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

The effect of second-generation antipsychotics on anxiety/depression in patients with schizophrenia: A systematic review and meta-analysis

OBJECTIVE

Despite the high prevalence of anxiety in schizophrenia, no established guideline exists for the management of these symptoms. We aimed to synthesize evidence on the effect of second-generation antipsychotics (SGAs) on anxiety in patients with schizophrenia.

METHODS

We systematically searched Medline, Embase, PsycInfo, Web of Science, PubMed, and Cochrane library to identify randomized controlled trials of SGAs that reporting anxiety measures in schizophrenia. The search was limited to English-language articles published before February 2024. Data were pooled using a random-effects model.

RESULTS

Among 48 eligible studies, 29 (n = 7712) were included in the meta-analyses comparing SGAs to placebo, haloperidol, or another SGAs for their effect on anxiety/depression. SGAs had a small effect on anxiety/depression versus placebo (SMD = -0.28 (95 % CI [-0.34, -0.21], p < .00001, I2 = 47 %, n = 5576)) associated with efficacy for positive (z = 5.679, p < .001) and negative symptoms (z = 4.490, p < .001). Furthermore, SGAs were superior to haloperidol (SMD = -0.44, 95 % CI [-0.75, -0.13], p = .005, n = 1068) with substantial study-level heterogeneity (I2 = 85 %). Excluding one study of quetiapine in first-episode patients (SMD = -3.05, n = 73), SGAs showed a small effect on anxiety/depression versus haloperidol without heterogeneity (SMD = -0.23, 95 % CI [-0.35, -0.12], p = 01; I2 = %0). Risperidone's effect on anxiety/depression was comparable to olanzapine (SMD = -0.02, 95 % CI [-0.24,0.20], p = .87, I2 = 45 %, n = 753) and amisulpride (SMD = 0.27, 95 % CI [-1.08,0.61], p = .13, I2 = 50 %, n = 315).

CONCLUSION

While SGAs showed a small effect on anxiety/depression, the findings are inconclusive due to scarcity of research on comorbid anxiety in schizophrenia, heterogeneity of anxiety symptoms, and the scales used to measure anxiety. Further studies employing specific anxiety scales are required to explore antipsychotics, considering their receptor affinity and augmentation with serotonin/norepinephrine reuptake inhibitors or benzodiazepines for managing anxiety in schizophrenia.

Data-driven, connectome-wide analysis identifies psychosis-specific brain correlates of fear and anxiety

Decades of psychosis research highlight the prevalence and the clinical significance of negative emotions, such as fear and anxiety. Translational evidence demonstrates the pivotal role of the amygdala in fear and anxiety. However, most of these approaches have used hypothesis-driven analyses with predefined regions of interest. A data-driven analysis may provide a complimentary, unbiased approach to identifying brain correlates of fear and anxiety. The aim of the current study was to identify the brain basis of fear and anxiety in early psychosis and controls using a data-driven approach. We analyzed data from the Human Connectome Project for Early Psychosis, a multi-site study of 125 people with psychosis and 58 controls with resting-state fMRI and clinical characterization. Multivariate pattern analysis of whole-connectome data was used to identify shared and psychosis-specific brain correlates of fear and anxiety using the NIH Toolbox Fear-Affect and Fear-Somatic Arousal scales. We then examined clinical correlations of Fear-Affect scores and connectivity patterns. Individuals with psychosis had higher levels of Fear-Affect scores than controls (p < 0.05). The data-driven analysis identified a cluster encompassing the amygdala and hippocampus where connectivity was correlated with Fear-Affect score (p < 0.005) in the entire sample. The strongest correlate of Fear-Affect was between this cluster and the anterior insula and stronger connectivity was associated with higher Fear-Affect scores (r = 0.31, p = 0.0003). The multivariate pattern analysis also identified a psychosis-specific correlate of Fear-Affect score between the amygdala/hippocampus cluster and a cluster in the ventromedial prefrontal cortex (VMPFC). Higher Fear-Affect scores were correlated with stronger amygdala/hippocampal-VMPFC connectivity in the early psychosis group (r = 0.33, p = 0.002), but not in controls (r = -0.15, p = 0.28). The current study provides evidence for the transdiagnostic role of the amygdala, hippocampus, and anterior insula in the neural basis of fear and anxiety and suggests a psychosis-specific relationship between fear and anxiety symptoms and amygdala/hippocampal-VMPFC connectivity. Our novel data-driven approach identifies novel, psychosis-specific treatment targets for fear and anxiety symptoms and provides complimentary evidence to decades of hypothesis-driven approaches examining the brain basis of threat processing.

Threat Responses in Schizophrenia: A Negative Valence Systems Framework

PURPOSE OF REVIEW

Emotions are prominent in theories and accounts of schizophrenia but are largely understudied compared to cognition. Utilizing the Research Domain Criteria (RDoC) Negative Valence Systems framework, we review the current knowledge of emotions in schizophrenia. Given the pivotal role of threat responses in theories of schizophrenia and the substantial evidence of altered threat responses, we focus on three components of Negative Valence Systems tied to threat responses: responses to acute threat, responses to potential threat, and sustained threat.

RECENT FINDINGS

Individuals with schizophrenia show altered responses to neutral stimuli during acute threat, bed nucleus of the stria terminalis connectivity in response to potential threat, and threat responses associated with sustained threat. Our review concludes that Negative Valence Systems are altered in schizophrenia; however, the level and evidence of alterations vary across the types of threat responses. We suggest avenues for future research to further understand and intervene on threat responses in schizophrenia.

BNST and amygdala connectivity are altered during threat anticipation in schizophrenia

In schizophrenia, impairments in affect are prominent and anxiety disorders are prevalent. Neuroimaging studies of fear and anxiety in schizophrenia have focused on the amygdala and show alterations in connectivity. Emerging evidence suggests that the bed nucleus of the stria terminalis (BNST) also plays a critical role in anxiety, especially during anticipation of an unpredictable threat; however, previous studies have not examined the BNST in schizophrenia. In the present study, we examined BNST function and connectivity in people with schizophrenia (n = 31; n = 15 with comorbid anxiety) and controls (n = 15) during anticipation of unpredictable and predictable threat. A secondary analysis tested for differences in activation and connectivity of the central nucleus of the amygdala (CeA), which has also been implicated in threat anticipation. Analyses tested for group differences in both activation and connectivity during anticipation of unpredictable threat and predictable threat (p < .05). Relative to controls, individuals with schizophrenia showed stronger BNST-middle temporal gyrus (MTG) connectivity during unpredictable threat anticipation and stronger BNST-MTG and BNST-dorsolateral prefrontal connectivity during predictable threat anticipation. Comparing subgroups of individuals with schizophrenia and a comorbid anxiety disorder (SZ+ANX) to those without an anxiety disorder (SZ-ANX) revealed broader patterns of altered connectivity. During unpredictable threat anticipation, the SZ+ANX group had stronger BNST connectivity with regions of the salience network (insula, dorsal anterior cingulate cortex). During predictable threat anticipation, the SZ+ANX group had stronger BNST connectivity with regions associated with fear processing (insula, extended amygdala, prefrontal cortex). A secondary CeA analysis revealed a different pattern; the SZ+ANX group had weaker CeA connectivity across multiple brain regions during threat anticipation compared to the SZ-ANX group. These findings provide novel evidence for altered functional connectivity during threat anticipation in schizophrenia, especially in individuals with comorbid anxiety.

Are there reliable and valid measures of anxiety for people with psychosis? A systematic review of psychometric properties

PURPOSE

Current models of psychosis posit a developmental and maintaining role for anxiety, supported by robust empirical evidence. Given the central role for anxiety in psychosis, valid and reliable assessment is necessary. This systematic review is the first to critically appraise measures of anxiety applied to psychosis samples.

METHODS

Web of Science, MEDLINE, PsycINFO, EMBASE, and CINAHL were systematically searched for studies evaluating psychometric properties of instruments measuring anxiety in samples with non-affective psychosis diagnoses. Psychometric properties were extracted and rated according to established criteria. The COnsensus-based Standards for the selection of health Measurement Instruments (COSMIN) checklist was used to assess the methodological quality of studies.

RESULTS

Of 4,344 records identified, 11 studies were identified as eligible for inclusion, by two independent raters with high reliability. Reported psychometric properties for 17 different instruments ranged from unacceptable to excellent. The Scale of Anxiety Evaluation in Schizophrenia was assessed most extensively and demonstrated consistently good psychometric properties. The Beck Anxiety Index, Depression Anxiety Stress Scale, DSM-based Generalised Anxiety Disorder Symptoms Severity Scale, Liebowitz Social Anxiety Scale, Obsessive-Compulsive Inventory, Psychological Stress Index, Perseverative Thinking Questionnaire, and Yale-Brown Obsessive Compulsive Scale demonstrated adequate reliability and/or validity on the limited properties reported. Methodological quality was largely poor according to the requirements of the COSMIN checklist.

CONCLUSIONS

The instruments listed are recommended as at least adequate for the assessment of anxiety in psychosis on the basis of these preliminary data. Further validation of existing instruments designed to measure anxiety in people with psychosis is strongly recommended.

PRACTITIONER POINTS

Anxiety has a developmental and maintaining role in psychosis; therefore, we should routinely screen for symptoms of anxiety when working with people with psychosis spectrum disorders. Studies included in this review reported reliable and valid measures of anxiety for people with psychosis; however, the methodological quality of most studies was poor. We recommend the BAI, DASS, or SAES for general screening, and the DGSS, LSAS, OCI, PSI, PTQ, and Y-BOCS to assess symptoms associated with specific anxiety disorders and anxiety-related processes.

Morphological Profiling of Schizophrenia: Cluster Analysis of MRI-Based Cortical Thickness Data

The diagnosis of schizophrenia is thought to embrace several distinct subgroups. The manifold entities in a single clinical patient group increase the variance of biological measures, deflate the group-level estimates of causal factors, and mask the presence of treatment effects. However, reliable neurobiological boundaries to differentiate these subgroups remain elusive. Since cortical thinning is a well-established feature in schizophrenia, we investigated if individuals (patients and healthy controls) with similar patterns of regional cortical thickness form naturally occurring morphological subtypes. K-means algorithm clustering was applied to regional cortical thickness values obtained from 256 structural MRI scans (179 patients with schizophrenia and 77 healthy controls [HCs]). GAP statistics revealed three clusters with distinct regional thickness patterns. The specific patterns of cortical thinning, clinical characteristics, and cognitive function of each clustered subgroup were assessed. The three clusters based on thickness patterns comprised of a morphologically impoverished subgroup (25% patients, 1% HCs), an intermediate subgroup (47% patients, 46% HCs), and an intact subgroup (28% patients, 53% HCs). The differences of clinical features among three clusters pertained to age-of-onset, N-back performance, duration exposure to treatment, total burden of positive symptoms, and severity of delusions. Particularly, the morphologically impoverished group had deficits in N-back performance and less severe positive symptom burden. The data-driven neuroimaging approach illustrates the occurrence of morphologically separable subgroups in schizophrenia, with distinct clinical characteristics. We infer that the anatomical heterogeneity of schizophrenia arises from both pathological deviance and physiological variance. We advocate using MRI-guided stratification for clinical trials as well as case-control investigations in schizophrenia.

Suicidal ideation and subsequent completed suicide in both psychiatric and non-psychiatric populations: a meta-analysis

AIMS

Several authors claimed that expression of suicidal ideation is one of the most important predictors of completed suicide. However, the strength of the association between suicidal ideation and subsequent completed suicide has not been firmly established in different populations. Furthermore, the absolute suicide risk after expression of suicidal ideation is unknown. In this meta-analysis, we examined whether the expression of suicidal ideation predicted subsequent completed suicide in various populations, including both psychiatric and non-psychiatric populations.

METHODS

A meta-analysis of cohort and case-control studies that assessed suicidal ideation as determinant for completed suicide in adults. Two independent reviewers screened 5726 articles for eligibility and extracted data of the 81 included studies. Pooled risk ratios were estimated in a random effects model stratified for different populations. Meta-regression analysis was used to determine suicide risk during the first year of follow-up.

RESULTS

The risk for completed suicide was clearly higher in people who had expressed suicidal ideation compared with people who had not, with substantial variation between the different populations: risk ratio ranging from 2.35 (95% confidence interval (CI) 1.43-3.87) in affective disorder populations to 8.00 (95% CI 5.46-11.7) in non-psychiatric populations. In contrast, the suicide risk after expression of suicidal ideation in the first year of follow-up was higher in psychiatric patients (risk 1.40%, 95% CI 0.74-2.64) than in non-psychiatric participants (risk 0.23%, 95% CI 0.10-0.54). Past suicide attempt-adjusted risk ratios were not pooled due to large underreporting.

CONCLUSIONS

Assessment of suicidal ideation is of priority in psychiatric patients. Expression of suicidal ideation in psychiatric patients should prompt secondary prevention strategies to reduce their substantial increased risk of suicide.

OPUS study: Suicidal behaviour, suicidal ideation and hopelessness among patients with first-episode psychosis

Background

Patients with first-episode psychosis comprise a high-risk group in terms of suicide.

Aims

To identify predictive factors for suicidal behaviour and to examine the effect of integrated treatment on suicidal behaviour and hopelessness.

Method

A total of 341 patients with a first-episode schizophrenia-spectrum disorder were randomised to integrated treatment or treatment as usual.

Results

During the 1-year follow-up period, 11% attempted suicide. This was associated with female gender, hopelessness, hallucinations and suicide attempt reported at baseline, with the two latter variables being the only significant ones in the final multivariate model. The integrated treatment reduced hopelessness.

Conclusions

Hallucinations and suicide attempt before inclusion in the study were the most significant predictors of suicide attempt in the follow-up period.

Reliability, validity and factorial structure of the Arabic version of the international suicide prevention trial (InterSePT) scale for suicidal thinking in schizophrenia patients in Doha, Qatar

BACKGROUND

Patients with schizophrenia are known to have higher rates of mortality and morbidity when compared to the general population. Suicidality is a major contributor to increased mortality. The International Suicide Prevention Trial (InterSePT) Scale for Suicidal Thinking (ISST) is a validated tool to assess current suicidal ideation in patients with schizophrenia. The aims of the study were to culturally adapt the Arabic translation of ISST and to examine the psychometric characteristics of the Arabic version of the ISST among patients with schizophrenia in Qatar.

METHODS

ISST was translated and adapted into formal Arabic using the back translation method. Patients diagnosed with schizophrenia were randomly recruited from the department of Psychiatry, Rumailah Hospital, Doha, Qatar. Healthy controls were randomly recruited from two primary health care centers in Doha, Qatar. The Arabic version of Module B for suicidality in Mini International Neuropsychiatric Interview was used as the gold standard to which the Arabic ISST was compared.

RESULTS

The study sample (n = 199) was composed of 100 patients diagnosed with schizophrenia (age 35.30 ± 10.04 years; M/F is 2/1) and 99 controls (age 33.98 ± 8.33 years; M/F is 2/3). The mean score on the ISST was 3.03 ± 4.75 vs. 0.47 ± 1.44 for the schizophrenia and control groups, respectively. Inter-rater reliability coefficient was 0.95, p > 0.001. The overall Cronbach's alpha was 0.92. Principal Component Analysis produced 3 factors explaining a total of 73.8% of variance.

CONCLUSIONS

This is the first study in the Arab countries to validate the Arabic version of the ISST. The psychometric properties indicate that the Arabic ISST is a valid tool to assess the severity of suicidal ideation in Arabic patients with schizophrenia.

Longitudinal relationship between Personal and Social Performance (PSP) and anxiety symptoms in schizophrenia

BACKGROUND

We aimed to examine the longitudinal relationship between the personal and social functioning and anxiety symptoms in patients with schizophrenia. For this purpose, we confirmed the validity of the anxiety subscale of the Symptom-Checklist-90-Revised (SCL-90-R) and then applied the latent growth modeling method for longitudinal causal relationships.

METHODS

Five hundred and seventy-eight patients diagnosed with schizophrenia were evaluated and 369 patients were included in the study at baseline. After conducting Rasch model analyses for the validation of the anxiety subscale in the SCL-90-R, we applied latent growth model to determine the causal relationship between the PSP and the anxiety symptoms.

RESULTS

The validity of the anxiety subscale of the SCL-90-R was confirmed based on the Rasch rating model, where the criteria for Infit, Outfit, item difficulty, and point-measure correlations were satisfied. The results from the latent growth model showed that the intercept and slope (rate of change) of the PSP negatively predicted the slope of anxiety symptoms along the longitudinal trajectory. Together with previous studies examining the predictive role of anxiety symptoms on quality of life, our longitudinal findings lend evidence for bidirectional effects between quality of life and anxiety symptoms. The transactional nature of the relationship between anxiety symptoms and quality of life warrant further investigation using a longitudinal cross-lagged design.

CONCLUSION

The anxiety subscale of the SCL-90-R may be utilized by clinicians and researcher to make inferences about quality of life in addition to assessing anxiety symptoms in patients with schizophrenia.

Olfactory performance segregates effects of anhedonia and anxiety on social function in patients with schizophrenia

BACKGROUND

Social dysfunction is common among individuals with schizophrenia. While often attributed to anhedonia, social dysfunction could also result from unrecognized anxiety. We examined the contributions of anhedonia and anxiety to social function using olfactory function to examine whether the domains had separate underpinnings.

METHODS

We assessed anhedonia, anxiety and social function as well as olfactory function in well-characterized patients with schizophrenia or schizoaffective disorder and healthy controls.

RESULTS

We included 56 patients and 37 controls in our study. Patients exhibited significantly higher levels of anhedonia and anxiety than controls, and the domains were highly correlated in patients. The combination of anhedonia and anxiety more strongly predicted social dysfunction than either measure alone. Smell identification was differentially related to the symptoms, with better performance predicting less anhedonia but more social fear in male patients.

LIMITATIONS

The use of self-report measures precludes differentiation between recollected or recounted experience. Aside from smell identification and odour threshold, additional measures of olfaction may be considered for future studies.

CONCLUSION

Anhedonia and anxiety were strongly correlated and both negatively impacted social function. The olfactory biomarker results support the conclusion that these domains are separate. Social function in patients with schizophrenia may improve with interventions for anxiety, even in the presence of marked negative symptoms.

A review of suicide risk assessment instruments and approaches

Introduction:

Conducting an accurate suicide risk assessment (SRA) is no simple task as there are a number of factors that influence an individual's level of suicidality and his/her willingness to share this information. Therefore, it is imperative that practitioners adopt a systematic approach to conducting and documenting the foreseeability that a patient will commit suicide.

Methods

PubMed was used to search for articles published in MEDLINE journals using the following keywords: suicide, risk assessment, measure, scale. Randomized trials and pilot, proof-of-concept publications investigating the use of specific SRA measurements were included in the review. The scales are described based on the prevailing opinions in psychiatry from the American Psychiatric Association's Textbook of Suicide Assessment and Management (2nd ed., 2012).

Results

Although various SRA scales exist, experts in the field have repeatedly concluded that there is not any one scale that can predict who will commit suicide to any useful degree. However, when used along with the clinical interview, standardized suicide risk factor components of clinical and research scales remain crucial to gaining information often omitted by patients regarding thoughts and preparation for suicide. A summary of the most widely cited scales and approaches used in SRA is provided.

Discussion

SRA remains a challenge largely due to the fact that suicidal behavior is multifactorial. As a result, risk formulation is a process that should involve both standardized measures and detailed clinical interviews repeated over time.

Opposite effective connectivity in the posterior cingulate and medial prefrontal cortex between first-episode schizophrenic patients with suicide risk and healthy controls

Objective

The schizophrenic patients with high suicide risk are characterized by depression, better cognitive function, and prominent positive symptoms. However, the neurobiological basis of suicide attempts in schizophrenia is not clear. The suicide in schizophrenia is implicated in the defects in emotional process and decision-making, which are associated with prefrontal-cingulate circuit. In order to explore the possible neurobiological basis of suicide in schizophrenia, we investigated the correlation of prefrontal-cingulate circuit with suicide risk in schizophrenia via dynamic casual modelling.

Method

Participants were 33 first-episode schizophrenic patients comprising of a high suicide risk group (N = 14) and a low suicide risk group (N = 19). A comparison group of healthy controls (N = 15) were matched for age, gender and education. N-back tasking functional magnetic resonance imaging data was collected.

Results

Compared with healthy controls group, the two patients groups showed decreased task-related suppression during 2-back task state versus baseline state in the left posterior cingulate and medial prefrontal cortex; the hyper-connectivity from the left posterior cingulate cortex to the left medial prefrontal cortex existed in both schizophrenic patients groups, but hypo-connectivity in the opposite direction only existed in the schizophrenic patients group with high suicide risk.

Conclusions

The hyper-connectivity from the left posterior cingulate cortex to the left medial prefrontal cortex may suggest that the abnormal effective connectivity was associated with risk for schizophrenia. The hypo-connectivity in the opposite direction may represent a possible correlate of increased vulnerability to suicide attempt.

Anxiety as a core aspect of schizophrenia

The clinical relevance of anxiety disorders in schizophrenia has been neglected for a long time and has only recently become the subject of a systematic investigation, although its consequences may have a very negative impact on the outcome and considerably worsen the trajectory of the disease. This could be originally related to the hierarchical organization of the Diagnostic and Statistical Manual of Mental Disorders (DSM) and to the lack of assessment instruments. In this article, we will review the most recent literature concerning two of the most impairing anxiety disorders in comorbidity with schizophrenia, such as panic disorder and social anxiety disorder, briefly analyze the role of anxiety in the prodromal phase of psychosis and provide suggestions for the clinical assessment.

A novel approach to determining violence risk in schizophrenia: developing a stepped strategy in 13,806 discharged patients

Clinical guidelines recommend that violence risk be assessed in schizophrenia. Current approaches are resource-intensive as they employ detailed clinical assessments of dangerousness for most patients. An alternative approach would be to first screen out patients at very low risk of future violence prior to more costly and time-consuming assessments. In order to implement such a stepped strategy, we developed a simple tool to screen out individuals with schizophrenia at very low risk of violent offending. We merged high quality Swedish national registers containing information on psychiatric diagnoses, socio-demographic factors, and violent crime. A cohort of 13,806 individuals with hospital discharge diagnoses of schizophrenia was identified and followed for up to 33 years for violent crime. Cox regression was used to determine risk factors for violent crime and construct the screening tool, the predictive validity of which was measured using four outcome statistics. The instrument was calibrated on 6,903 participants and cross-validated using three independent replication samples of 2,301 participants each. Regression analyses resulted in a tool composed of five items: male sex, previous criminal conviction, young age at assessment, comorbid alcohol abuse, and comorbid drug abuse. At 5 years after discharge, the instrument had a negative predictive value of 0.99 (95% CI = 0.98-0.99), meaning that very few individuals who the tool screened out (n = 2,359 out of original sample of 6,903) were subsequently convicted of a violent offence. Screening out patients who are at very low risk of violence prior to more detailed clinical assessment may assist the risk assessment process in schizophrenia.

The predictive value of risk categorization in schizophrenia

BACKGROUND

Risk assessment is increasingly used to inform decisions regarding the psychiatric treatment of patients with schizophrenia and other serious mental disorders.

AIMS

To examine the theoretical limits of risk assessment and risk categorization as applied to a range of harms known to be associated with schizophrenia.

METHODS

Using known rates of suicide, homicide, self-harm, and violence in schizophrenia, a hypothetical tool with an unrealistically high level of accuracy was used to calculate the proportion of true- and false-positive risk categorizations.

RESULTS

Risk categorization incorrectly classified a large proportion of patients as being at high risk of violence toward themselves and others.

CONCLUSION

Risk assessment and categorization have severe limitations. A large proportion of patients classified as being at high risk will not, in fact, cause or suffer any harm. Unintended consequences of inaccurate risk categorization include unwarranted detention for some patients, failure to treat others, misallocation of scarce health resources, and the stigma arising from patients' being labeled as dangerous.

Epidemiology of suicide attempts among persons with psychotic disorder in the general population

OBJECTIVE

To establish the epidemiology of suicide attempts in persons with psychotic disorder identified from the general population and to investigate the associations of suicidal behavior with other clinical characteristics and with physical violence against other people.

METHOD

A random sample of 9922 Finnish persons aged 18 years or over was screened for psychotic disorder using multiple sources of information. All screen positives and random sample of screen negatives were invited to an SCID interview. Diagnostic assessment, lifetime history of suicide attempts and violence against others were based on all available systematically evaluated information from the questionnaire, interview and/or case records.

RESULTS

Of persons with a lifetime history of any primary or substance-induced psychotic disorder (n = 264), 34.5% (women: 34.1%, men: 34.9%) had a history of at least one suicide attempt. There were no suicide attempts among persons with delusional disorder, while the rate of suicide attempts was higher among persons with substance-induced psychotic disorders (48.8%) than in persons with other psychotic disorders 41.8%) (χ(2) = 4.4, d.f. = 1, P = 0.036). Suicide attempts were associated with younger age, comorbid substance use disorders, depressive symptoms, and physical violence against other people.

CONCLUSION

Suicide attempts are common in all psychotic disorders except for delusional disorder. They are particularly common in substance-induced psychotic disorder and in persons with comorbid substance use disorders. They are associated with severe depressive symptoms but not with the severity of psychotic symptoms. Suicidal behavior correlates with physical violence against other people.

Management of schizophrenia with suicide risk

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

The InterSePT suicide scale for prediction of imminent suicidal behaviors

The present study examined the ability of the International Suicide Prevention Trial (InterSePT) Scale for Suicidal Thinking (ISST) and the Calgary Depression Scale (CDS) to predict suicide attempts or hospitalizations to prevent attempts (referred to as Type 1 events) during the InterSePT trial [Meltzer, H.Y., Alphs, L., Green, A.I., Altamura, A.C., Anand, R., Bertoldi, A., Bourgeois, M., Chouinard, G., Islam, M.Z., Kane, J., Krishman, R., Lindenmayer, J.P., Potkin, S., 2003. Clozapine treatment for suicidality in schizophrenia. Archive of General Psychiatry 60, 82-91]. The primary goal of this analysis was to determine if the ISST and CDS ratings indicated that the raters, an unblinded (UP) and a blinded psychiatrist (BP) using the ISST, and a blinded rater using the CDS, were able to identify those patients who had a Type 1 event. The ratings of patients adjudged to have experienced a Type 1 event (Group 1) were compared with patients who did not (Group 2). The ISST and the CDS ratings obtained 2-8 weeks prior to a Type 1 event (Pre-1) and Pre-2, the rating immediately prior to Pre-1, obtained 2-12 weeks before Pre-1, were analyzed to test the hypothesis that the difference between Pre-2 and Pre-1 ratings for the Group 1 patients was significantly greater than the difference in the comparable ratings for Group 2 patients. The prediction that patients with Type 1 events would show greater worsening in ISST and CDS ratings between Pre-2 and Pre-1 than the Group 2 patients was confirmed. However, the sensitivity and specificity of a worsening in ratings was not sufficient to provide definitive warning of an impending Type 1 event. Other characteristics of the patients with Type 1 events provide additional warning: e.g. overall higher ratings on these scales, slower improvement in suicidality during treatment, and previous number of suicide attempts. These results indicate that the ISST and CDS may provide some additional information that can assist clinical decision making regarding suicidal risk in patients with schizophrenia or schizoaffective disorder.

Subjective experience and suicidal ideation in schizophrenia

Suicidal ideation and behavior are a frequent complication of schizophrenia. Although a number of risk factors have been identified, specific features of suicidality in schizophrenia remain poorly understood. In this study, 19 patients with schizophrenia were interviewed in depth on their suicidal ideation and intentions, followed by a qualitative phenomenological analysis of the material. Solitude with inability to participate in human interactions and feelings of inferiority were found to be the main sources of suicidal ideation. These experiences seem to resemble ordinary depressive reactions, yet we found them to be reflective of a more basic self-alienation and incapacity for immersion in the shared world. Ignoring this experiential level of patients' disturbances may lead to trivialization (and misjudgment) of the experiences at the root of suicidality in schizophrenia.

Long-term suicide risk in schizophrenia spectrum psychoses: survival analysis by gender

Patients with schizophrenia spectrum psychoses have a high risk of suicide. Suicide is more frequent in men. Our objective in this study was to investigate the long term suicide risk in schizophrenia spectrum psychoses in relation to gender. A cohort from 1973 to 1987 of 385 schizophrenia spectrum psychoses inpatients in Stockholm were followed up for cause of death in 2006. Twenty-six suicides (6.8%) occurred during the follow up of 24.4 years. There was no significant difference in suicide mortality between men (6.5%) and women (6.9%). There was no gender difference in death from other causes. These results indicate that patients with schizophrenia spectrum psychoses have a high long term suicide risk in both men and women. The high suicide risk in female patients deserves further research attention.

Comorbidity with axis I anxiety disorders in remitted psychotic patients 1 year after hospitalization

INTRODUCTION

Comorbid anxiety disorders are frequently encountered in psychoses and mainly assessed during the hospitalization.

METHODS

Comorbidity was investigated in 98 patients with schizophrenia, schizoaffective, or bipolar disorder, previously hospitalized for psychotic symptoms. Assessments, including Structured Clinical Interview for the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Brief Psychiatric Rating Scale, and Clinical Global Impressions Scale, were performed during hospitalization (t0) and subsequently in a phase of remission (t1). Comorbidity was assessed at t1 only.

RESULTS

One or more comorbid anxiety diagnoses were made in 46 (46.9%) patients. Of these, 15 (32.6%) received multiple anxiety diagnoses, while 31 (67.4%) single anxiety diagnoses. Schizophrenic patients had a rate of social anxiety disorder (SAD) higher (P<.05) than the others. Patients assessed with panic disorder or with obsessive-compulsive disorder at t1 showed significantly greater severity of illness at t0; patients with SAD demonstrated greater severity at t1. No significant differences in the rates of individual anxiety disorders were found in patients treated with typical or atypical antipsychotics or with both.

CONCLUSION

Anxiety disorders, particularly obsessive-compulsive disorder, panic disorder and SAD, seem to be frequently comorbid in remitted psychotic patients; SAD would be more prevalent in schizophrenia and might negatively impact the course of the illness.

Schizophrenia: measurements of psychopathology

A key problem in schizophrenia research is how to assess the effects of treatment interventions given the spectrum of schizophrenia symptoms and patients' functioning. Measuring symptoms is complex, because these symptoms cover a wide variety of psychopathologic domains. The commonly recognized domains are the positive, negative, cognitive, excitement, and depression domains. This article critically reviews some of the available assessment tools of these domains together with other associated syndromes. The instruments discussed cover the broad range of psychopathology found in patients who have schizophrenia.

Avoidant personality disorder is a separable schizophrenia-spectrum personality disorder even when controlling for the presence of paranoid and schizotypal personality disorders The UCLA family study

It is unresolved whether avoidant personality disorder (APD) is an independent schizophrenia (Sz)-spectrum personality disorder (PD). Some studies find APD and social anxiety symptoms (Sxs) to be separable dimensions of psychopathology in relatives (Rels) of schizophrenics while other studies find avoidant Sxs to be correlated with schizotypal and paranoid Sxs. Rates of APD among first-degree Rels of Sz probands, attention-deficit/hyperactivity disorder (ADHD) probands, and community control (CC) probands were examined. Further analyses examined rates when controlling for the presence of schizotypal (SPD) and paranoid (PPD) personality disorders, differences in APD Sxs between relative groups, and whether APD in Rels of Szs reflects a near miss for another Sz-spectrum PD. Three hundred sixty-two first-degree Rels of Sz probands, 201 relatives of ADHD probands, and 245 Rels of CC probands were interviewed for the presence of DSM-III-R Axis I and II disorders. Diagnoses, integrating family history, interview information, and medical records, were determined. APD occurred more frequently in Rels of Sz probands compared to CC probands (p<0.001) and also when controlling for SPD and PPD (p<0.005). Two Sxs of APD were most characteristic of the Rels of Sz probands: "avoids social or occupational activities..." and "exaggerates the potential difficulties..." 65% of the Rels of Sz probands who had diagnoses of APD were more than one criterion short of a DSM-III-R diagnosis of either SPD or PPD. This indicates that APD is a separate Sz-spectrum disorder, and not merely a sub-clinical form of SPD or PPD.

Suicidal behavior in schizophrenia

There is a high prevalence of suicidal behavior in individuals suffering from schizophrenia and recent investigations substantially elucidate this problem and provide useful insights about clinical risk factors, neurobiologic underpinnings and the impact of various treatments on reducing such behavior. The risk of suicide is greatest early in the course of schizophrenic illness but continues throughout life; risk factors for suicidal behavior include psychosis, depression and substance abuse. Effectively treating positive symptoms and depression, reducing substance abuse, avoiding akathisia, addressing demoralization and instilling hope are important elements in this treatment approach. The newer generation of atypical antipsychotics (particularly clozapine) and new psychologic approaches (particularly cognitive behavioral therapy) appear to be useful in reducing suicidality in schizophrenia. The significant advances in defining the neurobiologic basis of suicidality may enable the development of more effective treatments. The renewed emphasis on resilience and recovery as desired outcomes in schizophrenia and the accompanying sense of hope encourage optimism about effectively reducing suicidality in schizophrenia. Over the past 10 years, much has been learnt and hopefully this momentum will be translated into increasingly better outcomes.

Rating suicidality in schizophrenia: items on global scales (HoNOS and CPRS) correlate with a validated suicidality rating scale (InterSePT)

The use of general scales such as the Health of the Nation Outcome Scale (HoNOS) and the Comprehensive Psychopathological Rating Scale (CPRS) are widespread. Both scales contain non-validated items on suicidality. This study aimed to establish whether an association between these suicidality items and the validated scale, InterSePT exists. Forty patients with a diagnosis of schizophrenia or schizo-affective disorder were assessed using the three scales. A highly significant association between the two items and the validated scale was found. The suicidality items from HoNOS and CPRS appear to be strong indicators of suicidality in this patient population. The findings allow for use of the suicidality items in clinical assessments and re-investigation of suicidality of other studies where these general rating scales have been used.

Schizophrenia and suicide: systematic review of risk factors

BACKGROUND

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

AIMS

To identify risk factors for suicide in schizophrenia.

METHOD

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

RESULTS

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

CONCLUSIONS

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

A Systematic Review of Suicide Rating Scales in Schizophrenia

Abstract. In spite of a substantial number of suicides in patients with schizophrenia, this area of research has until very recently been the Cinderella of schizophrenia research. Both clinical and research practices have been hampered by a lack of assessment tolls specifically designed to measure suicidality in patients with schizophrenia. This has partly been because of uncertainty about what constitutes reliable risk factors for suicide in schizophrenia. A literature search following evidence-based guidelines was carried out. A number of relevant articles were found, which were then critically reviewed. The majority of rating scales used for patients with schizophrenia were actually based - at least partly - on patients with other diagnoses than schizophrenia (affective conditions, schizoaffective disorder). This procedure could result in misleading conclusions as a result of the heterogeneity of the different mental illnesses. We conclude that, at present, only one rating scale measuring suicidality specifically designed for patients with schizophrenia (the InterSePT-scale) is based on both sound methodology and has clinical relevance. Suicide in patients with schizophrenia remains a pressing problem in the treatment of this high-risk group.

Suicidality and psychosis: the predictive potential of symptomatology and insight into illness

Recent research indicates that suicidal ideation and intent effect the majority of psychotic patients, a large proportion of whom eventually complete suicide. Some evidence suggests that psychotic symptomatology and awareness of the disorder may increase the suicidal risk in this patient population. This study investigated the predictive potential of insight into illness, years of treatment, recent traumatic stress, and depressive, manic, cognitive, anxiety, and psychotic symptomatology in the genesis of suicidality with psychotic patients. Results showed that increased insight into illness, fewer years of treatment, and more severe depressive symptoms each significantly heightened patients' risk of suicidality. Research and practice implications of these findings are discussed.

The InterSePT scale for suicidal thinking reliability and validity

BACKGROUND

The InterSePT Scale for Suicidal Thinking (ISST) is a 12-item instrument for the assessment of current suicidal ideation in patients with schizophrenia and schizoaffective disorders. We report the psychometric characteristics of this new scale based on two studies.

METHOD

In Study 1, 22 inpatients with schizophrenia and schizoaffective disorders, who had recently attempted suicide or engaged in suicidal ideation, were rated by three trained independent raters to examine interrater reliability. In Study 2, a total of 980 patients with schizophrenia or schizoaffective disorder with a history of suicidal ideation in the past 36 months were enrolled in a 2-year industry-sponsored suicide prevention study. At baseline, these patients were administered the ISST and the Clinical Global Impression Scale for Severity of Suicidality (CGI-SS) by the Principal Investigator (PI) and by a blinded rater (BR), who also administered the Positive and Negative Symptom Scale (PANSS), the Calgary Depression Scale (CDS), and the Scale of Functioning (SOF). Indices of internal reliability, construct and discriminant validity were examined.

RESULTS

The intraclass correlation coefficient (ICC) for the total ISST score for the 22 subjects in Study 1 was 0.90 and mean weighted item kappa coefficients ranged from 0.66 to 0.92. In Study 2, internal reliability (Cronbach alpha) was high, ranging from 0.86 to 0.89 for the individual items, and the overall Cronbach alpha coefficient for all items was 0.88. The ISST (PI) total score was highly correlated with the CGI-SS by the blind rater (r = 0.61, p < 0.0001). ISST total scores significantly differentiated the different levels of CGI-SS (F = 519.2; p < 0.0001). Results of construct and discriminant validity analyses are also presented.

CONCLUSION

The ISST is a reliable and valid instrument for the assessment of current suicidal thinking in patients with schizophrenia and schizoaffective disorder by both clinicians and researchers.