Association between medication and risk of suicide, attempted suicide and death in nationwide cohort of suicidal patients with schizophrenia

All-cause mortality risk in long-acting injectable versus oral antipsychotics in schizophrenia: a systematic review and meta-analysis

Patients with schizophrenia receiving antipsychotic treatment present lower mortality rates than those who do not. However, the non-adherence rate is high, which can be partially addressed using long-acting injectable (LAI) antipsychotics. The impact of LAI treatments on all-cause mortality compared to oral antipsychotics remains unclear. To fill that gap, a random effects meta-analysis was conducted to analyze the odds ratio (OR) of all-cause, suicidal, and non-suicidal mortality among patients taking LAI antipsychotics compared to oral antipsychotics (PROSPERO:CRD42023391352). Individual and pooled LAI antipsychotics were analyzed against pooled oral antipsychotics. Sensitivity analyses were performed for study design, setting, and industry sponsorship. Meta-regressions were conducted for gender, age, antipsychotic dose, and race. Seventeen articles, total sample 12,042 patients (N = 5795 oral, N = 6247 LAI) were included. Lower risk of all-cause mortality for patients receiving LAI antipsychotics vs receiving oral antipsychotics was found (OR = 0.79; 95%CI = 0.66-0.95). Statistical significance was maintained when only studies comparing the same LAI and oral antipsychotic were included (OR = 0.79; 95%CI = 0.66-0.95; p = <0.01), as well as for non-suicidal mortality (OR = 0.77: 95%CI = 0.63-0.94; p = 0.01), but not for suicidal mortality (OR = 0.86; 95%CI = 0.59-1.26; p = 0.44). Mortality reduction was more pronounced for LAI antipsychotics in first-episode psychosis (FEP) (OR = 0.79; 95%CI = 0.66-0.96) compared to chronic psychosis. No individual LAI reported statistically significant differences against all pooled oral antipsychotics. LAI antipsychotics are associated with a lower risk of all-cause and non-suicidal mortality in individuals with schizophrenia compared to oral antipsychotics. Better adherence to the medication and health services may explain this difference. Whenever possible, the use of LAIs should be considered from the FEP.

Psychotropic Medications Promote Time-Dependent Reduction of Suicidal Ideation in Mood Disorder: A Prospective Cohort Study

BACKGROUND

Despite a plethora of research on the topic, there is still no solid evidence that pharmacological treatment actually reduces the risk of suicide in patients with mental illness. In this study, we aimed to assess the effect of psychotropic medications on suicidal ideation in patients with major depressive disorder (MDD) and bipolar disorder (BPD) in two age groups: less than 25 years and 25 years and older.

METHODS

We analyzed 312 patients with mood disorders with current suicidal thoughts or recent suicide attempts. We followed the participants from baseline for 6 months and assessed changes in suicidal ideation with Columbia-Suicide Severity Rating Scale (C-SSRS). The effect of psychotropic drug administration on suicidal ideation over time was analyzed using a linear mixed model.

RESULTS

In patients aged 25 years and older with mood disorders, suicidal ideation was more severe when using psychotropic drugs than when not using them. However, suicidal ideation decreased rapidly over time. The time-dependent reduction in suicidal ideation was accelerated when using antidepressants and sedatives/hypnotics in adult MDD, and when using mood stabilizers in adult BPD. However, this effect was not observed in participants aged less than 25 years.

CONCLUSION

Adequate psychotropic medication may reduce suicidal ideation in patients with mood disorders aged 25 years and older. Additional research on psychotropic drugs is needed to effectively reduce the risk of suicide among children and adolescents with mood disorders.

Prevention of Suicidal Behavior in Bipolar Disorder

Background

Excess mortality is a critical hallmark of bipolar disorder (BD) due to co-occurring general medical disorders and especially from suicide. It is timely to review of the status of suicide in BD and to consider the possibility of limiting suicidal risk.

Methods

We carried out a semi-systematic review of recent research reports pertaining to suicide in BD.

Findings

Suicide risk in BD is greater than with most other psychiatric disorders. Suicide rates (per 100,000/year) are approximately 11 and 4 in the adult and juvenile general populations, but over 200 in adults, and 100 among juveniles diagnosed with BD. Suicide attempt rates with BD are at least 20 times higher than in the adult general population, and over 50 times higher among juveniles. Notable suicidal risk factors in BD include: previous suicidal acts, depression, mixed-agitated-dysphoric moods, rapid mood-shifts, impulsivity, and co-occurring substance abuse. Suicide-preventing therapeutics for BD remain severely underdeveloped. Evidence favoring lithium treatment is stronger than for other measures, although encouraging findings are emerging for other treatments.

Conclusions

Suicide is a leading clinical challenge for those caring for BD patients. Improved understanding of risk and protective factors combined with knowledge and close follow-up of BD patients should limit suicidal risk. Ethically appropriate and scientifically sound studies of plausible medicinal, physical, and psychosocial treatments aimed at suicide prevention specifically for BD patients are urgently needed.Reprinted from Bipolar Disord 2021; 23:14-23, with permission from John Wiley and Sons. Copyright © 2021.

How to save a life: From neurobiological underpinnings to psychopharmacotherapies in the prevention of suicide

The impact of suicide on our societies, mental healthcare, and public health is beyond questionable. Every year approximately 700 000 lives are lost due to suicide around the world (WHO, 2021); more people die by suicide than by homicide and war. Although suicide is a key issue and reducing suicide mortality is a global imperative, suicide is a highly complex biopsychosocial phenomenon, and in spite of several suicidal models developed in recent years and a high number of suicide risk factors identified, we still have neither a sufficient understanding of underpinnings of suicide nor adequate management strategies to reduce its prevalence. The present paper first overviews the background of suicidal behavior including its epidemiology, prevalence, age and gender correlations and its association with neuropsychiatric disorders as well as its clinical assessment. Then we give an overview of the etiological background, including its biopsychosocial contexts, genetics and neurobiology. Based on the above, we then provide a critical overview of the currently available intervention options to manage and reduce risk of suicide, including psychotherapeutic modalities, traditional medication classes also providing an up-to-date overview on the antisuicidal effects of lithium, as well as novel molecules such as esketamine and emerging medications and further molecules in development. Finally we give a critical overview on our current knowledge on using neuromodulatory and biological therapies, such as ECT, rTMS, tDCS and other options.

Suicidal Offenders and Non-Offenders with Schizophrenia Spectrum Disorders: A Retrospective Evaluation of Distinguishing Factors Using Machine Learning

Patients with schizophrenia spectrum disorders (SSD) have an elevated risk of suicidality. The same has been found for people within the penitentiary system, suggesting a cumulative effect for offender patients suffering from SSD. While there appear to be overlapping characteristics, there is little research on factors distinguishing between offenders and non-offenders with SSD regarding suicidality. Our study therefore aimed at evaluating distinguishing such factors through the application of supervised machine learning (ML) algorithms on a dataset of 232 offenders and 167 non-offender patients with SSD and history of suicidality. With an AUC of 0.81, Naïve Bayes outperformed all other ML algorithms. The following factors emerged as most powerful in their interplay in distinguishing between offender and non-offender patients with a history of suicidality: Prior outpatient psychiatric treatment, regular intake of antipsychotic medication, global cognitive deficit, a prescription of antidepressants during the referenced hospitalisation and higher levels of anxiety and a lack of spontaneity and flow of conversation measured by an adapted positive and negative syndrome scale (PANSS). Interestingly, neither aggression nor overall psychopathology emerged as distinguishers between the two groups. The present findings contribute to a better understanding of suicidality in offender and non-offender patients with SSD and their differing characteristics.

Association between psychotropic prescriptions and the total amount of psychotropics ingested during an intentional overdose: A single-center retrospective study

Aim

To investigate the association between psychotropic prescriptions and the total amount of psychotropics ingested during a subsequent intentional overdose and to examine factors related to the number of psychotropic prescriptions.

Methods

The initial sample comprised 69 patients who were admitted to the emergency department of a general hospital in Japan following an intentional overdose via psychotropic medications. We performed retrospective hierarchical multiple regression analysis with the total amount of psychotropics ingested at the overdose as a dependent variable and factors related to deliberate self‐harm or overdose identified in previous studies as independent variables. We compared two models, one that did not (Step 1) and one that did (Step 2) include the number of different prescribed psychotropic medications as an independent variable in the analysis.

Results

Forty‐seven patients were eligible for the analysis. The number of different prescribed psychotropic medications was associated with the total amount of psychotropics ingested at the overdose in Step 2 (β = 0.40, P = .01). There was a trend toward an association between the past number of deliberate self‐harm events and the total amount of psychotropics ingested at the overdose in Step 1 (β = 0.30, P = .05), but this trend was weakened in Step 2 (β = 0.15, P = .33).

Conclusion

The number of different prescribed psychotropics appeared to influence the risk of subsequent intentional overdose through increasing the total amount of psychotropics ingested. Cumulative psychotropic prescriptions, particularly those delivered after deliberate self‐harm, might be indirectly related to this risk.

The number of different prescribed psychotropics appeared to influence the risk of subsequent intentional overdose through increasing the total amount of psychotropics ingested. Cumulative psychotropic prescriptions, particularly those delivered after deliberate self‐harm, might be indirectly related to this risk.

A nationwide study of the risk of all-cause, sudden death, and cardiovascular mortality among antipsychotic-treated patients with schizophrenia in Taiwan

INTRODUCTION

Studies have reported higher risks of mortality for patients with schizophrenia, compared to the general population. This study aimed to evaluate the risk of all-cause, sudden death, and cardiovascular mortality among patients with schizophrenia in terms of types of antipsychotics.

METHODS

A retrospective cohort study assessed the risk of mortality among antipsychotic-treated patients with schizophrenia. The study linked the Taiwan National Health Insurance (NHI) claims and National Register of Death databases from 2001 to 2015. Patients were hierarchically assigned to the following index antipsychotic treatment groups: atypical long acting injection (LAI), typical LAI, atypical oral, and typical oral.

RESULTS

A total of 68,159 antipsychotic-treated patients with schizophrenia were analyzed. Under the hierarchical grouping, the largest percentages of patients were on atypical oral antipsychotic regimens (65.51%), followed by typical oral (14.00%), typical LAI (12.84%), and atypical LAI (7.65%). Typical oral patients had the highest incidence of all-cause mortality of 27.48 per 1000 patient-years and the atypical LAI group had the lowest incidence (13.95 per 1000 patient-years). Compared to typical oral users, there were lower risks of all-cause mortality for users of atypical LAI (aHR = 0.62, 95% CI: 0.47-0.81), typical LAI (aHR = 0.65, 95% CI: 0.55-0.78), and atypical orals (aHR = 0.55, 95% CI: 0.49-0.62).

CONCLUSION

Compared to typical oral users, we found a lower risk of all-cause mortality, sudden death, and cardiovascular mortality among schizophrenia users of LAIs and oral atypicals. Further research is warranted to characterize the risk of mortality among users of more recently available LAIs in the Asia Pacific region and elsewhere.

Effects of somatic treatments on suicidal ideation and completed suicides

OBJECTIVE

This work was undertaken to define and characterize the role of currently available somatic treatments in psychiatry in either increasing or reducing the risk for suicide.

METHODS

Members of the Suicide Prevention Task Group of the National Network of Depression Centers performed a literature review of somatic treatments known to increase or reduce the risk for suicide. The reviews ventured to include all relevant information about the risk for both suicide ideation and completed suicides.

RESULTS

Lithium and clozapine are the only two somatic treatments that have high-quality data documenting their antisuicide effects in mood disorders and schizophrenia, respectively. Lithium discontinuation is also associated with increased suicide risk. Ketamine and esketamine may have a small, but immediate, antisuicide effect. Despite the recent Food and Drug Administration approval of esketamine use in depressed suicidal patients, the small disproportional overrepresentation of suicide in subjects who had received esketamine versus placebo (3 vs. 0 among > 3500 subjects) requires ongoing evaluation. The purported antisuicide effect of electroconvulsive therapy is based on low-quality data. The effect of antidepressants is not at all clear. There appears to be direct evidence for antidepressants increasing suicidal ideation and the risk for suicide over the short-term in young people, but indirect (low quality) evidence that antidepressants reduce suicide risk over the long term.

CONCLUSIONS

Clinicians have an expanding pharmacopeia to address suicide potential in their patients. Some of the agents with documented antisuicide effects may also increase suicidality under specific circumstances.

Association between psychotropic drug prescription and suicide rates in Scotland: population study

Aims and method

Rates of prescriptions of antidepressants and suicide are inversely correlated at an epidemiological level. Less attention has been paid to relationships between other drugs used in mental health and suicide rates. Here we tested relationships between prescriptions of anxiolytics and antipsychotics and suicide rates in Scotland.

Results

Suicide rates were inversely correlated with prescriptions of antidepressants and antipsychotics over 14 years (2004–2018), and positively with prescriptions of anxiolytics.

Clinical implications

This illustrates the role of medications used in mental health in suicide prevention, and highlights the importance of identifying causal mechanisms that link anxiolytics with suicide.

Effects on suicidal risk: Comparison of clozapine to other newer medicines indicated to treat schizophrenia or bipolar disorder

BACKGROUND

Clozapine is the only treatment with regulatory-recognition of lowering suicidal risk, at least in schizophrenia patients. It remains uncertain whether such effects extend to other drugs for psychosis.

METHODS

We searched for reports on rates of suicidal behavior during treatment with clozapine and other modern drugs for psychosis (aripiprazole, olanzapine, risperidone, quetiapine, and ziprasidone) versus comparison or control treatments and analyzed the contrasts by random-effect meta-analysis to obtain pooled odds ratios (ORs) with 95% confidence intervals (CIs).

RESULTS

We identified 35 paired comparisons of modern drugs for psychosis versus comparison or control treatments in 18 reports. There was moderate overall superiority of all agents tested over alternatives (OR = 0.522, p = 0.004). With clozapine, this effect was large (OR = 0.229, p < 0.0001) and consistent (7/7 trials), but significant antisuicidal effects were not found with other drugs for psychosis in 28 other trials (OR = 0.941, p = 0.497). Apparent efficacy of specific agents ranked: risperidone ⩾ olanzapine ⩾ aripiprazole ⩾ ziprasidone ⩾ mixed drugs for psychosis ⩾ quetiapine, but none of these differences was significant.

CONCLUSIONS

An ability of clozapine to reduce risk of suicides and attempts in schizophrenia patients appears to be a unique effect not shared with other modern medicines indicated for schizophrenia or bipolar disorder.

Prevention of suicidal behavior in bipolar disorder

BACKGROUND

Excess mortality is a critical hallmark of bipolar disorder (BD) due to co-occurring general medical disorders and especially from suicide. It is timely to review of the status of suicide in BD and to consider the possibility of limiting suicidal risk.

METHODS

We carried out a semi-systematic review of recent research reports pertaining to suicide in BD.

FINDINGS

Suicide risk in BD is greater than with most other psychiatric disorders. Suicide rates (per 100,000/year) are approximately 11 and 4 in the adult and juvenile general populations, but over 200 in adults, and 100 among juveniles diagnosed with BD. Suicide attempt rates with BD are at least 20 times higher than in the adult general population, and over 50 times higher among juveniles. Notable suicidal risk factors in BD include: previous suicidal acts, depression, mixed-agitated-dysphoric moods, rapid mood-shifts, impulsivity, and co-occurring substance abuse. Suicide-preventing therapeutics for BD remain severely underdeveloped. Evidence favoring lithium treatment is stronger than for other measures, although encouraging findings are emerging for other treatments.

CONCLUSIONS

Suicide is a leading clinical challenge for those caring for BD patients. Improved understanding of risk and protective factors combined with knowledge and close follow-up of BD patients should limit suicidal risk. Ethically appropriate and scientifically sound studies of plausible medicinal, physical, and psychosocial treatments aimed at suicide prevention specifically for BD patients are urgently needed.

Suicidal Behavior and Medication Adherence in Schizophrenic Patients

Suicide is one of the potential complications in the Schizophrenic patient population. This review article deals with the significance of antipsychotic medication compliance in decreasing suicidal behavior and hospitalizations in Schizophrenic patients. The medication adherence with second-generation antipsychotics (SGA) like clozapine and long-acting injectables (LAIs) like paliperidone is associated with decrease suicidal behavior and all-cause mortality in Schizophrenic patients. Concomitant treatment of depression and substance abuse disorder in this patient population is also associated with decreasing all-cause mortality and hospitalizations. On the other hand, long-term benzodiazepine use is associated with increase mortality in Schizophrenic patients. We also discuss some important physician intervention strategies to improve medication adherence in Schizophrenic patients like motivational interviewing (MI), behavioral tailoring (BT), and psychosocial interventions like cognitive behavior therapy (CBT).

The Importance of Suicide Risk Formulation in Schizophrenia

Suicide is a cause of early mortality in nearly 5% of patients with schizophrenia, and 25-50% of patients with schizophrenia attempt suicide in their lifetime. Evidence points to numerous individual, clinical, social, and psychological risk factors for suicide in patients with schizophrenia. Although recognizing suicidal risk factors in schizophrenia is extremely important in suicidal risk assessment, we have recently witnessed a change in suicide risk management that shifts the focus from suicide risk assessment to suicide risk formulation. Suicide risk formulation is dependent on the data gathered in the suicide risk assessment and assigns a level of suicide risk that is indispensable for the choice of treatment and the management of patients with a high suicidal risk. In this article, we extend the suicide risk formulation model to patients with schizophrenia. Suicide risk formulation results from four different areas that help clinicians collect as much information as possible for the management of suicidal risk. The four distinct judgments comprise risk status (the risk relating to the specific group to which the patient belongs), risk state (the risk for the person compared with his baseline or another reference point in the course of his life), available resources (on whom the person can count during a crisis) and foreseeable events (which can exacerbate the crisis). In schizophrenia, the suicide risk formulation model allows the clinician to evaluate in depth the clinical context of the patient, the patient's own history and patient-specific opportunities for better choosing and applying suicide prevention strategies.

[Suicidality in schizophrenic psychosis: a current overview]

BACKGROUND

Suicidality in schizophrenic psychosis is an important topic but stands in clinical everyday work behind the perception of suicide especially in affective disorders. Schizophrenic psychosis is recognized as an independent risk factor for suicide attempts and suicides, whereas it poses particular challenges to the clinical professional due to the frequent unpredictability, abruptness and brutality of the methods used. For this reason, the suicide of a psychotic patient often leaves the professional and non-professional environment disturbed.

AIMS

An overview of the existing relevant literature on suicide in psychosis is given. Explanations on the psychodynamics, indications on pharmacotherapy and psychotherapy and considerations on prevention round off this article and provide an up to date overview of this topic for clinicians.

MATERIAL AND METHODS

A search was carried out in PubMed and Google scholar using the terms "suicide", "suicidality", "schizophrenia", "suicide AND schizophrenia", "suicide AND psychosis", "suicidality AND schizophrenia", "suicidality AND psychosis", "suicidality AND psychosis AND prevention", "suicide AND psychosis AND prevention", "suicidality AND schizophrenia AND prevention", "suicide AND schizophrenia AND prevention".

CONCLUSION

Clinicians must have knowledge of the specific risk factors for suicide in psychotic patients, the characteristics of suicide in terms of design and temporal connection with treatment. The exploration and assessment of suicidality is often more difficult in psychotic patients than in affective or personality disorder patients, as there are often impulsive suicide attempts that can be explained by (suddenly occurring) psychotic symptoms and are therefore difficult or even impossible to foresee.

Mortality during US FDA clinical trials in patients with diabetes, hypertension, depression and schizophrenia

Objectives: To evaluate the relationship between the mortality rates associated with psychiatric conditions like depression and schizophrenia compared with chronic medical conditions like hypertension and diabetes.Methods: Examined clinical trial safety data from New Drug Approval programmes reviewed by the US Food and Drug Administration and calculated all-cause and suicide/non-suicide mortality rates per 100,000 patient-exposure-years (PEY) for seven diabetes, 12 hypertension, 11 depression, and nine schizophrenia programmes (126,151 patients, 63,106.3 PEY).Results: Depression (894.8 ± 201.2) and schizophrenia (935.3 ± 214.6) had significantly higher all-cause mortality rates than diabetes (462.8 ± 70.8) and hypertension (448.4 ± 123.1). Psychiatric conditions had 1.9-2.1× the medical conditions' mortality (p < 0.001). Non-suicide mortality rates for depression (506.2 ± 151.3), schizophrenia (550.9 ± 164.7), diabetes (457.2 ± 70.4) and hypertension (430.8 ± 120.6) were comparable. Only antidiabetics showed a signal for all-cause mortality (reduction of 37%, p = 0.008).Conclusions: Depression and schizophrenia trial patients had comparable (if not higher) all-cause mortality rates as older populations in diabetes and hypertension trials, even when excluding suicides. While generalizability of the rates themselves is limited, this study can adequately estimate the relational mortality among these conditions because of the high internal consistency of clinical trials. Potential signals for mortality reduction with active treatment should be considered for all investigational medications for chronic conditions with increased mortality, including psychotropics.

Effect of Adjunctive Estradiol on Schizophrenia Among Women of Childbearing Age: A Randomized Clinical Trial

IMPORTANCE

Several lines of evidence suggest that estradiol influences the course of schizophrenia, and a previous randomized controlled trial demonstrated that transdermal estradiol improved symptoms in female patients of childbearing age. However, many initial positive findings in schizophrenia research are not later replicated.

OBJECTIVE

To independently replicate the results of the effect of estradiol on schizophrenia in women of childbearing age.

DESIGN, SETTING, AND PARTICIPANTS

An 8-week randomized, placebo-controlled trial performed in the Republic of Moldova between December 4, 2015, and July 29, 2016, among 200 premenopausal women aged 19 to 46 years with schizophrenia or schizoaffective disorder as defined by the DSM-5.

INTERVENTION

Patients were randomized to receive a 200-μg estradiol patch or placebo patch changed twice a week added to their antipsychotic treatment.

MAIN OUTCOMES AND MEASURES

The primary outcome was the positive subscale of the Positive and Negative Syndrome Scale (PANSS; lower scores indicated fewer symptoms and higher scores indicated more symptoms), analyzed with mixed models for repeated measures on an intention-to-treat basis.

RESULTS

A total of 100 women (median age, 38 years; interquartile range, 34-42 years) were randomized to receive an estradiol patch and 100 women (median age, 38 years; interquartile range, 31-41 years) were randomized to receive a placebo patch; the median age at baseline for the entire group of 200 women was 38.0 years (range, 19.5-46.0 years). At baseline, the mean positive PANSS score was 19.6 for both groups combined; at week 8, the mean positive PANSS score was 14.4 in the placebo group and 13.4 in the estradiol group. Compared with placebo, participants receiving add-on estradiol patches had statistically significant improvements in the primary outcome measure, PANSS positive subscale points (-0.94; 95% CI, -1.64 to -0.24; P = .008; effect size = 0.38). Post hoc heterogeneity analyses found that this effect occurred almost entirely in 100 participants older than 38.0 years (46 in placebo group vs 54 in estradiol group; difference, -1.98 points on the PANSS positive subscale; 95% CI, -2.94 to -1.02; P < .001). Younger participants did not benefit from estradiol (difference, 0.08 points on the PANSS positive subscale; 95% CI, -0.91 to 1.07; P = .87). Breast tenderness was more common in the estradiol group (n = 15) than in the placebo group (n = 1) as was weight gain (14 in estradiol group vs 1 in placebo group).

CONCLUSIONS AND RELEVANCE

The results independently replicate the finding that transdermal estradiol is an effective add-on treatment for women of childbearing age with schizophrenia and extend it, finding improvements in negative symptoms and finding that the effect could be specific to those older than 38 years. The results should be viewed in the context of the differences in the natural course of schizophrenia between females and males.

TRIAL REGISTRATION

ClinicalTrials.gov identifier: NCT03848234.

Suicide in Schizophrenia: An Educational Overview

Suicide is an important public health problem. The most frequent psychiatric illnesses associated with suicide or severe suicide attempt are mood and psychotic disorders. The purpose of this paper is to provide an educational overview of suicidal behavior in individuals with schizophrenia. A lifetime suicide rate in individuals with schizophrenia is approximately 10%. Suicide is the largest contributor to the decreased life expectancy in individuals with schizophrenia. Demographic and psychosocial factors that increase a risk of suicide in individuals with schizophrenia include younger age, being male, being unmarried, living alone, being unemployed, being intelligent, being well-educated, good premorbid adjustment or functioning, having high personal expectations and hopes, having an understanding that life’s expectations and hopes are not likely to be met, having had recent (i.e., within past 3 months) life events, having poor work functioning, and having access to lethal means, such as firearms. Throughout the first decade of their disorder, patients with schizophrenia are at substantially elevated suicide risk, although they continue to be at elevated suicide risk during their lives with times of worsening or improvement. Having awareness of symptoms, especially, awareness of delusions, anhedonia, asociality, and blunted affect, having a negative feeling about, or non-adherence with, treatment are associated with greater suicide risk in patients with schizophrenia. Comorbid depression and a history of suicidal behavior are important contributors to suicide risk in patients with schizophrenia. The only reliable protective factor for suicide in patients with schizophrenia is provision of and compliance with comprehensive treatment. Prevention of suicidal behavior in schizophrenia should include recognizing patients at risk, delivering the best possible therapy for psychotic symptoms, and managing comorbid depression and substance misuse.

Adherence to psychotropic medication in completed suicide in Sweden 2006-2013: a forensic-toxicological matched case-control study

OBJECTIVE

To investigate the influence of adherence to psychotropic medications upon the risk of completed suicide by comparing person-level prescriptions and postmortem toxicological findings among complete-suicide cases and non-suicide controls in Sweden 2006-2013.

METHODS

Using national registries with full coverage on dispensed prescriptions, results of medico-legal autopsies, causes of death, and diagnoses from inpatient care, estimated continuous drug use for 30 commonly prescribed psychotropic medications was compared with forensic-toxicological findings. Subjects who had died by suicide (cases) were matched (1:2) with subjects who had died of other causes (controls) for age, sex, and year of death. Odds ratios were calculated using logistic regression to estimate the risk of completed suicide conferred by partial adherence and non-adherence to pharmacotherapy. Adjustments were made for previous inpatient care and the ratio of initiated and discontinued dispensed prescriptions, a measure of the continued need of treatment preceding death.

RESULTS

In 5294 suicide cases and 9879 non-suicide controls, after adjusting for the dispensation ratio and other covariates, partial adherence and non-adherence to antipsychotics were associated with 6.7-fold and 12.4-fold risks of completed suicide, respectively, whereas corresponding risk estimates for antidepressant treatment were not statistically significant and corresponding risk increases for incomplete adherence to antidepressant treatment were lower (1.6-fold and 1.5-fold, respectively) and lacked statistical significance.

CONCLUSION

After adjustment for the need of treatment, biochemically verified incomplete adherence to antipsychotic pharmacotherapy was associated with markedly increased risks of completed suicide.

Comparative effect of antipsychotics on risk of self-harm among patients with schizophrenia

OBJECTIVE

To investigate the association of different antipsychotic treatments with hospitalization due to self-harm among patients with schizophrenia.

METHOD

This retrospective cohort study was based on Taiwan's universal health insurance database. Patients aged 15-45 years with a newly diagnosed schizophrenic disorder in 2001-2012 were included. The study outcome was the first hospitalization due to self-harm or undetermined injury after the diagnosis of schizophrenic disorders. The exposure status of antipsychotics was modeled as a time-dependent variable. The analyses were stratified by antipsychotic dosage based on defined daily dose (DDD).

RESULTS

Among 70 380 patients with a follow-up of 500 355 person-years, 2272 self-harm hospitalization episodes were identified. Compared with none or former use, current use of several second-generation antipsychotics with a dose of one DDD or above, including amisulpride, aripiprazole, clozapine, risperidone, and sulpiride, was associated with decreased risk of self-harm hospitalization, with clozapine showing the strongest effect (adjusted rate ratio = 0.26, 95% confidence interval 0.15-0.47).

CONCLUSION

The protective effect on self-harm may vary across different antipsychotics. Further studies are needed to replicate the findings.

Antipsychotic medication and long-term mortality risk in patients with schizophrenia; a systematic review and meta-analysis

Patients with schizophrenia have a higher mortality risk than patients suffering from any other psychiatric disorder. Previous research is inconclusive regarding the association of antipsychotic treatment with long-term mortality risk. To this aim, we systematically reviewed the literature and performed a meta-analysis on the relationship between long-term mortality and exposure to antipsychotic medication in patients with schizophrenia. The objectives were to (i) determine long-term mortality rates in patients with schizophrenia using any antipsychotic medication; (ii) compare these with mortality rates of patients using no antipsychotics; (iii) explore the relationship between cumulative exposure and mortality; and (iv) assess causes of death. We systematically searched the EMBASE, MEDLINE and PsycINFO databases for studies that reported on mortality and antipsychotic medication and that included adults with schizophrenia using a follow-up design of more than 1 year. A total of 20 studies fulfilled our inclusion criteria. These studies reported 23,353 deaths during 821,347 patient years in 133,929 unique patients. Mortality rates varied widely per study. Meta-analysis on a subgroup of four studies showed a consistent trend of an increased long-term mortality risk in schizophrenia patients who did not use antipsychotic medication during follow-up. We found a pooled risk ratio of 0.57 (LL:0.46 UL:0.76 p value <0.001) favouring any exposure to antipsychotics. Statiscal heterogeneity was found to be high (Q = 39.31, I 2 = 92.37%, p value < 0.001). Reasons for the increased risk of death for patients with schizophrenia without antipsychotic medication require further research. Prospective validation studies, uniform measures of antipsychotic exposure and classified causes of death are commendable.

Do Atypical Antipsychotics Have Antisuicidal Effects? A Hypothesis-Generating Overview

Modern antipsychotic drugs are employed increasingly in the treatment of mood disorders as well as psychoses, stimulating interest in their possible contributions to altering suicidal risk. Clozapine remains the only treatment with an FDA-recognized indication for reducing suicidal risk (in schizophrenia). We carried out a systematic, computerized search for reports of studies involving antipsychotic drug treatment and suicidal behaviors. A total of 19 reports provide data with preliminary support for potential suicide risk-reducing effects of olanzapine, quetiapine, ziprasidone, aripiprazole, and asenapine in addition to clozapine, and provide some support for antipsychotic drug treatment in general. These preliminary findings encourage further testing of antipsychotics for effects on suicidal behavior, making use of explicit, pre-planned assessments of suicidal behavior.

Suicidal Behavior in Mood Disorders: Response to Pharmacological Treatment

Suicidal behavior is strongly associated with depression, especially if accompanied by behavioral activation, dysphoria, or agitation. It may respond to some treatments, but the design of scientifically sound, ethical trials to test for therapeutic effects on suicidal behavior is highly challenging. In bipolar disorder, and possibly also unipolar major depression, an underprescribed medical intervention with substantial evidence of preventive effects on suicidal behavior is long-term treatment with lithium. It is unclear whether this effect is specifically antisuicidal or reflects beneficial effects of lithium on depression, mood instability, and perhaps aggression and impulsivity. Antisuicidal effects of anticonvulsant mood stabilizers (carbamazepine, lamotrigine, valproate) appear to be less than with lithium. Further evaluation is needed for potential antisuicidal effects of atypical antipsychotics with growing evidence of efficacy in depression, particularly acute bipolar depression, while generally lacking risk of inducing agitation, mania, or mood instability. Short-term and long-term value and safety of antidepressants are relatively secure for unipolar depression but uncertain and poorly tested for bipolar depression; their effects on suicidal risk in unipolar depression may be age-dependent. Sedative anxiolytics are virtually unstudied as regards suicidal risks. Adequate management of suicidal risks in mood disorder patients requires comprehensive, clinically skillful monitoring and timely interventions.

Reducing excess mortality due to chronic disease in people with severe mental illness: meta-review of health interventions

BACKGROUND

People with severe mental illness (SMI) have high rates of chronic disease and premature death.

AIMS

To explore the strength of evidence for interventions to reduce risk of mortality in people with SMI.

METHOD

In a meta-review of 16 systematic reviews of controlled studies, mortality was the primary outcome (8 reviews). Physiological health measures (body mass index, weight, glucose levels, lipid profiles and blood pressure) were secondary outcomes (14 reviews).

RESULTS

Antipsychotic and antidepressant medications had some protective effect on mortality, subject to treatment adherence. Integrative community care programmes may reduce physical morbidity and excess deaths, but the effective ingredients are unknown. Interventions to improve unhealthy lifestyles and risky behaviours can improve risk factor profiles, but longer follow-up is needed. Preventive interventions and improved medical care for comorbid chronic disease may reduce excess mortality, but data are lacking.

CONCLUSIONS

Improved adherence to pharmacological and physical health management guidelines is indicated.

Psychosis and Suicide

BACKGROUND

The life time risk of suicide among patients with long term psychosis is 5-15%. Suicide prevention in this group is a major clinical challenge.

AIMS

To capture specific characteristics of suicidal communication and critical events preceding suicide in patients with psychosis.

METHODS

Medical records were examined and a life event inventory applied to a one-year cohort of 21 cases of suicide in the clinical group in Stockholm county.

RESULTS

In most cases direct or indirect verbal communication of suicidal thoughts were documented before the suicide. Three months preceeding death, 20 of the 21 subjects had described one or more negative critical experiences, typically physical illness, loss of contact with an important other, loss of "home", and intolerable side effects of medication. In most cases the suicide appeared to be the culmination of prolonged suffering and suicidal deliberations.

CONCLUSIONS

Suicide prevention among patients with psychosis requires sensitivity, active listening, and responsiveness on the part of the care person to the patient's explicit suicidal communication and perceptions of care-related or other incidents or interactions, even when conveyed in an odd manner or with little emotion. To prevent suicide, attentive and long-term planning in collaboration with the patient is essential.

World Federation of Societies of Biological Psychiatry (WFSBP) Guidelines for Biological Treatment of Schizophrenia. Part 3: Update 2015 Management of special circumstances: Depression, Suicidality, substance use disorders and pregnancy and lactation

These updated guidelines are based on the first edition of the World Federation of Societies of Biological Psychiatry (WFSBP) guidelines for biological treatment of schizophrenia published in the years 2005 and 2006. For this 2015 revision, all available publications pertaining to the biological treatment of schizophrenia were reviewed systematically to allow for an evidence-based update. These guidelines provide evidence-based practice recommendations which are clinically and scientifically relevant. They are intended to be used by all physicians diagnosing and treating patients with schizophrenia. Based on the first version of these guidelines a systematic review, as well as a data extraction from national guidelines have been performed for this update. The identified literature was evaluated with respect to the strength of evidence for its efficacy and subsequently categorised into six levels of evidence (A-F) and five levels of recommendation (1-5). This third part of the updated guidelines covers the management of the following specific treatment circumstances: comorbid depression, suicidality, various comorbid substance use disorders (legal and illegal drugs), and pregnancy and lactation. These guidelines are primarily concerned with the biological treatment (including antipsychotic medication and other pharmacological treatment options) of patients with schizophrenia.

Excess mortality from mental, neurological and substance use disorders in the Global Burden of Disease Study 2010

AIMS

Mortality-associated burden of disease estimates from the Global Burden of Disease 2010 (GBD 2010) may erroneously lead to the interpretation that premature death in people with mental, neurological and substance use disorders (MNSDs) is inconsequential when evidence shows that people with MNSDs experience a significant reduction in life expectancy. We explore differences between cause-specific and excess mortality of MNSDs estimated by GBD 2010.

METHODS

GBD 2010 cause-specific death estimates were produced using the International Classification of Diseases death-coding system. Excess mortality (all-cause) was estimated using natural history models. Additional mortality attributed to MNSDs as underlying causes but not captured through GBD 2010 methodology is quantified in the comparative risk assessments.

RESULTS

In GBD 2010, MNSDs were estimated to be directly responsible for 840 000 deaths compared with more than 13 million excess deaths using natural history models.

CONCLUSIONS

Numbers of excess deaths and attributable deaths clearly demonstrate the high degree of mortality associated with these disorders. There is substantial evidence pointing to potential causal pathways for this premature mortality with evidence-based interventions available to address this mortality. The life expectancy gap between persons with MNSDs and the general population is high and should be a focus for health systems reform.

Antipsychotics-associated serious adverse events in children: an analysis of the FAERS database

OBJECTIVE

The reports submitted to the US Food and Drug Administration (FDA) Adverse Event Reporting System (FAERS) from 1997 to 2011 were reviewed to assess serious adverse events induced by the administration of antipsychotics to children.

METHODS

Following pre-processing of FAERS data by elimination of duplicated records as well as adjustments to standardize drug names, reports involving haloperidol, olanzapine, quetiapine, clozapine, ziprasidone, risperidone, and aripiprazole were analyzed in children (age 0-12). Signals in the data that signified a drug-associated adverse event were detected via quantitative data mining algorithms. The algorithms applied to this study include the empirical Bayes geometric mean, the reporting odds ratio, the proportional reporting ratio, and the information component of a Bayesian confidence propagation neural network. Neuroleptic malignant syndrome (NMS), QT prolongation, leukopenia, and suicide attempt were focused on as serious adverse events.

RESULTS

In regard to NMS, the signal scores for haloperidol and aripiprazole were greater than for other antipsychotics. Significant signals of the QT prolongation adverse event were detected only for ziprasidone and risperidone. With respect to leukopenia, the association with clozapine was noteworthy. In the case of suicide attempt, signals for haloperidol, olanzapine, quetiapine, risperidone, and aripiprazole were detected.

CONCLUSIONS

It was suggested that there is a level of diversity in the strength of the association between various first- and second-generation antipsychotics with associated serious adverse events, which possibly lead to fatal outcomes. We recommend that research be continued in order to gather a large variety and quantity of related information, and that both available and newly reported data be placed in the context of multiple medical viewpoints in order to lead to improved levels of care.

Cognitive function and suicide risk in Han Chinese inpatients with schizophrenia

The lifetime risk of suicide in patients with schizophrenia is estimated to be 4.9-13%. While there are many known risk factors for suicide in schizophrenia, the relationship between cognitive function and suicide risk is unclear, particularly in non-Caucasian populations. In our cross-sectional study, we administered the Repeatable Battery for the Assessment of Neuropsychological Status (RBANS) to 316 Han Chinese chronic inpatients with schizophrenia and compared the performance of those who had attempted suicide (n=25) to non-attempters (n=291). The lifetime suicide attempt data were collected from medical records and interviews with patients and their family members. We found a lifetime suicide attempt rate of 7.9%. Suicide attempters were more likely to be single, but showed no significant differences in other demographic factors such as age, gender, or living arrangements. Contrary to our hypothesis, there was no significant relationship between performance on the RBANS test and lifetime risk of suicide attempts in Han Chinese inpatients with schizophrenia. The literature remains mixed on this topic. Culturally influenced differences in suicidal behavior may have affected the outcome of this study and further investigation of this topic is necessary.

Risk factors for suicide in schizophrenia: systematic review and clinical recommendations

OBJECTIVE

To identify risk factors associated with suicide of patients with schizophrenia and provide clinical recommendations, which integrate research findings into a consensus based on clinical experience and evidence.

METHOD

A task force formed of experts and clinicians iteratively developed consensus through serial revisions using the Delphi method. Initial survey items were based on systematic literature review published up to June 2013.

RESULTS

Various risk factors were reported to be implicated in suicide in schizophrenia. Our findings indicate that suicide risk in schizophrenia is mainly related to affective symptoms, history of a suicide attempt and number of psychiatric admissions. Other risk factors identified are given by younger age, closeness to illness onset, older age at illness onset, male sex, substance abuse and period during or following psychiatric discharge. Integrating the evidence and the experience of the task force members, a consensus was reached on 14 clinical recommendations.

CONCLUSION

Identification of risk factors for suicide in individuals diagnosed with schizophrenia is imperative to improve clinical management and develop strategies to reduce the incidence of suicide in this population. This study provides the critical overview of available data and clinical recommendations on recognition and management of the above-mentioned risk factors.

Mortality, attempted suicide, re-hospitalisation and prescription refill for clozapine and other antipsychotics in Sweden-a register-based study

PURPOSE

The aim of this study was to analyse prescription refill, re-hospitalisation, total mortality, mortality because of suicide and attempted suicide among patients who were taking various types of antipsychotics.

METHODS

A population-based cohort study analysed all patients (n=26046) in Sweden who had been treated for schizophrenia from 2006 to 2009 with regard to re-hospitalisation and prescription refill for various types of antipsychotic treatment. A case-control study nested within the cohort analysed all-cause mortality, mortality because of suicide and attempted suicide in relation to antipsychotic use. The study adjusted for history of hospitalisation for psychiatric and medical care, attempted suicide and use of antidepressants.

RESULTS

Aripiprazole users were the only ones who showed significantly lower all-cause risks of death, but so few events occurred among users of this relatively new drug that the results should be interpreted with caution. Clozapine users showed lower odds of death by suicide (odds ratio [OR]=0.45 [95%CI 0.20-0.98]) and of attempted suicide (OR=0.44 [0.28-0.70]) than haloperidol users after adjustment for age, sex and year of discharge. Olanzapine users showed approximately the same favourable pattern. Patients who used clozapine were most likely to refill prescriptions and had lower rates of re-hospitalisation. Only one death and 23 cases of agranulocytosis were reported compared with 223 suicides and 831 suicide attempts. An etiologic fraction calculation suggests that the use of clozapine rather than traditional drugs could have prevented 95 suicide attempts during the period.

CONCLUSION

Clozapine and olanzapine reduce the risk of suicide, attempted suicide and re-hospitalisation.

Antipsychotics and mortality in first-onset schizophrenia: prospective Finnish register study with 5-year follow-up

OBJECTIVE

Our aim was to assess the impact of the most commonly used typical and atypical antipsychotics on mortality of patients with first-onset schizophrenia.

METHOD

We conducted a nationwide, register-based, five-year follow-up study of all patients presenting with first-onset of schizophrenia between 1998 and 2003. Details of reimbursed medicines were obtained from the register of Social Insurance Institution.

RESULTS

After adjusting for age, gender, comorbid physical diseases and patient group, the use of second generation antipsychotics (SGAs), especially clozapine, olanzapine and quetiapine, was associated with reduced risk of all-cause mortality in patients with schizophrenia, while clozapine associated with lower suicide risk. First generation antipsychotics (FGAs), specifically levomepromazine, thioridazine or clorprothixene, were associated with increased risk of all-cause mortality. The FGAs, particularly clorprothixene, were associated with decreased suicide mortality. An increased likelihood for cardiovascular deaths was found among users of levomepromazine. In antidepressants, the use of mirtazapine associated with increased risk of suicide.

CONCLUSIONS

Differences exist between FGAs' and SGAs' use in relation to mortality. These differences remain even when the patient's physical illness are taken into account when prescribing antipsychotic medication.

Guideline-concordant antipsychotic use and mortality in schizophrenia

OBJECTIVE

To determine if care concordant with 2009 Schizophrenia Patient Outcomes Research Team (PORT) pharmacological recommendations for schizophrenia is associated with decreased mortality.

METHODS

We conducted a retrospective cohort study of adult Maryland Medicaid beneficiaries with schizophrenia and any antipsychotic use from 1994 to 2004 (N = 2132). We used Medicaid pharmacy data to measure annual and average antipsychotic continuity, to calculate chlorpromazine (CPZ) dosing equivalents, and to examine anti-Parkinson medication use. Cox proportional hazards regression models were used to examine the relationship between antipsychotic continuity, antipsychotic dosing, and anti-Parkinson medication use and mortality.

RESULTS

Annual antipsychotic continuity was associated with decreased mortality. Among patients with annual continuity greater than or equal to 90%, the hazard ratio [HR] for mortality was 0.75 (95% confidence interval [CI] 0.57-0.99) compared with patients with annual medication possession ratios (MPRs) of less than 10%. The HRs for mortality associated with continuous annual and average antipsychotic continuity were 0.75 (95% CI 0.58-0.98) and 0.84 (95% CI 0.58-1.21), respectively. Among users of first-generation antipsychotics, doses greater than or equal to 1500 CPZ dosing equivalents were associated with increased risk of mortality (HR 1.88, 95% CI 1.10-3.21), and use of anti-Parkinson medication was associated with decreased risk of mortality (HR 0.72, 95% CI 0.55-0.95). Mental health visits were also associated with decreased mortality (HR 0.96, 95% CI 0.93-0.98).

CONCLUSIONS

Adherence to PORT pharmacological guidelines is associated with reduced mortality among patients with schizophrenia. Adoption of outcomes monitoring systems and innovative service delivery programs to improve adherence to the PORT guidelines should be considered.

Impact of psychotropic drugs on suicide and suicidal behaviors

OBJECTIVE

To examine the impact of psychotropic drugs on suicide and suicidal behaviors in bipolar disorders.

METHODS

A Medline search of articles published from January 1960 to January 2013 was performed using relevant keywords to identify studies examining the relationship of psychotropic drugs to suicidal behaviors. The publications were further reviewed for relevant references and information. Additionally, the US Food and Drug Administration Center for Drug Evaluation Research website was searched.

RESULTS

The available studies used differing methodologies, making interpretation of the findings difficult. Studies suggest that antidepressants may increase suicidal risk in bipolar disorder, this possibly being related to the induction of broadly defined mixed states. There is no evidence that antiepileptic drugs as a class increase suicidal risk in patients with bipolar disorder. Only lithium provides convincing data that it reduces the risk of suicide over the long term. There is little known regarding the effects of antipsychotics, as well as anti-anxiety and hypnotic drugs, on suicidal behavior.

CONCLUSIONS

The available evidence for the impact of psychotropics on suicidal risk in patients with bipolar disorder is largely methodologically flawed and, except for a few instances, clinically not useful at this point. Adequately powered, prospective randomized controlled studies are needed to assess the impact of each class of psychotropic and each psychotropic as well as common combination therapies. Until such studies have been carried out, clinicians are urged to exercise caution in using these drugs and rely on the traditional means of carefully assessing and monitoring patients with bipolar disorder who are at high risk for suicide.

Subtypes of antipsychotics and suicidal behavior in bipolar disorder

OBJECTIVE

Antipsychotics are commonly used in bipolar disorder, with newer (SGA) agents increasingly replacing FGA antipsychotics, particularly in bipolar depression. There are few data on differences between FGA and SGA antipsychotics in terms of their relationship to suicidal behavior in bipolar disorder.

METHOD

This was a retrospective chart review of 161 bipolar veterans treated naturalistically with antipsychotics at a university-affiliated VA hospital and clinics for up to 8 years. Charts were reviewed to determine monthly antipsychotic use and occurrence of suicidal behavior: completed suicide, attempted suicide or hospitalization to prevent suicide. Suicidal behavior events were compared across patients during treatment with individual antipsychotics and FGAs or SGAs as a class.

RESULTS

Non-lethal suicide events were more common during FGA than SGA monotherapy (9 events/110 months of exposure vs. 6 events/381 months of exposure; χ(2)=9.65, p=0.002). Suicide event rates did not differ between FGAs and SGAs when used in conjunction with mood stabilizers. Event rates were lower with lithium than anticonvulsants when used in conjunction with antipsychotics. No differences were found between olanzapine, risperidone and quetiapine.

LIMITATIONS

The retrospective chart review methodology may have led to confounding by indication and diagnostic inaccuracy. No completed suicides occurred. Study participants were primarily male veterans. Results may not be generalizable to SGAs marketed since 2003.

CONCLUSIONS

FGA antipsychotic monotherapy may be associated with higher suicidal behavior risk than SGA antipsychotic monotherapy. Antipsychotics used in conjunction with mood stabilizers, particularly lithium, are associated with lower rates, independent of antipsychotic subtype.

[Factors related to suicide attempts in a Tunisian sample of patients with schizophrenia]

INTRODUCTION

The mortality rate in schizophrenia is 4.5 times higher than in the general population. Suicide is one of the main causes of premature death in this affection. Life time prevalence of this behavior ranges from 10 to 15%, which represents a risk 20 to 50 times higher than in the general population. In addition, 40 to 93% of patients who committed suicide had attempted suicide previously. Thus, assessment of correlated variables with suicide attempts is a fundamental issue for developing preventive and therapeutic strategies in suicidal behavior. To the best of our knowledge, no systematic study has yet investigated suicide attempts in an Arabic Muslim population with schizophrenia, although many authors have demonstrated cultural differences in socio-demographic and clinical variables related to suicide attempts within many geographic areas around the world.

OBJECTIVES

The objectives of this study were to assess the frequency and characteristics of lifetime suicide attempts in Tunisian schizophrenic outpatients and to determine the correlated socio-demographic, clinical and therapeutic variables.

METHODS

A total of 134 patients with a DSM-IV diagnosis of schizophrenia who attended the outpatient department of the university psychiatric hospital of Tunis were included. The main demographic and lifetime clinical variables considered were: gender, marital status, family history of psychiatric disorders and suicide attempts, age at time of recruitment, age at onset of illness, duration of untreated psychosis defined as the interval between the onset of the illness and the first antipsychotic treatment, the type and dose of current treatment, dose of antipsychotic drugs converted to chlorpromazine equivalents, extrapyramidal side effects assessed with the Simpson Angus rating scale, number of hospitalizations, comorbid substance abuse, cigarette smoking, severity of psychopathology measured with the Positive And Negative Syndrome Scale (PANSS), and history of at least one suicide attempt. A suicide attempt was defined as a self-destructive act carried out with at least some intent to end one's life. We also assessed the number, the used methods and the causes of suicide attempts. We subdivided the sample into two sub samples according to the presence or absence of suicidal attempts. We analyzed and compared the demographic, clinical and therapeutic variables.

RESULTS

Out of the 134 patients, 45 (32%) had attempted suicide at least once. Half of them (49%) had attempted suicide more than once. The number of suicide attempts varied from one to five with an average of 1.8. The most used methods were medication overdose (n=18, 23.4%), followed by organophosphate poisoning (n=11, 14.3%), defenestration (n=9, 11.7%) and hanging or using sharp objects (n=7, 9.1% for each of them). The main reported reasons of suicide attempts were depressive symptoms (n=46, 60%) including depressed mood and hopelessness, stressful life events (bereavement, divorce, separation) (n=35, 46%) and presence of delusions and/or auditory hallucinations (n=25, 32.5%). No differences were found between the two groups regarding the different socio-demographic variables. Significant differences were found with respect to a duration of untreated psychosis equal to or more than one year (P<0.001), smoking in men (P=0.03), positive symptoms score on the PANSS (P<0.001), scores of Simpson-Angus scale (P=0.029) and poor medication compliance (P=0.02).

CONCLUSION

Demographic variables as suggested by other studies are less valuable predictors of suicide attempts in patients with schizophrenia. Interventions for reducing such behavior should focus on clinical variables and integrate an early diagnosis of the disease, reduce positive psychotic symptoms and tobacco consumption, correct extrapyramidal signs and improve medication compliance.

Use of antipsychotic medication and suicidality--the Northern Finland Birth Cohort 1966

In addition to psychoses, antipsychotic drugs are nowadays also prescribed for other psychiatric disturbances, such as mood disorders. We wanted to find out whether there is any association between the use of antipsychotic drugs and suicidality in cases of psychotic and non-psychotic disorders. Our sample was the population-based Northern Finland 1966 Birth Cohort. Information on the use of prescribed drugs was collected in 1997 from the nationwide medication register and with a postal questionnaire (N = 8218). The presence of suicidal ideation was assessed cross-sectionally using the Symptom Check List-25 questionnaire. We studied associations between suicidal ideation, adjusted for symptoms of depression and anxiety, and antipsychotic medication in different diagnostic groups (schizophrenia, other psychosis and no psychosis). Individuals receiving antipsychotic medication (n = 70, 0.9%) had in general more suicidal ideation regardless of diagnostic group, although the associations diminished when taking other symptoms into account. There were no statistically significant differences between those taking typical and atypical antipsychotics. In the non-psychotic group, higher antipsychotic doses were associated with more suicidal ideation even when adjusted for symptoms of depression and anxiety (p < 0.05). In the cases of schizophrenia or other forms of psychosis, no such associations were observed. Our results suggest that one should take suicidal ideation into account when prescribing antipsychotic medication, especially for off-label use.

All-cause mortality and medication risk factors in schizophrenia: a prospective cohort study

BACKGROUND

It is well established that persons with schizophrenia have high mortality rates. There is conflicting evidence that antipsychotic and perhaps other medications routinely used to treat schizophrenia contribute to mortality risk.

METHODS

A health insurer database was used to examine schizophrenia diagnosis and mortality in 2008. Information from the period 2006-2008 was used to analyze demographics and medication prescriptions. The risk set composed of patients with schizophrenia using an antipsychotic (n = 7415) and a group of randomly chosen control subjects (n = 97,726).

RESULTS

The mortality risk for having a diagnosis of schizophrenia and using an antipsychotic versus the random control group was a hazard ratio (HR) of 2.6; 95% CI, 2.0-3.2. Over the 3-year period, age, receiving a first-generation antipsychotic, and the use of a mood stabilizer were associated with a higher risk of mortality: HR, 1.06; 95% CI, 1.04-1.08; HR, 2.36; 95% CI, 1.38-4.04; and HR, 8.42; 95% CI, 3.06-24.07, respectively.

CONCLUSION

Patients with schizophrenia have higher mortality rates than normal controls. The type of antipsychotic and concomitant medication can affect mortality rates in schizophrenia.

Violence among persons diagnosed with schizophrenia: how pharmacists can help

Violence among those diagnosed with schizophrenia has been reported but is not a diagnostic component of the disorder. The position of the courts regarding fulfillment of the requisite intent to commit violent acts has not been extensively reported. This article discusses the impact of a diagnosis of schizophrenia in an individual and how the pharmacist can help integrate information into the health care system. The recent Supreme Court case of Clark versus Arizona and the older case of Patterson versus Cockrell are discussed with respect to the concept of intent (to commit the act) and the implications this has on an individual in the midst of a psychotic episode. Quality of life, the perception of the stigma associated with a diagnosis of schizophrenia, and pharmacotherapy are briefly discussed. The origin of schizophrenia is multifactorial. Persons with schizophrenia are not innately violent, but alteration in perception may precipitate aggressive acts. Given the complex and diverse nature of schizophrenia and the fact that even with successful pharmacological treatment residual symptoms may still be present, there is a need to provide information to health care practitioners and the court.

Suicide attempts in a prospective cohort of patients with schizophrenia treated with sertindole or risperidone

The incidence of suicide attempts (fatal and non-fatal) was analysed in a prospective cohort of patients with schizophrenia randomly assigned to sertindole (4905 patients) or risperidone (4904 patients) in a parallel-group open-label study with blinded classification of outcomes (the sertindole cohort prospective study--SCoP). The total exposure was 6978 and 7975 patient-years in the sertindole and risperidone groups, respectively. Suicide mortality in the study was low (0.21 and 0.28 per 100 patients per year with sertindole and risperidone, respectively). The majority (84%) of suicide attempts occurred within the first year of treatment. Cox's proportional hazards model analysis of the time to the first suicide attempt, reported by treating psychiatrists and blindly reviewed by an independent expert group according to the Columbia Classification Algorithm of Suicide Assessment (both defining suicide attempts by association of suicidal act and intent to die), showed a lower risk of suicide attempt for sertindole-treated patients than for risperidone-treated patients. The effect was statistically significant with both evaluation methods during the first year of randomized treatment (hazard ratios [95% CI]: 0.5 [0.31-0.82], p=0.006; and 0.57 [0.35-0.92], p=0.02, respectively). With classification by an independent safety committee using a broader definition including all incidences of intentional self-harm, also those without clear suicidal intent, the results were not significant. A history of previous suicide attempts was significantly associated with attempted suicides in both treatment groups.

Antidepressant utilization patterns and mortality in Swedish men and women aged 20-34 years

PURPOSE

To compare antidepressant utilization patterns and mortality in relation to antidepressant use in men and women aged 20-34 years.

METHODS

We used data from the Swedish Prescribed Drug Register to identify adults aged 20-34 years who purchased at least one antidepressant in 2006. Information on death and migration was obtained from the Total Population Register by record linkage. One-year prevalence and proportion of new users, amount of purchased antidepressants, concurrent use of other antidepressants, mood stabilizers and antipsychotics and mortality were assessed.

RESULTS

The one-year prevalence of antidepressant use was 5.6% among all Swedes aged 20-34 years (n = 94,239) and was higher among women than men (7.2 vs. 4.0%, p < 0.001). Selective serotonin reuptake inhibitors were the most dominant class of antidepressants at baseline and were more common among women than men (78.7 vs. 71.7%, p < 0.001). Of the new users, 22.3% filled only one prescription during the study period, men more often than women (24.1 vs. 21.4%, p < 0.001). The mortality rate was higher in men than in women (24 vs. 14 per 10,000, p = 0.009). Concurrent use of mood stabilizers (48 vs. 16 per 10,000, p < 0.001) and antipsychotics (50 vs. 14 per 10,000, p < 0.001) was associated with increased mortality in men and women.

CONCLUSIONS

Almost twice as many Swedish women than men aged 20-34 years purchased antidepressants in 2006. Differences in utilization patterns between sexes were rather small. Discontinuation rates were high, indicating that health care providers need to acquire an increased awareness on attitudes to treatment. In both sexes, mortality rates were elevated among those concurrently using mood stabilizers and antipsychotics, which needs further investigation.

Mortality in schizophrenia: a measurable clinical endpoint

Over the last five years, large data sets on mortality in schizophrenia have been published which have established mortality as a measurable clinical endpoint. Four issues need clarification: whether mortality rates are declining, what the causes of death are, the effects antipsychotic treatments have on mortality and whether these data inform as to how mortality may be reduced in the future. A PubMed search was carried out to identify relevant publications. The search strategy was conducted as a review focusing predominantly on data since 2006. A large number of retrospective epidemiological and prospective studies have been published on mortality rates and causation in schizophrenia, predominantly from 2006-2009. Data suggest that the mortality gap with the general population increased from the 1970s but may have peaked in the mid-1990s. The main causes of mortality are suicide, cancer and cardiovascular disease, with evidence that cancer mortality rates are similar to cardiovascular mortality rates. Mortality causation is dependent upon age of the cohort, length of follow up and type of study. Antipsychotic treatments reduce mortality when compared with no treatment and atypical antipsychotics do not appear to increase cardiovascular mortality and morbidity compared with conventionals; further research is required for any definitive conclusion.

Suicide and schizophrenia: a systematic review of rates and risk factors

Risk assessment is a core skill in psychiatry. Risk prediction for suicide in schizophrenia is known to be complex. We undertook a systematic review of all original studies concerning suicide in schizophrenia published since 2004. We found 51 data-containing studies (from 1281 studies screened) that met our inclusion criteria, and ranked these by standardized quality criteria. Estimates of rates of suicide and risk factors associated with later suicide were identified, and the risk factors were grouped according to type and strength of association with suicide. Consensus on the lifetime risk of suicide was a rate of approximately 5%. Risk factors with a strong association with later suicide included being young, male, and with a high level of education. Illness-related risk factors were important predictors, with number of prior suicide attempts, depressive symptoms, active hallucinations and delusions, and the presence of insight all having a strong evidential basis. A family history of suicide, and comorbid substance misuse were also positively associated with later suicide. The only consistent protective factor for suicide was delivery of and adherence to effective treatment. Prevention of suicide in schizophrenia will rely on identifying those individuals at risk, and treating comorbid depression and substance misuse, as well as providing best available treatment for psychotic symptoms.

All-cause mortality among people with serious mental illness (SMI), substance use disorders, and depressive disorders in southeast London: a cohort study

BACKGROUND

Higher mortality has been found for people with serious mental illness (SMI, including schizophrenia, schizoaffective disorders, and bipolar affective disorder) at all age groups. Our aim was to characterize vulnerable groups for excess mortality among people with SMI, substance use disorders, depressive episode, and recurrent depressive disorder.

METHODS

A case register was developed at the South London and Maudsley National Health Services Foundation Trust (NHS SLAM), accessing full electronic clinical records on over 150,000 mental health service users as a well-defined cohort since 2006. The Case Register Interactive Search (CRIS) system enabled searching and retrieval of anonymised information since 2008. Deaths were identified by regular national tracing returns after 2006. Standardized mortality ratios (SMRs) were calculated for the period 2007 to 2009 using SLAM records for this period and the expected number of deaths from age-specific mortality statistics for the England and Wales population in 2008. Data were stratified by gender, ethnicity, and specific mental disorders.

RESULTS

A total of 31,719 cases, aged 15 years old or more, active between 2007-2009 and with mental disorders of interest prior to 2009 were detected in the SLAM case register. SMRs were 2.15 (95% CI: 1.95-2.36) for all SMI with genders combined, 1.89 (1.64-2.17) for women and 2.47 (2.17-2.80) for men. In addition, highest mortality risk was found for substance use disorders (SMR = 4.17; 95% CI: 3.75-4.64). Age- and gender-standardised mortality ratios by ethnic group revealed huge fluctuations, and SMRs for all disorders diminished in strength with age. The main limitation was the setting of secondary mental health care provider in SLAM.

CONCLUSIONS

Substantially higher mortality persists in people with serious mental illness, substance use disorders and depressive disorders. Furthermore, mortality risk differs substantially with age, diagnosis, gender and ethnicity. Further research into specific risk groups is required.

Suicide in schizophrenia

Schizophrenia is a disorder with an estimated suicide risk of 4-5%. Many factors are involved in the suicidal process, some of which are different from those in the general population. Clinical risk factors include attempted suicide, depression, male gender, substance abuse and hopelessness. Biosocial factors, such as a high intelligence quotient and high level of premorbid function, have also been associated with an increased risk of suicide in patients with schizophrenia. Suicide risk is especially high during the first year after diagnosis. Many of the suicides occur during hospital admission or soon after discharge. Management of suicide risk includes both medical treatment and psychosocial interventions. Still, risk factors are crude; efforts to predict individual suicides have not proved useful and more research is needed.

Do antipsychotic medications reduce or increase mortality in schizophrenia? A critical appraisal of the FIN-11 study

Compared to the general population, people with schizophrenia are at risk of dying prematurely due to suicide and due to different somatic illnesses. The potential role of antipsychotic treatment in affecting suicide rates and in explaining the increased mortality due to somatic disorders is highly debated. A recent study of death registers in Finland compared the cause-specific mortality in 66,881 patients versus the total population (5.2 million) between 1996 and 2006, suggesting that antipsychotic use decreased all-cause mortality compared to no antipsychotic use in patients with schizophrenia, and that clozapine had the most beneficial profile in this regard (Tiihonen et al., 2009). The benefits of clozapine were conferred by significant protective effects for suicide compared to perphenazine, whereas, a mixed group of 'other' antipsychotics, haloperidol, quetiapine and risperidone were reported to be associated with significantly higher all-cause mortality than perphenazine. By contrast, despite known differences in effects on cardiovascular risk factors, there were no significant differences between any of the examined antipsychotics regarding death due to ischemic heart disease. A number of methodological and conceptual issues make the interpretation of these findings problematic, including incomplete reporting of data, questionable selection of drug groups and comparisons, important unmeasured risk factors, inadequate control for potentially confounding variables, exclusion of deaths occurring during hospitalization leading to exclusion of 64% of deaths on current antipsychotics from the analysis, and survivorship bias due to strong and systematic differences in illness duration across the treatment groups. Well designed, prospective mortality studies, with direct measurement of and adjustment for all known relevant risk factors for premature mortality, are needed to identify risk and protective medication and patient factors and to, ultimately, inform clinical practice.