Violent offending and IQ level as predictors of suicide in schizophrenia: national cohort study

Suicide rates among people with serious mental illness: a systematic review and meta-analysis

BACKGROUND

People with serious mental illness are at great risk of suicide, but little is known about the suicide rates among this population. We aimed to quantify the suicide rates among people with serious mental illness (bipolar disorder, major depression, or schizophrenia).

METHODS

PubMed and Web of Science were searched to identify studies published from 1 January 1975 to 10 December 2020. We assessed English-language studies for the suicide rates among people with serious mental illness. Random-effects meta-analysis was used. Changes in follow-up time and the suicide rates were presented by a locally weighted scatter-plot smoothing (LOESS) curve. Suicide rate ratio was estimated for assessments of difference in suicide rate by sex.

RESULTS

Of 5014 identified studies, 41 were included in this analysis. The pooled suicide rate was 312.8 per 100 000 person-years (95% CI 230.3-406.8). Europe was reported to have the highest pooled suicide rate of 335.2 per 100 000 person-years (95% CI 261.5-417.6). Major depression had the highest suicide rate of 534.3 per 100 000 person-years (95% CI 30.4-1448.7). There is a downward trend in suicide rate estimates over follow-up time. Excess risk of suicide in males was found [1.90 (95% CI 1.60-2.25)]. The most common suicide method was poisoning [21.9 per 100 000 person-years (95% CI 3.7-50.4)].

CONCLUSIONS

The suicide rates among people with serious mental illness were high, highlighting the requirements for increasing psychological assessment and monitoring. Further study should focus on region and age differences in suicide among this population.

Search for solutions, learning, simulation, and choice processes in suicidal behavior

Suicide may be viewed as an unfortunate outcome of failures in decision processes. Such failures occur when the demands of a crisis exceed a person's capacity to (i) search for options, (ii) learn and simulate possible futures, and (iii) make advantageous value‐based choices. Can individual‐level decision deficits and biases drive the progression of the suicidal crisis? Our overview of the evidence on this question is informed by clinical theory and grounded in reinforcement learning and behavioral economics. Cohort and case–control studies provide strong evidence that limited cognitive capacity and particularly impaired cognitive control are associated with suicidal behavior, imposing cognitive constraints on decision‐making. We conceptualize suicidal ideation as an element of impoverished consideration sets resulting from a search for solutions under cognitive constraints and mood‐congruent Pavlovian influences, a view supported by mostly indirect evidence. More compelling is the evidence of impaired learning in people with a history of suicidal behavior. We speculate that an inability to simulate alternative futures using one's model of the world may undermine alternative solutions in a suicidal crisis. The hypothesis supported by the strongest evidence is that the selection of suicide over alternatives is facilitated by a choice process undermined by randomness. Case–control studies using gambling tasks, armed bandits, and delay discounting support this claim. Future experimental studies will need to uncover real‐time dynamics of choice processes in suicidal people. In summary, the decision process framework sheds light on neurocognitive mechanisms that facilitate the progression of the suicidal crisis.

This article is categorized under:

Economics > Individual Decision‐Making

Psychology > Emotion and Motivation

Psychology > Learning

Neuroscience > Behavior

Insight and risk of suicidal behaviour in two first-episode psychosis cohorts: Effects of previous suicide attempts and depression

BACKGROUND

The role of insight dimensions - illness recognition (IR), symptoms relabelling (SR), treatment compliance (TC) - in suicide risk in first-episode psychosis (FEP) remains unclear.

METHOD

The AESOP (n = 181) and GAP (n = 112) FEP cohorts were followed-up over 10- and 5 years. Survival analysis modelled time to first suicidal event in relation to baseline scores on the Schedule for the Assessment of Insight, whilst adjusting for demographic, clinical, psychopathological and neuropsychological variables.

RESULTS

AESOP: those with previous suicide attempts scored higher on IR (7.6 ± 1.9 vs. 5.9 ± 3.0, p < 0.01) and total insight scores (TIS) (17.2 ± 5.0 vs. 13.4 ± 6.7, p = 0.03). IR (r = 0.23, p < 0.01), SR (r = 0.18, p = 0.04) and TC (r = 0.26, p < 0.01) correlated with depression. Univariable analyses: IR (HR = 1.14, 95% CI = 0.98-1.34, p = 0.09), TC (HR = 1.30, 95% CI = 0.99-1.71, p = 0.06) and TIS (HR = 1.06, 95% CI = 0.99-1.13, p = 0.08) were linked with suicidal behaviour. Multivariable regression models: depression (HR = 1.55, 95% CI = 1.22-1.97, p < 0.01) predicted suicidal behaviour. GAP: SR (6.4 ± 3.1 vs. 4.5 ± 3.4, p = 0.03) and TIS (16.8 ± 6.4 vs. 12.8 ± 7.4, p = 0.03) were higher in those with suicidal antecedents. IR (r = 0.32, p < 0.01) and SR (r = 0.27, p = 0.01) correlated with depression. Univariable analyses: TC (HR = 1.36, 95% CI = 1.01-1.83, p = 0.04) and TIS (HR = 1.06, 95% CI = 0.99-1.14, p = 0.08) were associated with suicidal behaviour. Multivariable regression models: previous suicide attempts (HR 5.17, 95% CI 1.32-20.29, p = 0.02) and depression (HR 1.16, 95% CI = 1.00-1.35, p = 0.04) predicted suicidal behaviour.

CONCLUSIONS

Suicide attempts prior to FEP and depression at that point were associated with baseline insight levels and predicted risk of suicidal behaviour over the follow-up, which was not linked with insight. This may explain the apparent association of insight with suicidality in FEP.

Exploring service users', carers' and professionals' perspectives and experiences of current antipsychotic prescribing: A qualitative study

Objectives Shared decision-making is the pinnacle of patient-centred care; mental health stakeholders value shared decision-making but find it difficult to enact. The objective was to compare and synthesise mental health stakeholder views on antipsychotic prescribing in one NHS Trust, to understand potential reasons for the difficult enactment of shared decision-making in practice. Methods We conducted 12 interviews and 5 focus groups with 33 mental health stakeholders, after obtaining their informed consent. They shared their experiences in and perceptions of antipsychotic prescribing and were recruited from Manchester Mental Health and Social Care Trust. Results Stakeholders agreed that successful shared decision-making demands a collaborative approach. We elucidated a striking divergence in views of the decision-making process and understanding of collaboration. Nurses, consultants and the pharmacist seemed most satisfied with the amount of collaboration but most pessimistic about the scope for it. Carers and most service users did not feel that there was any collaboration. Discussion Comparison of perspectives demonstrated the complexity of shared decision-making which is not addressed in current operational definitions or policy or nursing practice initiatives. The findings have the potential to progress initiatives in the mental health field from those that emphasise the need for shared decision-making to those that develop tools to promote shared decision-making.

Secular Slowing of Auditory Simple Reaction Time in Sweden (1959-1985)

There are indications that simple reaction time might have slowed in Western populations, based on both cohort- and multi-study comparisons. A possible limitation of the latter method in particular is measurement error stemming from methods variance, which results from the fact that instruments and experimental conditions change over time and between studies. We therefore set out to measure the simple auditory reaction time (SRT) of 7,081 individuals (2,997 males and 4,084 females) born in Sweden 1959-1985 (subjects were aged between 27 and 54 years at time of measurement). Depending on age cut-offs and adjustment for aging related slowing of SRT, the data indicate that SRT has increased by between 3 and 16 ms in the 27 birth years covered in the present sample. This slowing is unlikely to be explained by attrition, which was evaluated by comparing the general intelligence × birth-year interactions and standard deviations for both male participants and dropouts, utilizing military conscript cognitive ability data. The present result is consistent with previous studies employing alternative methods, and may indicate the operation of several synergistic factors, such as recent micro-evolutionary trends favoring lower g in Sweden and the effects of industrially produced neurotoxic substances on peripheral nerve conduction velocity.

[Suicide and suicide tendencies in adolescent detainees]

Following accidents, suicide is the second leading cause of death in adolescence. This stage of life has the most suicide attempts of all age groups. In addition to mentally ill juveniles, adolescent delinquents represent a high-risk group for suicidal behavior and completed suicide. In particular, the population of detainees, an extreme form of juvenile delinquency, have a 16- to 18-fold higher risk of suicidal behavior and suicide compared to the general population. Because the composition of juvenile detainees differs greatly from that of detained adults, age-specific scientific approaches and prevention programs are needed. This task cannot be addressed by juvenile detention staff alone, but rather demands close cooperation between adolescent psychiatrists, psychologists, prison medical staff, legal experts and prison officers to use the opportunity for suicide prevention in juvenile detention facilities.

The association between childhood relocations and subsequent risk of suicide attempt, psychiatric problems, and low academic achievement

BACKGROUND

Given the frequency with which families change residences, the effects of childhood relocations have gained increasing research attention. Many researchers have demonstrated that childhood relocations are associated with a variety of adverse outcomes. However, drawing strong causal claims remains problematic due to uncontrolled confounding factors.

METHOD

We utilized longitudinal, population-based Swedish registers to generate a nationally representative sample of offspring born 1983-1997 (n = 1 510 463). Using Cox regression and logistic regression, we examined the risk for numerous adverse outcomes after childhood relocation while controlling for measured covariates. To account for unmeasured genetic and environmental confounds, we also compared differentially exposed cousins and siblings.

RESULTS

In the cohort baseline model, each annual relocation was associated with risk for the adverse outcomes, including suicide attempt [hazard ratio (HR) 1.19, 95% confidence interval (CI) 1.19-1.20]. However, when accounting for offspring and parental covariates (HR 1.08, 95% CI 1.07-1.09), as well as genetic and environmental confounds shared by cousins (HR 1.07, 95% CI 1.05-1.09) and siblings (HR 1.00, 95% CI 0.97-1.04), the risk for suicide attempt attenuated. We found a commensurate pattern of results for severe mental illness, substance abuse, criminal convictions, and low academic achievement.

CONCLUSIONS

Previous research may have overemphasized the independent association between relocations and later adverse outcomes. The results suggest that the association between childhood relocations and suicide attempt, psychiatric problems, and low academic achievement is partially explained by genetic and environmental confounds correlated with relocations. This study demonstrates the importance of using family-based, quasi-experimental designs to test plausible alternate hypotheses when examining causality.

A population-based longitudinal study of suicide risk in male schizophrenia patients: Proximity to hospital discharge and the moderating effect of premorbid IQ

Suicide is a major cause of death in schizophrenia. Identifying factors which increase the risk of suicide among schizophrenia patients might help focus prevention efforts. This study examined risk of suicide in male schizophrenia patients using population-based data, examining the timing of suicide in relation to the last hospital discharge, and the effect of premorbid IQ on risk of suicide. Data on 930,000 male adolescents from the Israeli military draft board were linked with data from the Israeli Psychiatric Hospitalization Case Registry and vital statistics from the Israeli Ministry of Health. The relationship between premorbid IQ and risk for suicide was examined among 2881 males hospitalized with schizophrenia and compared to a control group of 566,726 males from the same cohort, who were not hospitalized for a psychiatric disorder, using survival analysis methods. Over a mean follow-up period of 9.9 years (SD=5.8, range: 0-22 years), 77/3806 males with schizophrenia died by suicide (a suicide rate of 204.4 per 100,000 person-years). Approximately 48% of the suicides occurred within a year of discharge from the last hospital admission for schizophrenia. Risk of suicide was higher in male schizophrenia patients with high premorbid IQ (HR=4.45, 95% CI=1.37-14.43) compared to those with normal premorbid IQ. These data indicate that male schizophrenia patients with high premorbid IQ are at particularly high risk of suicide, and the time of peak risk is during the first year after the last hospitalization discharge.

Suicide in Recent Onset Psychosis Revisited: Significant Reduction of Suicide Rate over the Last Two Decades - A Replication Study of a Dutch Incidence Cohort

This study aims to compare the suicide risk over the past decade following recent onset psychosis to findings from the eighties and nineties in the same catchment area and to identify predictors of suicide in the context of the Psychosis Recent Onset Groningen-Survey (PROGR-S). A medical file search was carried out to determine the current status of all patients admitted between 2000 and 2009. The suicide rate was compared with a study executed in 1973–1988 in the same catchment area. Predictors of suicide were investigated using Cox regression. The status of 424 of the 614 patients was known in July 2014. Suicide occurred in 2.4% of patients with psychosis disorders (n = 10; mean follow-up 5.6 years); 6 out of 10 suicides took place within two years. Within two decades, the suicide rate dropped from 11% (follow-up 15 years, 8.5% after 5 years) to 2.4%. The Standardized Mortality Rate (SMR) of suicides compared with the general population was 41.6. A higher age was the only significant predictor for suicide. Neuroticism, living situation, disorganized and negative symptoms, and passive coping style all showed a trend for significance. A significant reduction in the suicide rate was found for people with psychosis over the past decades. Given the high SMR, suicide research should be given the highest priority. Identifying predictors may contribute to further reduction of suicide among patients with psychosis.

Suicide in first episode psychosis: a nationwide cohort study

BACKGROUND

Relatively little is known about suicide in diagnostic subtypes of first episode psychosis (FEP). Our aim was to assess suicide rates and potential risk factors for suicide in FEP.

METHODS

This is a national register-based cohort study of patients born in 1973-1978 in Sweden and who were hospitalized with a FEP between ages 15 and 30years (n=2819). The patients were followed from date of discharge until death, emigration, or 31st of December 2008. The suicide rates for six diagnostic subtypes of FEP were calculated. Suicide incidence rate ratios (IRRs) were calculated to evaluate the association between suicide and psychiatric, familial, social, and demographic factors.

RESULTS

In total 121 patients died by suicide. The overall suicide rate was 4.3 (95% confidence interval [CI] 3.5-5.0) per 1000person-years. The highest suicide rates were found in depressive disorder with psychotic symptoms and in delusional disorder. In an adjusted model, the strongest risk factors for suicide were self-harm (IRR 2.7, CI 1.7-4.4) or a conviction for violent crime (IRR 2.0, CI 1.3-3.2). Also having a first-degree relative with a schizophrenia/bipolar diagnosis (IRR 2.1, CI 1.2-3.6) or substance use disorder (IRR 2.0, CI 1.2-3.2) were significant risk factors for suicide.

CONCLUSIONS

Impulsive behavior such as self-harm as well as having a family history of severe mental disorder or substance use are important risk factors for suicide in FEP.

Pharmacoeconomics of depot antipsychotics for treating chronic schizophrenia in Sweden

AIMS

To determine the cost-effectiveness of long-acting injectable (LAI) antipsychotics for chronic schizophrenia in Sweden.

METHODS

A 1-year decision tree was developed for Sweden using published data and expert opinion. Five treatment strategies lasting 1 year were compared: paliperidone palmitate (PP-LAI), olanzapine pamoate (OLZ-LAI), risperidone (RIS-LAI), haloperidol decanoate (HAL-LAI) and olanzapine tablets (oral-OLZ). Patients intolerant/failing drugs switched to another depot; subsequent failures received clozapine. Resources and employment time lost (indirect costs) were costed in 2011 Swedish kroner (SEK), from standard government lists. The model calculated the average cost/patient and quality-adjusted life-years (QALYs), which were combined into incremental cost-effectiveness ratios. Multivariate and 1-way sensitivity analyses tested model stability.

RESULTS

PP-LAI followed by OLZ-LAI had the lowest cost/patient (189,696 SEK) and highest QALYs (0.817), dominating in the base case. OLZ-LAI followed by PP-LAI cost 229,775 SEK (0.812 QALY), RIS-LAI followed by HAL-LAI cost 221,062 SEK (0.804 QALY), HAL-LAI followed by oral-OLZ cost 243,411 SEK (0.776 QALY), and oral-OLZ followed by HAL-LAI cost 249,422 SEK (0.773 QALY). The greatest proportions of costs (52.5-83.8%) were for institutional care; indirect costs were minor (2.4-3.8%). RESULTS were sensitive to adherence and hospitalization rates, but not drug cost. PP-LAI followed by OLZ-LAI dominated OLZ-LAI followed by PP-LAI in 59.4% of simulations, RIS-LAI followed by HAL-LAI in 65.8%, HAL-LAI followed by oral-OLZ in 94.0% and oral-OLZ followed by HAL-LAI in 95.9%; PP-LAI followed by OLZ-LAI was dominated in 1.1% of the 40,000 iterations.

CONCLUSION

PP-LAI followed by OLZ-LAI was cost-effective in Sweden for chronic schizophrenia and cost-saving overall to the healthcare system.

Violent crime, suicide, and premature mortality in patients with schizophrenia and related disorders: a 38-year total population study in Sweden

BACKGROUND

People with schizophrenia and related disorders are at an increased risk of adverse outcomes, including conviction of a violent offence, suicide, and premature mortality. However, the rates of, and risk factors for, these outcomes need clarification as a basis for population-based and targeted interventions. We aimed to determine rates and risk factors for these outcomes, and investigate to what extent they are shared across outcomes and are specific to schizophrenia and related disorders.

METHODS

We undertook a total population cohort study in Sweden of 24 297 patients with schizophrenia and related disorders between January, 1972 and December, 2009. Patients were matched by age and sex to people from the general population (n=485 940) and also to unaffected sibling controls (n=26 357). First, we investigated rates of conviction of a violent offence, suicide, and premature mortality, with follow-up until conviction of a violent offence, emigration, death, or end of follow-up (Dec 31, 2009), whichever occurred first. Second, we analysed associations between these adverse outcomes and sociodemographic, individual, familial, and distal risk factors, for men and women separately, with Cox proportional hazards models. Finally, we assessed time trends in adverse outcomes between 1972 and 2009, for which we compared patients with unaffected siblings, and analysed associations with changes in the number of nights spent in inpatient beds in psychiatric facilities nationwide.

FINDINGS

Within 5 years of their initial diagnosis, 13·9% of men and 4·7% of women with schizophrenia and related disorders had a major adverse outcome (10·7% of men and 2·7% of women were convicted of a violent offence, and 3·3% of men and 2·0% of women died prematurely of any cause). During the study, the adjusted odds ratio of any adverse outcomes for patients compared with general population controls was 7·5 (95% CI 7·2-7·9) in men and 11·1 (10·2-12·1) in women. Three risk factors that were present before diagnosis were predictive of any adverse outcome: drug use disorders, criminality, and self-harm, which were also risk factors for these outcomes in unaffected siblings and in the general population. Over the period 1973-2009, the odds of these outcomes increased in patients with schizophrenia and related disorders compared with unaffected siblings.

INTERPRETATION

Schizophrenia and related disorders are associated with substantially increased rates of violent crime, suicide, and premature mortality. Risk factors for these three outcomes included both those specific to individuals with schizophrenia and related disorders, and those shared with the general population. Therefore, a combination of population-based and targeted strategies might be necessary to reduce the substantial rates of adverse outcomes in patients with schizophrenia and related disorders.

The relationship between suicide and violence in schizophrenia: analysis of the Clinical Antipsychotic Trials of Intervention Effectiveness (CATIE) dataset

BACKGROUND

Suicide and violence often co-occur in the general population as well as in mentally ill individuals. Few studies, however, have assessed whether these suicidal behaviors are predictive of violence risk in mental illness.

AIMS

The aim of this study is to investigate whether suicidal behaviors, including suicidal ideation, threats, and attempts, are significantly associated with increased violence risk in individuals with schizophrenia.

METHOD

Data for these analyses were obtained from the Clinical Antipsychotic Trials of Intervention Effectiveness (CATIE) trial, a randomized controlled trial of antipsychotic medication in 1460 adults with schizophrenia. Univariate Cox regression analyses were used to calculate hazard ratios (HRs) for suicidal ideation, threats, and attempts. Multivariate analyses were conducted to adjust for common confounding factors, including: age, alcohol or drug misuse, major depression, antisocial personality disorder, depression, hostility, positive symptom, and poor impulse control scores. Tests of discrimination, calibration, and reclassification assessed the incremental predictive validity of suicidal behaviors for the prediction of violence risk.

RESULTS

Suicidal threats and attempts were significantly associated with violence in both males and females with schizophrenia with little change following adjustment for common confounders. Only suicidal threats, however, were associated with a significant increase in incremental validity beyond age, diagnosis with a comorbid substance use disorder, and recent violent behavior.

CONCLUSIONS

Suicidal threats are independently associated with violence risk in both males and females with schizophrenia, and may improve violence risk prediction.

School performance and the risk of suicide attempts in young adults: a longitudinal population-based study

BACKGROUND

Poor school performance is strongly associated with attempted suicide, but the mechanisms underlying this association are uncertain. We examined this relationship and the extent to which it is explained by (i) adult health behaviours and (ii) social conditions. Furthermore, we examined the potential modifying role of previous suicidal thoughts in the relationship.

METHOD

We conducted a longitudinal cohort study of 6146 individuals aged 18-33 years, recruited in 2002 and 2006 in Stockholm and resurveyed in 2007 and 2010 respectively. We estimated the risk of reported lifetime suicide attempts at follow-up among individuals without a history of suicide attempts at baseline and in relation to compulsory school-leaving grades, controlling for possible confounders and mediators.

RESULTS

There were 91 cases of self-reported suicide attempts during the follow-up (5-year incidence of 1.5%). ORs ranged from 3.35 [95% confidence interval (CI) 1.88-5.96] for those in the lowest grade quartile to 2.60 (95% CI 1.48-4.57) and 1.76 (95% CI 0.99-3.13) for those in the second and third quartiles respectively. The relationship between school performance and risk of suicide attempts did not differ by sex. Adult health behaviours and social conditions marginally attenuated, but did not explain, the relationship. The gradient varied with baseline history of suicidal thoughts, and was found only among individuals without such a history.

CONCLUSIONS

Poor school performance was found to predict suicide attempts among young adults without a history of suicidal thoughts. Adult health behaviours and social conditions did not explain this relationship. Instead, other factors linked with poor school performance, such as poor coping ability, may increase the risk of suicide attempts.

Cognitive ability in early adulthood is associated with later suicide and suicide attempt: the role of risk factors over the life course

BACKGROUND

Cognitive ability/intelligence quotient (IQ) in youth has previously been associated with subsequent completed and attempted suicide, but little is known about the mechanisms underlying the associations. This study aims to assess the roles of various risk factors over the life course in explaining the observed relationships.

METHOD

The present investigation is a cohort study based on data on IQ test performance and covariates, recorded on 49 321 Swedish men conscripted in 1969-1970, at ages 18-20 years. Information on suicides and hospital admissions for suicide attempt up to the age of 57 years, childhood and adult socio-economic position, and adult family formation, was obtained from linkage to national registers.

RESULTS

Lower IQ was associated with increased risks of both suicide and suicide attempt during the 36 years of follow-up. The associations followed a dose-response pattern. They were attenuated by approximately 45% in models controlling for social background, mental ill-health, aspects of personality and behavior, adult socio-economic position and family formation. Based on one-unit decreases in IQ test performance on a nine-point scale, the hazard ratios between ages 35 and 57 years were: for suicide 1.19 [95% confidence interval (CI) 1.13-1.25], fully adjusted 1.10 (95% CI 1.04-1.18); and for suicide attempt 1.25 (95% CI 1.20-1.31), fully adjusted 1.14 (95% CI 1.09-1.20).

CONCLUSIONS

Cognitive ability was found to be associated with subsequent completed and attempted suicide. The associations were attenuated by 45% after controlling for risk factors measured over the life course. Psychiatric diagnosis, maladjustment and aspects of personality in young adulthood, and social circumstances in later adulthood, contributed in attenuating the associations.