TRANQUILIZERS AND SUICIDE IN THE SCHIZOPHRENIC PATIENT

Alcohol use and suicide-related outcomes in people with a diagnosis of schizophrenia: a comprehensive systematic review and meta-analysis

Suicide is the leading cause of unnatural death among people with a diagnosis of schizophrenia. Alcohol use is a prevalent comorbid feature of schizophrenia and a modifiable risk factor for suicide. We conducted a prospectively registered (PROSPERO, CRD42022358214) systematic review and meta-analysis to quantify the relationship between alcohol use and suicide-related outcomes in schizophrenia.We searched Medline, Embase, and PsycINFO for cross-sectional, case-control and longitudinal studies using exhaustive terms from database inception to December 2022 inclusive. Computation of odds ratios (ORs) and hazard ratios (HRs) were performed using a random-effects model with DerSimonian-Laird estimation. We also evaluated publication bias, study quality, and performed subgroup analysis and meta-regression. Fifty studies, comprising 65 samples, met eligibility criteria. Overall, alcohol use was associated with suicide (OR 1.38, 95% CI 1.21-1.58; HR = 1.32, 95% CI 1.00-1.74), attempted suicide (OR 1.69, 95% CI 1.45-1.98), and suicidal ideation (OR 1.69, 95% CI 1.22-2.34). While there was no evidence of publication bias, between-sample heterogeneity was moderate in analyses of attempted suicide (I2 = 39.6%, p = 0.01) and suicidal ideation (I2 = 56.0%, p = 0.01). Summary effects were significant in all subgroups except for longitudinal studies of attempted suicide (OR 1.60, 95% CI 0.86-3.00) and studies of suicidal ideation using gender combined samples (OR 1.63, 95% CI 0.99-2.67). Alcohol use is significantly associated with suicide-related outcomes in schizophrenia. Clinicians should routinely inquire about alcohol use in mental health services to focus preventative treatment efforts.

Model for the Prediction of Suicidal Behavior

A three-factorial model for the prediction of suicidal behaviors has been proposed. This model allows both the integration of past research findings and the generation of new propositions regarding suicidal behaviors by analyzing the interaction of variables on different dimensions.

Managing suicide risk in patients with schizophrenia

The management of suicide risk in patients with schizophrenia poses many challenges for clinicians. Compared with the general population, these patients have an 8.5-fold greater risk of suicide. This article reviews the literature dealing with the treatment of at-risk patients with schizophrenia. An integrated psychosocial and pharmacological approach to managing this population of patients is recommended. Although there is at least modest evidence suggesting that antipsychotic medications protect against suicidal risk, the evidence appears to be most favourable for second-generation antipsychotics, particularly clozapine, which is the only medication approved by the US FDA for preventing suicide in patients with schizophrenia. In addition, treating depressive symptoms in patients with schizophrenia is an important component of suicide risk reduction. While selective serotonin receptor inhibitors (SSRIs) ameliorate depressive symptoms in patients with schizophrenia, they also appear to attenuate suicidal thoughts. Further research is needed to more effectively personalize the treatment of suicidal thoughts and behaviours and the prevention of suicide in patients with schizophrenia.

Outcome of suicidal patients with schizophrenia: results from a naturalistic study

OBJECTIVE

Purpose was to assess suicidality before and at the time of admission in patients with schizophrenia and compare outcome differences.

METHOD

Biweekly PANSS (Positive and Negative Syndrome Scale), HAMD (Hamilton Depression Rating Scale) and UKU (Udvalg for Klinske Undersogelser Side Effect Rating Scale) ratings were evaluated in 339 in-patients with schizophrenic spectrum disorders. Response was defined as an initial 20% PANSS total score reduction at discharge, remission was defined according to the proposed consensus criteria by the Remission in Schizophrenia Working Group.

RESULTS

Suicidal patients (22%) scored significantly higher on the PANSS negative subscore, PANSS insight item and HAMD total score at admission and at discharge. They developed significantly more side effects. No differences were found concerning response and remission between the two patient subgroups.

CONCLUSION

Despite receiving significantly more antidepressants the suicidal patients suffered from significantly more depressive symptoms up to discharge, yet without differing regarding response and remission.

Management of schizophrenia with suicide risk

Suicidal behavior remains a major source of morbidity and mortality among schizophrenics. The National Institute of Mental Health Longitudinal Study of Chronic Schizophrenia found that over a mean of 6 years, 38% of the patients had at least one suicide attempt and 57% admitted to substantial suicidal ideation. Suicide is also a major issue among inpatients, with serious implications for clinical practice and patient-doctor relationships. The management of schizophrenic patients with suicide risk remains a difficult area for clinicians despite attempts to better understand it by gathering experts in the field. This article discusses the frequency of suicidal behavior in schizophrenia, offers a model for understanding it, and discusses various aspects of the management of the at-risk schizophrenic patient.

Suicide risk in schizophrenia: learning from the past to change the future

Suicide is a major cause of death among patients with schizophrenia. Research indicates that at least 5-13% of schizophrenic patients die by suicide, and it is likely that the higher end of range is the most accurate estimate. There is almost total agreement that the schizophrenic patient who is more likely to commit suicide is young, male, white and never married, with good premorbid function, post-psychotic depression and a history of substance abuse and suicide attempts. Hopelessness, social isolation, hospitalization, deteriorating health after a high level of premorbid functioning, recent loss or rejection, limited external support, and family stress or instability are risk factors for suicide in patients with schizophrenia. Suicidal schizophrenics usually fear further mental deterioration, and they experience either excessive treatment dependence or loss of faith in treatment. Awareness of illness has been reported as a major issue among suicidal schizophrenic patients, yet some researchers argue that insight into the illness does not increase suicide risk. Protective factors play also an important role in assessing suicide risk and should also be carefully evaluated. The neurobiological perspective offers a new approach for understanding self-destructive behavior among patients with schizophrenia and may improve the accuracy of screening schizophrenics for suicide. Although, there is general consensus on the risk factors, accurate knowledge as well as early recognition of patients at risk is still lacking in everyday clinical practice. Better knowledge may help clinicians and caretakers to implement preventive measures. This review paper is the result of a joint effort between researchers in the field of suicide in schizophrenia. Each expert provided a brief essay on one specific aspect of the problem. This is the first attempt to present a consensus report as well as the development of a set of guidelines for reducing suicide risk among schizophrenia patients.

Emotional processing in schizophrenia

INTRODUCTION

Persons with schizophrenia have impaired emotional processing, involving experience, expression, and recognition of emotions.

METHODS

This article reviews the historical descriptions and more recent work on emotion processing in schizophrenia.

RESULTS

Although abilities of emotional processing relate directly to interpersonal communication and psychosocial functioning, methodological issues exist in the current body of studies and resultant knowledge, which limit translation to novel treatment options.

CONCLUSIONS

Further improvement in emotion processing in persons with stable schizophrenia are unlikely to result from conventional pharmacotherapy of psychosis. New treatment modalities and behavioural interventions offer possible improvements in quality of life and psychosocial functioning.

Where schizophrenic patients commit suicide: a review of suicide among inpatients and former inpatients

OBJECTIVE

To review the literature on suicide of inpatients with schizophrenia, to identify suicide risk factors as well as typical patterns of behavior and to suggest a rationale and strategies for future interventions.

METHOD

A computerized MedLine, Excerpta Medica and PsycLit search supplemented by an examination of cross-references and reviews.

RESULTS

Up to half the suicides among patients with schizophrenia occur during inpatient admission. Inpatient suicides were found among those of a young age group who were predominantly single, childless and socially isolated. The vast majority experienced an illness characterized by long duration and prolonged psychiatric hospitalizations or multiple admissions and discharges. Up to 50% of the suicides occurred in the first few weeks and months following discharge from the hospital. The paranoid subtype of schizophrenia, where positive symptoms prevail and negative symptoms are few, is associated with a suicide risk that is three times greater than that associated with nonparanoid subtypes and eight times greater than the risk associated with the deficit subtype.

CONCLUSIONS

Treatment of suicide is a major problem among inpatients with schizophrenia. Evidence suggests that suicide is generally carried-out by patients who have been recently discharged or by those who manage to get away from the hospital. Strategies aimed at preventing this phenomenon have been introduced to the medical personnel, but suicide in these patients does not seem to have been reduced. We emphasize the need to establish guidelines for the prevention of suicide in hospitalized patients with 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.

Antisuicide properties of psychotropic drugs: a critical review

The authors consider the extent to which psychotropic medications demonstrate benefits in the prevention of suicidal behavior in psychiatric patients. Results of a MedLine search are critically reviewed for lithium, divalproex and other anticonvulsants, conventional and atypical antipsychotics, and antidepressants. The existing literature is almost entirely limited to noncontrolled, often retrospective studies that do not control for potential biases in treatment selection, the use of multiple medications, the impact of medication nonadherence, and nonrandomized treatment discontinuations. Nevertheless, an extensive literature has arisen regarding observed reductions in suicidal behavior with lithium for mood disorders and, to a lesser extent, with clozapine for schizophrenia. A substantially smaller literature suggests more negative than positive data with divalproex or carbamazepine in bipolar disorder, while minimal information exists regarding suicidality with atypical antipsychotics other than clozapine. Studies of antidepressants have mostly been short-term and have focused more on whether they induce (rather than ameliorate) suicidal thoughts or behaviors. The sum of existing studies is generally inconclusive about whether antidepressants appreciably reduce risk for suicide completions. Relatively little is known about pharmacotherapy effects on suicidal ideation as distinct from behaviors. Possible mechanistic considerations for understanding antisuicide properties include a therapeutic impact on depression, impulsivity, or aggression, potentially mediated through serotonergic or other neuromodulatory systems. Recommendations are provided to guide future research as well as clinical practice.

Neurocognitive performance does not correlate with suicidality in schizophrenic and schizoaffective patients at risk for suicide

BACKGROUND

Almost 50% of schizophrenic persons attempt suicide at some time in their lives and 9-13% of patients ultimately commit suicide. While numerous studies have elucidated the relationship between psychiatric symptomatology and neurocognition in patients with schizophrenia, this is the first report, to our knowledge, to investigate the relationship between suicidal behavior and neurocognition in schizophrenia and schizoaffective disorder.

METHODS

A subgroup of 188 patients participating in the InterSePT trial was assessed at baseline with an extensive neurocognitive battery and measures of suicidality and psychiatric symptomatology.

RESULTS

Measures of suicidality did not significantly correlate with neurocognitive performance. Confirmatory analyses between patients currently judged to be at high and low risk for suicide also revealed no neurocognitive differences. Consistent with previous studies, poor neurocognitive performance tended to be modestly correlated with the Positive and Negative Syndrome Rating Scale (PANSS) negative symptom scale. The relationship between suicidality and neurocognitive performance was similar for schizoaffective and schizophrenic patients.

CONCLUSIONS

The findings suggest that suicidality in patients with schizophrenia and schizoaffective disorder is not correlated with cognition and may, in fact, be a separate domain worthy of investigation and intervention.

Postpsychotic depression in schizophrenia patients

Depression is a frequent comorbidity in the course of schizophrenia and is associated with increased mortality from suicide. Postpsychotic depression is defined as the syndrome of major depression occurring following remission of psychotic symptoms in a person with schizophrenia. Various proposed causes, differential diagnosis, and issues regarding management of postpsychotic depression are discussed.

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.

Depression in schizophrenia: I. Association with neuropsychological deficits

BACKGROUND

The presence of depression in schizophrenia has been well described with regard to stage and symptoms of illness; however, little is known about the possible etiology.

METHODS

In an effort to advance the understanding of the neurobiology of depression in schizophrenia, we grouped patients with schizophrenia based on their ratings on the 21-item Hamilton Depression Rating Scale. There were 63 patients (35 men, 28 women) in the high (> or = 18) depression group and 81 patients (52 men, 29 women) in the low (< 18) depression group. The groups were compared in demographic, clinical, and eight neuropsychological domains.

RESULTS

The two groups differed in age at onset of illness, severity of delusions, and performance in a single neuropsychological domain: attention. The specific component of impaired attention was vigilance, with poorest performance seen in women with higher depression scores.

CONCLUSION

The presence of specific attentional impairment associated with depressive symptoms in schizophrenia is consistent with the hypothesis of frontal lobe dysfunction in depression, because these regions have been implicated in attentional processes.

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.

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.

Antipsychotic medication and suicide risk among schizophrenic and paranoid inpatients. A controlled retrospective study

A retrospective analysis of the psychotrophic medication, illness history and recent mental symptoms of 28 schizophrenic or paranoid inpatients who had committed suicide and the same number of matched control subjects was carried out. The groups were first compared separately for every variable, and 6 statistically most significant variables in the paired comparisons were then entered into a stepwise linear logistic regression model. Four statistically significant differences between the groups were found with the paired comparisons. The suicide group had more often previous suicide attempts, lower neuroleptic doses, more depressive symptoms and less positive schizophrenic symptoms compared to their controls. The results of the regression analysis suggested that the lower neuroleptic doses in the suicide group were more probably a consequence of the differences in the symptom profile than in a direct causal relationship to the suicides per se.

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.

Age, mortality and chronic schizophrenia

Mortality data are presented from a 0 to 10 year follow-up of 636 chronic schizophrenic patients. Death ascertainment was made through a record-linkage process and comparisons made with the general population of the State of Iowa using sex and age standardized mortality ratios (SMRs). Risk for mortality was most pronounced among men younger than 40 and women younger than 70. No suicides occurred in chronic schizophrenic patients over age 40 years. The data demonstrate that patients at greatest risk for premature death are those younger than 40 years. Reasons for these findings are discussed.

Depression and suicide in schizophrenic patients

This study supports the idea that schizophrenic patients represent a distinctive subgroup of patients who can suffer from a major depressive illness and also can commit suicide. The study showed that 22.4% of the schizophrenic population in a medium-sized psychiatric facility showed severe depressive symptoms that met the criteria for the diagnosis of a major depressive episode according to the DSM-III classification. Seven patients committed suicide during the acute phase of the illness--five during hospitalization, and two within a year of discharge. Nine patients attempted suicide during the hospitalization period, and 10 attempted suicide within a year of discharge. Nearly one-third (215) of the patients were readmitted during that year because of a recurrence of acute schizophrenic symptoms; of these, 84 were having severe depressive symptoms. The study also provides indications of the causes of suicide in these patients.

Risk factors for suicide among patients with schizophrenia

In order to assess risk factors for suicide among patients with schizophrenia, we compared 32 patients with schizophrenia who committed suicide during an 11 year follow-up with a control group of 64 schizophrenics who did not commit suicide. A history of previous suicide attempts was the factor most strongly related to suicide. In females we found an increased risk for suicide among unmarried, divorced or widowed and among those living alone. In males we found an increased risk among those with a history of alcohol abuse. In contrast to findings in other studies, distribution of age and sex and a history of depressive episodes were factors not associated with an increased risk for suicide. We conclude that suicidal acts among schizophrenics are often impulsive and difficult to predict. Traditional risk scales are of limited value in the clinical assessment of suicidal risk.

Assessment of suicide risk

Among the many clinical skills that psychiatrists must acquire, the ability to assess the risk of patients killing themselves is probably the most important and demanding. It is often a crucial factor when making clinical decisions, such as in the choice of treatments, when deciding whether admission to a psychiatric hospital is necessary and when implementing the Mental Health Act. This review first explores the problems in assessing suicide risk. Subsequently, the risks of suicide for patients with major psychiatric disorders and for particular clinical populations, including hospitalised patients and suicide attempters, are examined together with the findings from research investigations which can assist psychiatrists when making decisions about the risk of suicide.

Suicide among schizophrenics: a comparison of attempters and completed suicides

Schizophrenics who completed suicide were compared with those who made suicide attempts, on the basis of blind ratings of previous hospital records and follow-up interviews with treating clinicians. Results indicated that the two groups were relatively distinct. Suicides tended to live alone and to feel depressed, hopeless, worthless, and suicidal. Attempters, on the other hand, lived with their families or others and were less likely to manifest several features of depression during a period in hospital. In evaluating suicide potential among schizophrenics, living situation and mental state changes indicating depression, suicidal intent, worthlessness, and hopelessness are more important than a history of suicidal behaviour.

Depression, hopelessness and suicide in chronic schizophrenia

Hospital records for 104 schizophrenic patients, 15 of whom subsequently committed suicide, were rated blindly for individual depressive symptoms comprising DSM III major depressive episode, and for hopelessness. Our results indicate that a large proportion of schizophrenic patients experienced major depressive episodes, and that these can be reliably identified. Presuicidal schizophrenics also experienced depressed mood, but only a minority developed the full syndrome; they typically exhibited the psychological, but not somatic symptoms. The relationship between depression and suicide disappears when hopelessness is taken into account.

Patterns of self-destructive behaviour in schizophrenia

Of 110 consecutive, young schizophrenic patients, 18 (16.4%) died during a follow-up period of 14-17 years from first admission. Fifteen of them met with a sudden death. Definite suicide was proven in 10 cases (9%). Suicide was associated with chronicity in course, social dependency, and lowered efficiency. Some type of warning was present in all suicide cases. The frequency of suicide thoughts and attempts was high in the whole material. Suicide attempts were associated with protracted non-regressive symptomatology, readmission to hospital, social intervention, and female sex. The disparity of characteristics between attempted suicide and definite suicide cases may partly be explained by the preponderance of women among the former and by the fact that only half of the suicidal deaths occurred when the frequency of attempts was at its peak. In attempted suicide in men their characteristics were compatible with those of the whole group, as well as with those of the suicide cases.

A clinical and epidemiological survey of parasuicide and suicide in Edinburgh schizophrenics

Between 1968 and 1981 there were roughly equal numbers of male and female schizophrenic parasuicides in Edinburgh: males were significantly younger than females at parasuicide (33 v. 37 years), and had received a diagnosis of schizophrenia for a shorter time (3.4 v. 7.2 years). The clinical, epidemiological and social characteristics of such parasuicides are, by and large, those that might be expected from a knowledge of the epidemiology of schizophrenia. Eight per cent of a sample of Edinburgh schizophrenic first-ever parasuicides subsequently committed suicide, when followed up for up to 14 years. This percentage is close to what would be expected for later suicide in non-schizophrenic parasuicides. When all the suicides were considered, similar numbers of male and female schizophrenics killed themselves; their mean ages at death were 42 and 43 years respectively; and the mean duration of the schizophrenic illness was 10 years in both cases, according to hospital records. We found slight evidence that parasuicide is commoner in schizophrenic suicides than in schizophrenic controls but little evidence to support the contention that there may be a specific relationship between suicide (or parasuicide) and the presence of auditory hallucinations, recent discharge from in-patient care, the use of depot neuroleptic medication, or recent parasuicide. From the point of view of the prevention of suicide and parasuicide in schizophrenics, it is noteworthy that we found few differences between the clinical characteristics and management of schizophrenic parasuicides and suicides, and schizophrenic controls.

Suicide in chronic schizophrenia

A matched controlled study of 30 chronic schizophrenic suicides is presented. Eighty per cent were male and committed suicide at a mean age of 25.8 years after a mean duration of illness of 4.8 years. Significantly more of the suicides had a chronic relapsing schizophrenic illness; 23.3 per cent committed suicide while in-patients, and 50 per cent of the out-patients committed suicide within three months of discharge from in-patient care. Significantly more of the suicides had a past history of depression (56.6 per cent), were depressed in the last episode of contract (53.3 per cent), had their last admission for depression or suicidal ideation (55.2 per cent) and were unemployed (80 per cent).

Studies of depressive symptoms in schizophrenia

Depression assessed by clinical examination and Hamilton rating scale was found in half of 37 untreated new acute schizophrenics, and in about a third of chronic schizophrenics who relapsed whether treated with depot injections (89) or not (79). A significant part of depressive illness in schizophrenics is thus not drug-related. However, depression was commoner in those on higher doses of depot neuroleptic (P <.05) or who showed extrapyramidal side effects (P <.001), suggesting that drugs can play a part. Patients maintained in remission on moderate doses of depot drug had the lowest prevalence of depression.

A comparative trial of the decanoates of flupenthixol and fluphenazine

A double-blind trial was carried out comparing the effects of decanoates of flupenthixol and fluphenazine on the symptoms, ward behaviour and functional capacity in occupational therapy in 51 chronic schizophrenic patients. The patients were carefully selected on the basis of rigid criteria for diagnoses. To exclude nonresponders to neuroleptics the patients were first taken off neuroleptic drugs and only those who appeared to show deterioration were included in the trial. The dosage of drugs was varied according to clinical indications. The length of the trial was initially 4 months and 31 patients were followed for an additional 4 months. To ensure reliability multiple assessments were made at the start and the end of the trial. Most of the statistical tests showed no differences between the treatments, but some of those relating to affective symptoms showed an advantage for flupenthixol as compared with fluphenazine. There were no differences in the incidence of extra-pyramidal side-effects which required treatment in only 32% of the patients on each drug.

Attitude to psychiatric treatment before suicide in schizophrenia and paranoid psychoses

The purpose of the study was to clarify the attitude of patients with schizophrenia and paranoid psychoses towards hospital personnel and treatment procedures during the two pre-suicidal months. The study was carried out on subjects from south Finland who had committed suicide during a three-year period and had been treated under these diagnoses. The controls included suicides who had received psychiatric treatment for other reasons. A questionnaire was issued to ascertain the opinions of the doctor last in charge of the patient and other personnel. Both groups answered independently, and the opinions given were almost the same. Both groups stated that during the last pre-suicidal months the patients with schizophrenia and paranoid psychoses had shown a more negative or indifferent attitude towards personnel than the controls, and their attitude towards medication had been clearly more negative. Among them there were considerably more patients who had ceased to request support or attention. Thus these patients had developed a degree of despair which manifested itself in a negative attitude towards personnel and treatment.

Long-acting phenothiazines in the prevention of relapse of schizophrenic patients

The development of the depot fluphenazine preparations has been a major advance in the drug treatment of schizophrenia, ensuring continuous medication and stimulating the development of adequate community care services, resulting in significant reduction of relapse and readmission.

This report compares the incidence of readmissions and the duration of hospital stay in a group of chronic schizophrenic patients who had first received oral medication and then long-acting injectable fluphenazine enanthate and decanoate over identical periods of time. A percentage of 93.3 of the subjects were maintained on continuous treatment for twelve to forty months. The readmission rate was reduced from 191 to 50, and the time spent in hospital from 8,713 to 1,335 days.