Suicide in schizophrenia. A review of the literature

The role of child sexual abuse in the etiology of suicide and non-suicidal self-injury

OBJECTIVE

To address the best available scientific evidence on the role of child sexual abuse in the etiology of suicide and non-suicidal self-injury.

METHOD

Seven databases were searched, supplemented with hand-search of reference lists from retrieved papers. The author and a psychiatrist independently evaluated the eligibility of all studies identified, abstracted data, and assessed study quality. Disagreements were resolved by consensus.

RESULTS

Four reviews, including about 65,851 subjects from 177 studies, were analyzed. There is evidence that child sexual abuse is a statistically significant, although general and non-specific, risk factor for suicide and non-suicidal self-injury. The relationship ranges from small to medium in magnitude and is moderated by sample source and size. Certain biological and psychosocial variables, such as serotonin hypoactivity and genes, family dysfunction, other forms of maltreatment, and some personality traits and psychiatric disorders, may either act independently or interact with child sexual abuse to promote suicide and non-suicidal self-injury in abuse victims, with child sexual abuse conferring additional risk, either as a 'distal' and indirect cause or as a 'proximal' and direct cause.

CONCLUSION

Child sexual abuse should be considered one of the several risk factors for suicide and non-suicidal self-injury and included in multifactorial etiological models.

Suicide risk in schizophrenia: explanatory models and clinical implications, The Schematic Appraisal Model of Suicide (SAMS)

PURPOSE

The objective of this paper was to evaluate the Cry of Pain model of suicide behaviour as applied to psychosis and to derive theoretically driven guidelines for prevention. Suicide risk in psychotic patients is a serious but poorly understood clinical and social problem. There is a dearth of psychological models to explain suicidal behaviour and to guide effective preventative clinical interventions. Understanding suicidal behaviour in psychosis may be facilitated by utilizing models from depression. The 'Cry of Pain' model of suicide is founded on an evolutionary approach to understanding suicidal behaviour in depression.

METHODS

The model was critically evaluated and relevant literature reviewed.

RESULTS

Although strengths of the model were identified, lack of clarity regarding the concepts of defeat, entrapment, and lack of rescue appeared to limit its theoretical and clinical utility. We suggest a modification to this model which replaces concepts of defeat, entrapment, and lack of rescue with a four-stage appraisal process in conjunction with information-processing biases and suicidal schema.

CONCLUSIONS

Methods of testing this model are suggested and guidelines for a clinical intervention (Cognitive Behavioural Suicide Prevention for Psychosis; CBSPp) are outlined.

Correlates of self-harm behaviour in acutely ill patients with schizophrenia

OBJECTIVE

This study compared acutely ill patients with schizophrenia with a history of self-harm (N=17) to those without a history of self-harm (N=16) on measures of depression, hopelessness, suicidal ideation, and demographic and psychiatric variables. A subgroup of these patients who experience auditory hallucinations, with and without a history of self-harm, were selected and compared on measures of depression, hopelessness, suicidal ideation and beliefs about voices.

DESIGN

Employing a cross-sectional design, in-patients of two local psychiatric hospital, who met DSM-IV-TR criteria for schizophrenia and who were in an acute phase of the illness, were selected.

METHOD

Each patient was assessed using the Beck Depressions Inventory (BDI), Beck Hopelessness Scale (BHS) and the Beck Suicide Scale (BSS). Patients who experienced auditory verbal hallucinations completed the Beliefs About Voices Questionnaire Revised (BAVQ-R). Patients with a history of self-harm completed the Beck Suicide Intent Scale (BSI).

RESULTS

Patients with a history of self-harm (N=17) had significantly greater symptoms of depression, greater suicidal thoughts, increased number of hospital admissions, greater duration of illness and were more likely to be married, compared to patients without a history of self-harm (N=16). Among the subgroup of patients who experience auditory hallucinations, those with a history of self-harm (N=9), believed their voice to be more malevolent, had a tendency to resist their voice and experienced significantly greater symptoms of depression and hopelessness compared to those without a history of self-harm (N=6).

CONCLUSIONS

These findings highlight the importance for screening by clinicians during inpatient hospital stays and for monitoring to be ongoing following discharge. For the subgroup of patients who experience auditory hallucinations, future research should seek to explore the relationship between self-harm and beliefs about voices.

Are there subtypes of suicidal schizophrenia? A prospective study

BACKGROUND

Tragically, suicide is not uncommon in schizophrenia. The principal objective of this study was to examine possible subtypes of suicidal schizophrenic patients and identify their clinical and psychopathological profiles at long-term follow-up.

METHOD

The study involved 62 patients diagnosed with schizophrenia according to ICD-10 criteria, who were consecutively admitted following a suicide attempt. Of these subjects, 47 (75.8%) could be re-evaluated after 1 year. Sociodemographic, general clinical, and psychopathological variables were evaluated.

RESULTS

Two predominant subgroups were identified according to suicidal motivation: psychotic motivation and depressive motivation. At re-evaluation after 1 year, the depressive motivation subgroup showed higher depression and hopelessness scores. This subgroup also had greater educational level, age, and duration of illness, and more frequent existence of previous suicide attempts compared to the psychotic motivation subgroup. Of note in the psychotic motivation subgroup was the presence of hopelessness. The variables of educational level, duration of illness, and previous suicide attempts were the ones that best distinguished these subgroups.

CONCLUSION

These findings reinforce the notion that meaningful subgroups occur among suicidal schizophrenic patients. The different psychopathological profiles of the two prominent subgroups suggest the need for a different management approach in each case. The identification of these profiles in both subtypes at long-term follow-up may facilitate their detection by clinicians and, therefore, foster the adoption of appropriate preventive measures against subsequent suicidal behavior.

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

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

Schizophrenia and deliberate self-harm: a systematic review of risk factors

Deliberate self-harm (DSH) is a strong predictor of suicide in schizophrenia. The aim of this review was to identify risk factors for DSH in schizophrenia. This systematic review of the international literature examined cohort and case-control studies of patients with schizophrenia or related diagnoses that reported DSH as an outcome. Studies were identified by searching electronic databases and reference lists, and by consulting international experts. Fourteen studies met the eligibility criteria. Of the 29 variables examined by two or more studies, five (past or recent suicidal ideation, previous DSH, past depressive episode, drug abuse or dependence, and higher mean number of psychiatric admissions) were associated with an increased risk of DSH, and one (unemployment) was associated with a reduced risk. Schizophrenic patients with these risk factors need careful follow-up and monitoring, with treatment of any associated comorbid depression or drug abuse. Large, prospective studies of DSH in schizophrenia are needed to further define risk factors and to build on the findings of this review.