amelioration of disabilities, occasionally within a framework of relative asylum. We would propose a third paradigm of "early intervention", involving a combination of medical and psychosocial interventions targeted at young, vulnerable people with the aim of preventing or limiting likely social, psychological and mental deterioration. Vigorous intervention early in the course of illness, early recognition and treatment of relapse and the promotion of psychological adjustment to psychotic illness are proposed as key elements of this third paradigm.

Suicide in psychiatric patients: risk and prevention

The prevention of suicide requires an understanding of protective as well as risk factors, and the recognition of high-risk groups. Factors which increase the risk in patient populations include previous parasuicide, recent relapse or discharge, features of mental state (depression, psychosis), social circumstances (isolation, unemployment), and demographic characteristics (male sex, young age). Protective factors are under-researched but are likely to lie in the nature of psychiatric care. Consequently, community care may affect suicide by altering the level of protection at critical periods in an episode of illness. The clinical prevention of suicide should therefore be a priority for community services, and the relationship between suicide and mental health care should be researched by a national process of monitoring.

Suicide precautions for psychiatric inpatients: a review

This paper reviews the literature on the assessment and management of suicide risk of psychiatric inpatients. Even though a large number of scales have been developed to assist the prediction of suicide for patients admitted for suicide ideas and attempts, none of them were designed to predict suicide in the short term. However the Modified Suicide Intent Scale and the Hopelessness Scale appear to have the potential to predict immediate suicide risk. Risk factors associated with specific psychiatric conditions were all derived retrospectively and their predictive validities have not been established by prospective studies. Important issues relating to the management of suicidal inpatients, such as staff-patient relationships, use of constant observation and medical-legal aspects are reviewed.

Suicide attempts of high medical seriousness in schizophrenic patients

A retrospective study was conducted that included all patients who in the previous 6 years had required admission to our hospital for medical reasons following attempted suicide (N = 253). Those diagnosed as schizophrenic (n = 43) in accordance with DSM-III-R criteria were compared with the other nonschizophrenic suicide attempters. Schizophrenic patients were significantly different in that they were younger and generally unmarried, usually used violent methods, made more attempts while in a psychiatric center, and presented a lower incidence of concurrent organic illness than the nonschizophrenics; almost all of them were chronic. A large majority (80%) showed delusional and hallucinatory symptoms at the time of the attempt. In contrast, depressive symptoms were noted in an appreciably lower percentage of subjects than that in other studies of suicidal behavior in schizophrenics.

Mortality in DSM-IIIR schizophrenia

Mortality was investigated in 356 DSM-IIIR schizophrenics admitted to a university psychiatric hospital over a 12-year period. Determination of death was made through a record-linkage process and observed death was compared with the mortality experience of the general population of the State of Iowa. Schizophrenics had nearly a three-fold increase in overall mortality. Mortality was primarily attributable to unnatural causes of death, particularly suicide, which was more than twenty-three times greater than expected. Mortality was greater in schizophrenic patients younger than 40 years and during the early portion of follow-up. Studies of mortality in psychiatric patients continue to be important, particularly as diagnostic criteria become better refined.

A study of suicide in schizophrenic in-patients

A retrospective analysis of the clinical records of 53 schizophrenic in-patients who committed suicide, and the same number of matched control subjects, was carried out using a larger set of demographic, psychosocial and clinical variables. Univariate analysis of the data indicated an early disturbed psychosocial adjustment, more severe mental illness, unsatisfactory social situation, and more frequent suicidal behaviour in the suicide group. Suicide in schizophrenic in-patients thus appears to be closely connected with a particularly incapacitating form of the illness and its deleterious psychosocial consequences.

A clinical study of schizophrenic suicides. 42 cases in Taiwan

A clinical study of 25 male and 17 female schizophrenic suicides is presented. Jumping from a height was the most common method used. The 42 suicidal schizophrenics in Taiwan were compared with both 84 sex- and age-matched and 60 5-year illness course non-suicidal schizophrenic control groups. The suicidal schizophrenics were not significantly different from the non-suicidal counterparts of both control groups with regard to age, sex, ethnicity, religion, educational background, the presence of suicide cases in the family history, and the presence of insight, but were significantly different in characteristics of a history of previous suicide attempts, presence of psychotic symptoms during their final month, depression during their final month, a history of depression, a history of previous psychiatric hospitalizations, and the number of hospitalizations. We discuss the findings from this study and others in the literature in the context of the different clinical and socio-cultural backgrounds of these Taiwanese schizophrenic suicides.

Mortality in a cohort of patients with schizophrenia: a record linkage study

A retrospective study of mortality was conducted in which 3,623 patients with schizophrenia receiving treatment in Alberta between 1976 and 1985 were followed to the end of 1985. Vital status was determined by record linkage to the Statistics Canada Mortality Data Base. There were 301 deaths in the cohort, 97 of which were due to suicide. For all causes of death combined, the risk of mortality was approximately double that of the Alberta population; for suicide, risk was increased by a factor of 20. Mortality from circulatory, respiratory, digestive and genitourinary diseases was also greater than expected. It is estimated that those who suffer from schizophrenia have a life expectancy which is approximately 20% shorter than that of the general population. This study confirms earlier research demonstrating an increased risk of mortality associated with schizophrenia and extends those findings to specific causes of death.

Suicidal indicators in schizophrenia

The clinical and sociodemographic profile of suicidal and nonsuicidal schizophrenia patients was investigated in 801 patients with this diagnosis seen at a comprehensive psychiatric facility between 1983 and 1987. Suicidal patients tended to exhibit depression, aggressiveness, substance abuse and a severe and progressive impairment in adaptive functioning.