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

Clozapine may consistently protect from suicidal behaviors while other antipsychotics may lack a specific protective effect: a comprehensive VigiBase study interpreted in the context of the prior literature

BACKGROUND

In the United States, clozapine was first approved for treatment-resistant schizophrenia and then for suicidality in schizophrenia psychoses. Systematic reviews support clozapine's anti-suicidal effect, but the forensic literature stresses its lethality during overdoses.

RESEARCH DESIGN AND METHODS

Clozapine reports to the international pharmacovigilance database (VigiBase) were analyzed for suicidal ideation, suicide attempts, intentional overdose, and completed suicides from introduction to 1 January 2024. VigiBase uses the information component (IC) as a disproportionality analysis.

RESULTS

The clozapine ICs (range: other antipsychotics) were: 1) suicidal ideation IC = 0.570 with IC025 = 0.454 to IC975 = 0.680 (IC = 3.568 for aripiprazole and 1.729 for risperidone), 2) suicide attempt IC = 1.428 with IC025 = 1.323 to IC975 = 1.529 (IC = 4.150 for quetiapine and 2.968 for risperidone), 3) intentional overdose: IC = 0.995 with IC025 = 0.864 to IC975 = 1.120 (IC = 4.080 for quetiapine and 1.957 for aripiprazole), and 4) completed suicide IC = 1.133 with IC025 = 1.026 to IC975 = 1.235 (IC = 4.648 for quetiapine and 2.160 for risperidone). In summary, all clozapine ICs were significantly lower. We found 2391 clozapine-treated patients on the suicidality spectrum (627 cases with suicidal ideation, 752 with suicide attempt, 488 with intentional overdose, and 731 with completed suicide) but many were taking other antipsychotics. The most frequent reporting countries were the United States, the United Kingdom, and Croatia.

CONCLUSION

This pharmacovigilance study, with all its inherent limitations, provides independent proof, not overlapping with prior literature, that clozapine may have specific strong anti-suicidal effects that do not appear to be present in other antipsychotics. Further VigiBase studies are needed to compare the lethality of an intentional overdose of clozapine (14.3%) with other antipsychotics.

Gender differences in clinical and biochemical parameters among patients hospitalized for schizophrenia: towards precision medicine

BACKGROUND

The scientific literature shows some gender differences in the clinical course of schizophrenia. The aim of this study is to identify gender differences in clinical and biochemical parameters in subjects affected by schizophrenia. This would allow for the implementation of individualized treatment strategies.

METHODS

We examined a large set of clinical and biochemical parameters. Data were obtained from clinical charts and blood analyses from a sample of 555 schizophrenia patients consecutively admitted for exacerbation of symptoms to the inpatient clinic of Fondazione IRCCS Policlinico (Milan) or ASST Monza in Italy from 2008 to 2021. Univariate analyses, binary logistic regression, and a final logistic regression model were performed with gender as dependent variable.

RESULTS

The final logistic regression models showed that male patients (compared to females) were more prone to lifetime substance use disorders (p = 0.010). However, they also had higher GAF (global functioning) mean scores (p < 0.001) at the time of hospitalization. Univariate analyses showed that male patients (with respect to females) had an earlier age at onset (p < 0.001), a more frequent family history of multiple psychiatric disorders (p = 0.045), were more often smokers (p < 0.001), had a more frequent comorbidity with at least one psychiatric disorder (p = 0.001), and less often suffered from hypothyroidism (p = 0.011). In addition, men had higher levels of albumin (p < 0.001) and bilirubin (t = 2.139, p = 0.033), but lower levels of total cholesterol (t = 3.755, p < 0.001).

CONCLUSIONS

Our analyses indicate a less severe clinical profile in female patients. This is evident especially in the early years of the disorder, as suggested by less comorbidity with psychiatric disorders or later age at onset; this is consistent with the related literature. In contrast, female patients seem to be more vulnerable to metabolic alterations as demonstrated by more frequent hypercholesterolemia and thyroid dysfunction. Further studies are needed to confirm these results in the framework of precision medicine.

My Reasons for Living: A Descriptive Study of the Motives for Not Committing Suicide Among Patients Diagnosed With Schizophrenia

Background and objective Reasons for Living (RFL) constitute a construct that enables identifying the reasons for not committing suicide. These reasons are based on significant aspects of life, on the commitment to some ideals which may inhibit the impulse of committing suicide. The present study aimed to explore the RFL in a sample of patients with chronic schizophrenia; analyze the association of RFL with the duration of illness, previous suicide attempts, hospitalizations, and schooling; and describe the potential differences between male and female patients in this context. Materials and methods A total of 94 patients with schizophrenia were assessed. The Reasons for Living Inventory (RFLI) was applied and a structured interview for clinical and sociodemographic data was performed to gather data. Frequencies and descriptive statistics were calculated, and Spearman's correlation analysis was employed. Results The mean score among the sample was 3.9, with 3.8 as the cut-off point under which the presence of suicide risk is significant. The RFLs indicated as most important by patients were those in the domains of Survival and Coping Beliefs and Responsibility to Family. Non-significant differences were observed between groups. An association was observed in terms of age, duration of illness, number of hospitalizations, and RFLI scores. Conclusions The sample in the present study obtained high scores in the RFL domain of Survival and Coping Beliefs and low scores in the domain of Fear of Suicide, reflecting a specific response pattern that contrasts with other high suicidal-risk populations. We suggest that this construct could represent a protective factor for schizophrenia patients, including chronic patients with previous suicide attempts and high hospitalization rates, which were common variables observed in our clinical sample.

Clinical decision-making before discharge in hospitalized persons with schizophrenia: a Spanish Delphi expert consensus

Introduction

The care of people with schizophrenia (PWS) is usually provided in an outpatient setting by community mental health teams. However, PWS frequently require inpatient treatment because of a wide array of clinical, personal and/or social situations. Unfortunately, to our knowledge, there are no guidelines available to help psychiatrists in the decision-making process on hospital discharge for PWS. The aim of this project was to develop an expert consensus on discharge criteria for PWS after their stay in an acute inpatient psychiatric unit.

Methods

Using a modified Delphi method a group of 42 psychiatrists throughout Spain evaluated four areas of interest regarding this issue: clinical symptomatology, treatment-related factors, follow-up health care units after discharge, and physical health and monitoring.

Results

After two rounds, among the 64 statements, a consensus was reached for 59 (92.2%) statements. In three (17.7%) of the 17 statements on 'clinical symptomatology' and 2 (13.3%) of the 15 statements on 'follow-up health care units after discharge', a consensus was not reached; in contrast, a consensus was reached for all statements concerning 'treatment-related factors' and those concerning 'physical health and monitoring'. The consensus results highlight the importance for discharge of the control of symptoms rather than their suppression during admission and of tolerability in the selection of anantipsychotic.

Discussion

Although there is a lack of relevant data for guiding the discharge of PWS after hospitalization in an acute inpatient psychiatric unit, we expect that this consensus based on expert opinion may help clinicians to take appropriate decisions.

Incidence and Risk Profiles for Suicide Mortality in Patients With Schizophrenia Receiving Homecare Case Management in Taiwan

Case management (CM)-based community therapy for patients with schizophrenia had little effect on reducing suicide mortality. We investigate the long-term suicide mortality outcome and associated risk factors in patients with schizophrenia receiving homecare (CM) in Taiwan. We enrolled a nationwide cohort of patients with schizophrenia who newly received homecare CM intervention (n = 13 317) between January 1, 2001, and December 31, 2015; their data were derived from Taiwan's National Health Insurance Research Database. We calculated the incidence rate of suicide methods. We examined the demographic and medical utilization profile for suicide and then performed a nested case-control study and multivariate regression to identify independent risk factors for suicide mortality. Among the 13 317 patients who received homecare CM intervention, 1766 died during the study period, of whom 213 died by suicide, which is the leading cause of unnatural death. Jumping from a high place, self-poisoning, and hanging were the top 3 suicide methods. Increased medical utilization was noted for both psychiatric and non-psychiatric services within 3 months of suicide mortality. Comorbidities of depressive disorder, nonspecific heart diseases, pneumonia, and gastrointestinal ulcers were identified as independent risk factors for suicide mortality. Suicide was the leading cause of unnatural mortality in patients with schizophrenia receiving homecare CM intervention in Taiwan. We noted the preferred suicide methods, high medical utilization, and comorbidities before suicide. Thus, we suggest that the CM team should assess lethal methods for suicide and ensure that patients adhere to psychiatry treatment for improving the current care model for this specified population.

Effectiveness of Gatekeeper Training for Families of People With Mental Disorders in Korea: A Randomized Controlled Trial

OBJECTIVE

Given the high suicide risk among people with schizophrenia and other mental disorders and the significance of intervention in the daily life setting, tailored gatekeeper training is necessary for families of people with mental disorders. This study evaluated the effectiveness of a suicide prevention education program for families of people with mental disorders (SPEM-F), developed by the Korea Foundation for Suicide Prevention.

METHODS

Fifty-nine family members of people with mental disorders were recruited from eight community psychiatric rehabilitation centers in Korea and enrolled in a cluster randomized controlled trial. Four facilities were randomized to the experimental group (n=30) and four to the control group (n=29). The study parameters were measured at baseline, post-intervention, and 1-month follow-up; the effects of SPEM-F (90 minutes, conducted offline) were analyzed using repeated-measures analysis of variance. The dependent variables were suicide-related knowledge, attitude, self-efficacy, preventive behavioral intention, and family problem-solving communication.

RESULTS

The experimental group showed significant increases in suicide-related knowledge (p<0.001), self-efficacy (p<0.05), and preventive behavioral intention (p<0.01) compared with the control group until the 1-month follow-up, including an upward trend in improved family problem-solving communication (p=0.069).

CONCLUSION

The results confirm that SPEM-F is an effective evidence-based gatekeeper training program for families of people with mental disorders, as it focuses on knowledge, self-efficacy, preventive behavioral intention, and communication improvement. As families of people with mental disorders including schizophrenia, are both highly motivated and close to people at high risk for suicide, SPEM-F can effectively promote suicide prevention and gatekeeper activities.

The relationship between sleep and suicidality in schizophrenia spectrum and other psychotic disorders: A systematic review

Individuals with Schizophrenia Spectrum Disorders (SSDs) have significantly higher rates of suicidal thoughts, attempts, and death by suicide in comparison to the general population. Sleep disturbances (reduced duration, timing and quality of sleep) are risk factors for suicidality in the general population, with research indicating the relationship is both immediate and accumulative. Sleep disturbances are also considered to be implicated in the onset and exacerbation of psychotic symptoms in SSDs. Reducing the risk of suicidality in SSDs remains an important public health priority, thus exploration of contributing risk factors is warranted. Sleep monitoring may also offer an adjunct risk monitoring method to suicidality assessments in SSDs, and a potential treatment target for psychotic symptoms. This review aimed to explore proximal and longitudinal relationships between self-reported and objectively measured sleep and suicidality in SSDs and other psychotic disorders. A comprehensive search of four databases was conducted. Eleven studies met the inclusion criteria (10 cross sectional and 1 longitudinal). Narrative synthesis indicated that self-reported sleep disturbances and sleep disorders (e.g. insomnia) were associated with increased risk of suicidal ideation and attempt. However, one study employing polysomnography did not find sleep to be associated with suicidality. Methodological limitations of the evidence base include: i) little experimental or longitudinal evidence, (ii) self-report and/or single item assessment of sleep disturbance, (iii) limited use of validated measures of suicidality, (iv) considerable research in long-term schizophrenia but sparse evidence in early psychosis. Future research should explore (i) cross-sectional and longitudinal relationships between specific aspects of suicidality and objective sleep parameters, (ii) use qualitative or mixed-methods designs to disentangle the nuances and bidirectionality in the sleep-suicide relationship, (iii) explore the psychological processes underpinning or mediating the sleep-suicide relationship in SSDs.

Are all reasons for living made equally? Reasons for living and dysfunctional attitudes in psychotic disorders and bipolar I

OBJECTIVES

Persons with schizophrenia, schizoaffective, or bipolar I disorder are more likely to die by suicide compared to the general population. Dysfunctional attitudes have been shown to be significant predictors of cognitive vulnerability to depression, hopelessness, and poor problem-solving skills, which predict suicidal ideation. Dysfunctional attitudes are common in persons with schizophrenia spectrum disorders (SSDs) and bipolar I. The Reasons for Living Inventory (RFLI) examines distinct reasons for not dying by suicide. This study's objectives were to examine the relationship between the RFLI subscales and dysfunctional attitudes among persons with SSDs and bipolar I. We hypothesized significant positive correlations between two RFLI subscales (Fear of Suicide and Fear of Social Disapproval) and total score on the Dysfunctional Attitude Scale (DAS). We did not expect significant correlations between other subscales.

DESIGN AND METHODS

This correlational, cross-sectional study examined baseline scores on the RFLI and dysfunctional attitudes (DAS) among N = 102 outpatients with SSDs or bipolar I.

RESULTS

Significant positive correlations were observed between RFLI subscales Fear of Suicide and Fear of Social Disapproval and DAS total scores. No other significant relationships were observed.

CONCLUSIONS

Certain reasons for living (i.e. fear of suicide and social disapproval) may be associated with dysfunctional attitudes among persons with SSDs or bipolar I. These, in turn, may place these individuals at a greater risk for suicide by increasing their cognitive vulnerability. These findings may inform clinical treatment targets for persons with SSDs and bipolar I.

Achieving integrated treatment: a realist synthesis of service models and systems for co-existing serious mental health and substance use conditions

Approximately 30-50% of people with serious mental illness have co-existing drug or alcohol problems (COSMHAD), associated with adverse health and social care outcomes. UK guidelines advocate both co-occurring needs being met within mental health services, but uncertainty remains about how to operationalise this to improve outcomes. Various unevaluated service configurations exist in the UK. A realist synthesis was done to identify, test, and refine programme theories of how context shapes the mechanisms through which UK service models for COSMHAD work, for whom, and in what circumstances. Structured and iterative realist searches of seven databases identified 5099 records. A two-stage screening process identified 132 papers. Three broad contextual factors shaped COSMHAD services across 11 programme theories: committed leadership, clear expectations regarding COSMHAD from mental health and substance use workforces, and clear care-coordination processes. These contextual factors led to increased staff empathy, confidence, legitimisation, and multidisciplinary ethos, which improved care coordination and increased the motivation of people with COSMHAD to work towards their goals. Our synthesis highlights that integrating COSMHAD care is complex, and both individual and cultural behavioural shifts in leadership, workforce, and service delivery are essential to ensure people with COSMHAD receive compassionate, trauma-informed care that meets their needs.

Auditory Hallucinations, Depressive Symptoms, and Current Suicidal Ideation or Behavior Among Patients with Acute-episode Schizophrenia

Suicide risk and auditory hallucinations are common in schizophrenia, but less is known about its associations. This cross-sectional study aimed to determine whether the presence and severity of auditory hallucinations were associated with current suicidal ideation or behavior (CSIB) among patients with schizophrenia. We interviewed 299 individuals with schizophrenia and acute symptoms and reviewed their medical records. Measurement included the Psychotic Symptom Rating Scale (PSYRATS-AH), the Calgary Depression Scale for Schizophrenia (CDSS), and the Positive and Negative Syndrome Scale. Logistic regression and path analysis were used. The CSIB prevalence was higher among patients with current auditory hallucination than those without (19.5% vs. 8.6%, crude odds ratio = 2.58, p = .009). Lifetime auditory hallucination experience (adjusted odds ratio [AOR] = 3.81; 95% CI: 1.45-10.05) or current auditory hallucination experience (AOR = 3.22; 95% CI: 1.25-8.28) can elevate the likelihood of CSIB while controlling for depressive symptoms and lifetime suicide-attempt history. Among those with auditory hallucinations, the emotional score of the PSYRATS-AH was positively associated with the CDSS score and there was a small indirect effect of the CDSS score on the association between the emotional domain score and CSIB (bias-corrected 95% CI, 0.02-0.20). In conclusion, the presence of auditory hallucinations was strongly associated with CSIB, independent of depressive symptoms and lifetime suicide attempts. Suicide risk assessment should consider auditory hallucination experience and patients' appraisal of its emotional characteristics. Future cohort studies are necessary to provide more conclusive evidence for the mediating pathways between auditory hallucinations and CSIB.HIGHLIGHTSThe presence of auditory hallucinations was associated with current suicidality.Auditory hallucinations' emotional severity was related to depressive symptoms.The severity of auditory hallucination was not directly associated with suicidality.

Identification of Risk Factors for Suicide and Insights for Developing Suicide Prevention Technologies: A Systematic Review and Meta-Analysis

Suicide is a termite that engulfs close to seven hundred thousand people worldwide each year. Existing work on risk factors that predict suicide lacks statistical associations, does not consider most countries, and has a wide range of risk factor domains. The goal of this systematic review and meta-analysis is to enhance our current understanding of suicidality by identifying risk factors that are most strongly associated with suicide and their impact on developing technological interventions for suicide prevention. A search strategy was carried out on four databases: (1) PsycINFO, (2) IEEE Xplore, (3) the ACM Digital Library, and (4) PubMed, and twenty-five studies were included based on the inclusion criteria. Factors statistically associated with suicide are any diagnosed mental disorder, adverse life events, past suicide attempts, low education level, loneliness or high levels of isolation, bipolar disorder, depression, multiple chronic health conditions, family history of suicide, sexual trauma, and being female. Domain-wise, comorbid disorders, and behavior-related risk factors are most strongly associated with suicide. We present a new hierarchical model of risk factors for suicide that advances our understanding of suicide and its causes. Finally, we present open research directions and considerations for developing suicide prevention technologies.

Depression trajectories and cytokines in schizophrenia spectrum disorders - A longitudinal observational study

Depression occurs frequently in all phases of schizophrenia spectrum disorders. Altered activity in the immune system is seen in both depression and schizophrenia. We aimed to uncover depressive trajectories in a sample of 144 adult individuals with schizophrenia spectrum disorders followed for one year, in order to identify possible cytokine profile differences. Patients were assessed longitudinally with the Positive and Negative Syndrome Scale (PANSS) and the Calgary Depression Scale for Schizophrenia (CDSS), where a score above 6 predicts depression. The serum cytokine concentrations for tumor necrosis factor (TNF)-alpha, interferon (IFN)-gamma, interleukin (IL)-1beta, IL-2, IL-4, IL-6, IL-10, IL-12p70 and IL-17A were measured using immunoassays. Latent growth curve models, multilevel models and latent class growth analysis (LCGA) were applied. The LCGA model supported three latent classes (trajectories) with differing CDSS profiles during the one-year follow-up: a high CDSS group (40.8 % of participants), a moderate CDSS group (43.9 %) and a low CDSS group (15.3 %). Five single PANSS items predicted affiliation to depressive trajectory: hallucinations, difficulty in abstract thinking, anxiety, guilt feelings and tension. In the high CDSS group, despite diminishing psychotic symptoms, depressive symptoms persisted throughout one year. The pro-inflammatory cytokines IFN-γ, IL-1β and TNF-α were differentially distributed between the depressive trajectories, although levels remained remarkably stable throughout 12 months. Significant changes were found for the anti-inflammatory cytokine IL-10 at baseline with an accompanying difference in change over time. More research is required to optimize future treatment stratification and investigate the contribution of inflammation in depressed patients with schizophrenia spectrum disorders.

Relationship between cognition and suicidal behavior in recent-onset psychosis

Suicidal behavior (SB) is common in first-episode psychosis (FEP), and cognitive impairment has also been described in psychosis. Despite well-established risk factors for SB in psychosis, the role of cognition and insight remains unclear. This study aimed to explore the relationship between history of SB and cognition in recent-onset FEP, distinguishing between neurocognition, social cognition, and metacognition, and including cognitive insight (CI) as a metacognitive variable. The sample consisted of 190 participants with recent-onset FEP recruited from two multicentric studies. Two groups were formed based on presence/absence of a history of SB. Demographic, clinical, and cognitive data were compared by group, including significance level adjustments and size effect calculation. No differences were found regarding demographic, clinical, neurocognitive, social cognition, and metacognitive variables except for CI (18.18 ± 4.87; t = -3.16; p = 0.0020; d = -0.635), which showed a medium effect size. Small to medium effect size were found for attributional style (externalizing bias) (1.15 ± 3.94; t = 2.07; d = 0.482), theory of mind (ToM) (1.73 ± 0.22; t = 2.04; d = -0.403), jumping to conclusions bias (JTC) (23.3 %; X² = 0.94; V = 0.178). In recent-onset psychosis, neurocognitive functioning was not related to the history of SB. As novelty, individuals with previous SB showed higher CI. Also, regarding social cognition and metacognition, individuals with prior SB tended to present extremely low externalizing bias, better ToM, and presence of JTC.

Compliance with the Zero Suicide Initiative by Mental Health Clinicians at a Regional Mental Health Service: Development and Testing of a Clinical Audit Tool

AIM

The aim of this study is to investigate the compliance of mental health clinicians in applying the Zero Suicide (ZS) approach to their clinical practice in a rural and regional health community setting.

METHODS

A retrospective clinical audit of six mental health teams was undertaken at a single site. A clinical audit tool was developed and validated using a six-step approach. The data was extracted and analysed via descriptive and inferential statistics and compared to a specialised mental health team, experienced with the ZS approach.

RESULTS

A total of 334 clinical records were extracted for January, April, August, November 2019 and June 2020. The clinical audit and analysis confirmed that the mental health teams are not consistently using the assessments from their training and are therefore not implementing all of these elements into their practice. This could have implications for the risk formulation and treatment for people at risk of suicide.

CONCLUSIONS

The use of a validated clinical audit tool can be beneficial to establish compliance with the mental health clinicians and to determine any areas requiring further improvement. Further education and reinforcement may be required to ensure consistency with incorporating the elements of ZS into everyday clinical practice.

Mortality in Schizophrenia-Spectrum Disorders: Recent Advances in Understanding and Management

Schizophrenia is a life-shortening disease and life expectancy in patients may be 15-20 years shorter than in the general population, with increasing longevity gap over time. Premature mortality in schizophrenia-spectrum disorders is mainly due to preventable natural causes, such as cardio-vascular disease, infections, respiratory tract diseases and cancer, alongside suicide, homicide and accidents. There is a complex interplay of factors that act synergistically and cause physical morbidity to patients and subsequent mortality. Smoking, alcohol/substance abuse and sedentary life style, alongside disease-related factors, such as metabolic abnormalities and accelerating aging contribute to physical morbidity. Moreover, the symptomatology of psychosis and stigma may limit patients' access to quality medical care. Interventions to promote physical health in those patients should be multifaceted, and should target all patient-related modifiable factors, but also should address service-related healthcare disparities. Long-term antipsychotic use (including clozapine and long-acting injectables) is associated with substantially decreased all-cause mortality, including suicide and cardiovascular mortality, in patients with schizophrenia despite the well-known cardiometabolic adverse effects of second-generation agents. Integrated care may involve co-location of physical and mental health services, liaison services, shared protocols and information sharing systems, and has emerged as a way to address the physical health needs of those patients. Interventions to address mortality in schizophrenia and related syndromes should take place as early as possible in the course of the patients' treatment, and could be an integral component of care delivered by specialized early intervention services.

Antipsychotic dose reduction compared to dose continuation for people with schizophrenia

BACKGROUND

Antipsychotic drugs are the mainstay treatment for schizophrenia, yet they are associated with diverse and potentially dose-related side effects which can reduce quality of life. For this reason, the lowest possible doses of antipsychotics are generally recommended, but higher doses are often used in clinical practice. It is still unclear if and how antipsychotic doses could be reduced safely in order to minimise the adverse-effect burden without increasing the risk of relapse.

OBJECTIVES

To assess the efficacy and safety of reducing antipsychotic dose compared to continuing the current dose for people with schizophrenia.

SEARCH METHODS

We conducted a systematic search on 10 February 2021 at the Cochrane Schizophrenia Group's Study-Based Register of Trials, which is based on CENTRAL, MEDLINE, Embase, CINAHL, PsycINFO, PubMed, ClinicalTrials.gov, ISRCTN, and WHO ICTRP. We also inspected the reference lists of included studies and previous reviews.

SELECTION CRITERIA

We included randomised controlled trials (RCTs) comparing any dose reduction against continuation in people with schizophrenia or related disorders who were stabilised on their current antipsychotic treatment.  DATA COLLECTION AND ANALYSIS: At least two review authors independently screened relevant records for inclusion, extracted data from eligible studies, and assessed the risk of bias using RoB 2. We contacted study authors for missing data and additional information. Our primary outcomes were clinically important change in quality of life,  rehospitalisations and dropouts due to adverse effects; key secondary outcomes were clinically important change in functioning, relapse, dropouts for any reason, and at least one adverse effect. We also examined scales measuring symptoms, quality of life, and functioning as well as a comprehensive list of specific adverse effects. We pooled outcomes at the endpoint preferably closest to one year. We evaluated the certainty of the evidence using the GRADE approach.

MAIN RESULTS

We included 25 RCTs, of which 22 studies provided data with 2635 participants (average age 38.4 years old). The median study sample size was 60 participants (ranging from 18 to 466 participants) and length was 37 weeks (ranging from 12 weeks to 2 years). There were variations in the dose reduction strategies in terms of speed of reduction (i.e. gradual in about half of the studies (within 2 to 16 weeks) and abrupt in the other half), and in terms of degree of reduction (i.e. median planned reduction of 66% of the dose up to complete withdrawal in three studies). We assessed risk of bias across outcomes predominantly as some concerns or high risk.  No study reported data on the number of participants with a clinically important change in quality of life or functioning, and only eight studies reported continuous data on scales measuring quality of life or functioning. There was no difference between dose reduction and continuation on scales measuring quality of life (standardised mean difference (SMD) -0.01, 95% confidence interval (CI) -0.17 to 0.15, 6 RCTs, n = 719, I2 = 0%, moderate certainty evidence) and scales measuring functioning (SMD 0.03, 95% CI -0.10 to 0.17, 6 RCTs, n = 966, I2 = 0%, high certainty evidence). Dose reduction in comparison to continuation may increase the risk of rehospitalisation based on data from eight studies with estimable effect sizes; however, the 95% CI does not exclude the possibility of no difference (risk ratio (RR) 1.53, 95% CI 0.84 to 2.81, 8 RCTs, n = 1413, I2 = 59% (moderate heterogeneity), very low certainty evidence). Similarly, dose reduction increased the risk of relapse based on data from 20 studies (RR 2.16, 95% CI 1.52 to 3.06, 20 RCTs, n = 2481, I2 = 70% (substantial heterogeneity), low certainty evidence).   More participants in the dose reduction group in comparison to the continuation group left the study early due to adverse effects (RR 2.20, 95% CI 1.39 to 3.49, 6 RCTs with estimable effect sizes, n = 1079, I2 = 0%, moderate certainty evidence) and for any reason (RR 1.38, 95% CI 1.05 to 1.81, 12 RCTs, n = 1551, I2 = 48% (moderate heterogeneity), moderate certainty evidence). Lastly, there was no difference between the dose reduction and continuation groups in the number of participants with at least one adverse effect based on data from four studies with estimable effect sizes (RR 1.03, 95% CI 0.94 to 1.12, 5 RCTs, n = 998 (4 RCTs, n = 980 with estimable effect sizes), I2 = 0%, moderate certainty evidence).  AUTHORS' CONCLUSIONS: This review synthesised the latest evidence on the reduction of antipsychotic doses for stable individuals with schizophrenia. There was no difference between dose reduction and continuation groups in quality of life, functioning, and number of participants with at least one adverse effect. However, there was a higher risk for relapse and dropouts, and potentially for rehospitalisations, with dose reduction. Of note, the majority of the trials focused on relapse prevention rather potential beneficial outcomes on quality of life, functioning, and adverse effects, and in some studies there was rapid and substantial reduction of doses. Further well-designed RCTs are therefore needed to provide more definitive answers.

Antipsychotic polypharmacy reduction versus polypharmacy continuation for people with schizophrenia

BACKGROUND

In clinical practice, different antipsychotics can be combined in the treatment of people with schizophrenia (polypharmacy). This strategy can aim at increasing efficacy, but might also increase the adverse effects due to drug-drug interactions. Reducing polypharmacy by withdrawing one or more antipsychotics may reduce this problem, but must be done carefully, in order to maintain efficacy.

OBJECTIVES

To examine the effects and safety of reducing antipsychotic polypharmacy compared to maintaining people with schizophrenia on the same number of antipsychotics.

SEARCH METHODS

On 10 February 2021, we searched the Cochrane Schizophrenia Group's Study-Based Register of Trials, which is based on CENTRAL, CINAHL, ClinicalTrials.Gov, Embase, ISRCTN, MEDLINE, PsycINFO, PubMed and WHO ICTRP.

SELECTION CRITERIA

We included randomised controlled trials (RCTs) that compared reduction in the number of antipsychotics to continuation of the current number of antipsychotics. We included adults with schizophrenia or related disorders who were receiving more than one antipsychotic and were stabilised on their current treatment.

DATA COLLECTION AND ANALYSIS

Two review authors independently screened all the identified references for inclusion, and all the full papers. We contacted study authors if we needed any further information. Two review authors independently extracted the data, assessed the risk of bias using RoB 2 and the certainty of the evidence using the GRADE approach. The primary outcomes were: quality of life assessed as number of participants with clinically important change in quality of life; service use assessed as number of participants readmitted to hospital and adverse effects assessed with number of participants leaving the study early due to adverse effects.

MAIN RESULTS

We included five RCTs with 319 participants. Study duration ranged from three months to one year. All studies compared polypharmacy continuation with two antipsychotics to polypharmacy reduction to one antipsychotic.  We assessed the risk of bias of results as being of some concern or at high risk of bias. A lower number of participants left the study early due to any reason in the polypharmacy continuation group (risk ratio (RR) 0.44, 95% confidence interval (CI) 0.29 to 0.68; I2 = 0%; 5 RCTs, n = 319; low-certainty evidence), and a lower number of participants left the study early due to inefficacy (RR 0.21, 95% CI 0.07 to 0.65; I2 = 0%; 3 RCTs, n = 201).  Polypharmacy continuation resulted in more severe negative symptoms (MD 3.30, 95% CI 1.51 to 5.09; 1 RCT, n = 35). There was no clear difference between polypharmacy reduction and polypharmacy continuation on readmission to hospital, leaving the study early due to adverse effects, functioning, global state, general mental state and positive symptoms, number of participants with at least one adverse effect, weight gain and other specific adverse effects, mortality and cognition. We assessed the certainty of the evidence as very low or low across measured outcomes. No studies reported quality of life, days in hospital, relapse, depressive symptoms, behaviour and satisfaction with care. Due to lack of data, it was not possible to perform some planned sensitivity analyses, including one controlling for increasing the dose of the remaining antipsychotic. As a result, we do not know if the observed results might be influenced by adjustment of dose of remaining antipsychotic compound.

AUTHORS' CONCLUSIONS

This review summarises the latest evidence on polypharmacy continuation compared with polypharmacy reduction. Our results show that polypharmacy continuation might be associated with a lower number of participants leaving the study early, especially due to  inefficacy. However, the evidence is of low and very low certainty and the data analyses based on few study only, so that it is not possible to draw strong conclusions based on the results of the present review. Further high-quality RCTs are needed to investigate this important topic.

Expert consensus recommendations on the use of randomized clinical trials for drug approval in psychiatry- comparing trial designs

The use of randomized clinical trials, in particular placebo-controlled trials, for drug approval, is the subject of long-standing debate in the scientific community and beyond. This study offers consensus recommendations from clinical and academic experts to guide the selection of clinical trial design in psychiatry. Forty-one highly cited clinical psychiatrists and/or researchers participated in a Delphi survey. Consensus statements were developed based on the findings of a published, peer-reviewed systematic review. Participants evaluated statements in two survey rounds, following the Delphi method. The expert panel achieved consensus on 7 of 21 recommendations regarding the use of randomized clinical trials. The endorsed recommendations were: (i) Results from placebo-controlled trials are the most reliable and (ii) are necessary despite the growing placebo-effect; (iii) it is ethical to enroll patients in placebo-arms when established treatment is available, if there is no evidence of increased health risk; (iv) There is a need to approve new drugs with the same efficacy as existing treatments, but with different side-effect profiles; (v) Non-inferiority trials incur an increased risk of approving ineffective medications; (vi) The risk of approving an ineffective drug justifies trial designs that incur higher costs, and (vii) superiority trials incur the risk of rejecting potentially efficacious treatments. The endorsed recommendations inform the choice of trial-design appropriate for approval of psychopharmacological drugs. The recommendations strongly support the use of randomized clinical trials in general, and the use of placebo-controlled trials in particular.

Development of a Checklist for Predicting Suicidality Based on Risk and Protective Factors: The Gwangju Checklist for Evaluation of Suicidality

OBJECTIVE

The aim of the study was to develop a checklist for mental health clinicians to predict and manage suicidality.

METHODS

A literature review of the risk and protective factors for suicide was conducted to develop a checklist for evaluating suicidality.

RESULTS

The fixed risk factors included sex (male), age (older individuals), history of childhood adversity, and a family history of suicide. Changeable risk factors included marital status (single), economic status (poverty), physical illness, history of psychiatric hospitalization, and history of suicide attempts. Recent discharge from a mental hospital and a recent history of suicide attempts were also included. Manageable risk factors included depression (history and current), alcohol problems (frequent drinking and alcohol abuse), hopelessness, agitation, impulsivity, impaired reality testing, and command hallucinations. Protective factors included responsibility to family, social support, moral objections to suicide, religiosity, motivation to get treatment, ability to cope with stress, and a healthy lifestyle. A final score was assigned based on the sum of the risk and protective factor scores.

CONCLUSION

We believe that the development of this checklist will help mental health clinicians to better assess those at risk for suicidal behavior. Further studies are necessary to validate the checklist.

Psychological Resilience to Suicidal Experiences in People with Non-Affective Psychosis: A Position Paper

It is important to understand the psychological factors which underpin pathways to suicidal experiences. It is equally as important to understand how people develop and maintain resilience to such psychological factors implicated in suicidal experiences. Exploring optimal routes to gaining this understanding of resilience to suicidal thoughts and acts in people with severe mental health problems, specifically non-affective psychosis, was the overarching aim of this position paper. There are five central suggestions: 1. investigating resilience to suicidal experiences has been somewhat over-looked, especially in those with severe mental health problems such as schizophrenia; 2. it appears maximally enlightening to use convergent qualitative, quantitative and mixed research methods to develop a comprehensive understanding of resilience to suicide; 3. relatedly, involving experts-by-experience (consumers) in suicide research in general is vital, and this includes research endeavours with a focus on resilience to suicide; 4. evidence-based models of resilience which hold the most promise appear to be buffering, recovery and maintenance approaches; and 5. there is vast potential for contemporary psychological therapies to develop and scaffold work with clients centred on building and maintaining resilience to suicidal thoughts and acts based on different methodological and analytical approaches which involve both talking and non-talking approaches.

Prevalence and correlates of suicide attempts in high-risk populations: a cross-sectional study among patients receiving opioid agonist therapy in Norway

BACKGROUND

Death by suicide in patients enrolled in opioid agonist therapy (OAT) is a major clinical concern. However, little knowledge exists regarding suicide attempts in this patient group. This study presents the lifetime prevalence of suicide attempts and the associations between suicide attempts and clinical and sociodemographic variables such as education, sex, early onset of substance use (< 13 years of age), substance use patterns, and injecting substance use among patients receiving OAT.

METHODS

We used data from a cohort of OAT patients in Norway obtained from a health assessment of self-reported suicide attempts and sociodemographic and clinical factors. A total of 595 patients receiving OAT were assessed from 2016 to 2020. A binary logistic regression analysis was performed and reported with an unadjusted odds ratio and 95% confidence intervals (OR). The purpose of this assessment was to analyze associations between suicide attempts and substance use patterns as well as the injection of substances during the 30 days leading up to the health assessment. A negative binomial regression analysis with an incidence rate ratio and 95% confidence intervals (IRR) was performed to investigate sex, education, early onset of substance use, and the number of suicide attempts.

RESULTS

Forty-one percent of the OAT patients had attempted to die by suicide at least once during their lifetime. An early onset of substance use was strongly associated with the suicide attempts (IRR: 1.7, 1.3-2.2). No significant association was found between suicide attempts and sex (IRR: 1.2, 0.9-1.6) or education (IRR: 0.6, 0.2-2.1). Likewise, no association was identified between suicide attempts and injecting substance use (OR: 0.9, 0.6-1.3), nor using alcohol (OR: 0.9, 0.7-1.3), amphetamines (OR: 1.0, 0.7-1.3), benzodiazepines (OR: 1.0, 0.7-1.4), cannabis (OR: 1.2, 0.9-1.7), cocaine (OR: 1.3, 0.6-3.0), or opioids (OR: 1.4, 0.9-2.0).

CONCLUSION

The lifetime prevalence of suicide attempts was alarmingly high in the OAT population. An early onset of substance use seemed to be an important risk factor for suicide attempts. There was a non-significant association to more current use of opioids among OAT patients with previous suicide attempts.

Self-Harm and Suicide Attempts Preceding and Following Electroconvulsive Therapy: A Population-Based Study

OBJECTIVE

The beneficial effect of electroconvulsive therapy (ECT) on suicidality has been documented in clinical trials, whereas naturalistic studies on the topic are scarce and restricted to individuals with mood disorders. Here, based on population-based data from Danish registers, we aimed to investigate the course of self-harm and suicide attempts preceding and following ECT across 4 major mental disorders. This was done to examine whether data from the real-world clinical setting are compatible with the positive results from clinical trials.

METHODS

We identified all patients diagnosed with unipolar depression (n = 8843), bipolar disorder (n = 2713), psychotic disorder (n = 2692), or personality disorder (n = 2085) who received ECT for the first time in the period from 2008 to 2019, as well as age-, sex-, diagnosis-, illness duration-, and admission-matched comparison groups not receiving ECT. A mirror-image model was used to examine whether the number of incidents of self-harm/suicide attempts changed following ECT (paired t test).

RESULTS

There were substantial and statistically significant reductions in the number of incidents of self-harm/suicide attempts when comparing the month leading up to and the month following initiation of ECT for all diagnostic groups (unipolar depression: reduction, 83% [P < 0.001]; bipolar disorder: reduction, 72% [P < 0.001]; psychotic disorder: reduction, 82% [P < 0.001]; personality disorder: reduction, 83% [P < 0.001]). The analog results for the comparison groups not receiving ECT suggested that these reductions in self-harm/suicide attempts were partly mediated by a protective effect of admission.

CONCLUSIONS

Data from the real-world clinical setting are compatible with results from clinical trials with regard to the protective effect of ECT on suicidality.

Evaluating the Risk of Suicide and Violence in Severe Mental Illness: A Feasibility Study of Two Risk Assessment Tools (OxMIS and OxMIV) in General Psychiatric Settings

BACKGROUND

Two OxRisk risk assessment tools, the Oxford Mental Illness and Suicide (OxMIS) and the Oxford Mental Illness and Violence (OxMIV), were developed and validated using national linked registries in Sweden, to assess suicide and violence risk in individuals with severe mental illness (schizophrenia-spectrum disorders and bipolar disorders). In this study, we aim to examine the feasibility and acceptability of the tools in three different clinical services.

METHOD

We employed a two-step mixed-methods approach, by combining quantitative analyses of risk scores of 147 individual patients, and thematic analyses of qualitative data. First, 38 clinicians were asked to use OxMIS and OxMIV when conducting their routine risk assessments in patients with severe mental illness. The risk scores for each patient (which provide a probability of the outcome over 12 months) were then compared to the unstructured clinical risk assessment made by the treating clinician. Second, we carried out semi-structured interviews with the clinicians on the acceptability and utility of the tools. Thematic analysis was conducted on the qualitative data to identify common themes, in terms of the utility, accuracy, and acceptability of the tools. The investigations were undertaken in three general adult psychiatric clinics located in the cities of Barcelona and Sevilla (Spain), and Changsha (China).

RESULTS

Median risk probabilities over 12 months for OxMIS were 1.0% in the Spanish patient sample and 1.9% in the Chinese sample. For OxMIV, they were 0.7% (Spanish) and 0.8% (Chinese). In the thematic analysis, clinicians described the tools as easy to use, and thought that the risk score improved risk management. Potential additions to predictors were suggested, including family history and the patient's support network. Concordance rates of risk estimates between the tools and clinicians was high for violence (94.4%; 68/72) and moderate for suicide (50.0%; 36/72).

CONCLUSION

Both OxMIS and OxMIV are feasible and practical in different general adult psychiatric settings. Clinicians interviewed found that both tools provide a useful structured approach to estimate the risk of suicide and violence. Risk scores from OxMIS and OxMIV can also be used to assist clinical decision-making for future management.

Investigating the phenotypic and genetic associations between personality traits and suicidal behavior across major mental health diagnoses

Personality traits influence risk for suicidal behavior. We examined phenotype- and genotype-level associations between the Big Five personality traits and suicidal ideation and attempt in major depressive, bipolar and schizoaffective disorder, and schizophrenia patients (N = 3012) using fixed- and random-effects inverse variance-weighted meta-analyses. Suicidal ideations were more likely to be reported by patients with higher neuroticism and lower extraversion phenotypic scores, but showed no significant association with polygenic load for these personality traits. Our findings provide new insights into the association between personality and suicidal behavior across mental illnesses and suggest that the genetic component of personality traits is unlikely to have strong causal effects on suicidal behavior.

Stratification by Sex and Hormone Level When Contrasting Men and Women in Schizophrenia Trials Will Improve Personalized Treatment

BACKGROUND

Sex and gender differences have been reported in the prevalence, expression, treatment response, and outcome of schizophrenia, but most reports are based on relatively small samples that have not been stratified for the impact of sex hormone levels. This literature review aims to show how women's hormone levels can impact the results of male/female comparisons.

METHODS

This is a narrative review of data from publications of the last decade.

RESULTS

Epidemiologic evidence, reports of the impact of hormones on cognition, results of sexually dimorphic responses to treatment, and male/female trajectories of illness over time all suggest that female hormone fluctuations exert major effects on male/female differences in schizophrenia.

CONCLUSIONS

Information on hormonal status in women participants is rarely available in clinical studies in schizophrenia, which makes male/female comparisons largely uninterpretable. These are the current challenges. Opportunities for individualized treatment are growing, however, and will undoubtedly result in improved outcomes for both women and men in the future.

Suicide prevention in psychiatric patients

An increased risk of suicide has been reported for psychiatric patients. In several world regions, an underlying psychiatric disorder is reported in up to 90% of people who die from suicide, though this rate seems to be considerably lower in low- and middle-income countries. Major psychiatric conditions associated with suicidality are mood disorders, alcohol and substance use disorders, borderline personality disorder, and schizophrenia. Comorbidity between different disorders is frequently associated with a higher suicide risk. A history of suicide attempts, feelings of hopelessness, impulsivity and aggression, adverse childhood experiences, severe psychopathology, and somatic disorders are common risk factors for suicide among psychiatric patients. Stressful life events and interpersonal problems, including interpersonal violence, are often triggers. A comprehensive and repeated suicide risk assessment represents the first step for effective suicide prevention. Particular attention should be paid during and after hospitalization, with the first days and weeks after discharge representing the most critical period. Pharmacological treatment of mood disorders and schizophrenia has been shown to have an anti-suicidal effect. A significant reduction of suicidal thoughts and behavior has been reported for cognitive behavioral therapy and dialectical behavior therapy. Brief interventions, including psychoeducation and follow-ups, are associated with a decrease in suicide deaths. Further development of suicide prevention in psychiatric patients will require a better understanding of additional risk and protective factors, such as the role of a person's decision-making capacity and social support, the role of spiritual and religious interventions, and the reduction of the treatment gap in mental health care.

Incidence and method of suicide mortality in patients with schizophrenia: a Nationwide Cohort Study

PURPOSE

Suicide is a leading cause of death in patients with schizophrenia. This nationwide cohort study investigated the incidence of each suicide method in patients with schizophrenia compared with the general population.

METHODS

In total, records of 174,039 patients with schizophrenia were obtained from the National Health Insurance Research Database in Taiwan from 2001 to 2016. This schizophrenia cohort was linked with the national mortality database, and 26,926 patients died during this follow-up period. Of the deceased, 3033 had died by suicide. Univariate Cox regression was used to estimate the demographic variables associated with suicide. We estimated the difference in the proportion of each suicide method used in patients with schizophrenia compared with the general population. The incidence and standardized mortality ratio (SMR) of each suicide method were calculated and stratified based on sex.

RESULTS

Patients aged 25-34 years exhibited the highest suicide risk. Compared with the general population, patients with schizophrenia were more likely to commit suicide by jumping and drowning and less likely to use charcoal-burning and hanging. Women showed a higher incidence of suicide by drowning and jumping than did men. Comorbidity with substance use disorders (SUDs) was associated with a high suicide SMR (26.9, 95% confidence interval [CI] = 23.4-28.9), particularly for suicide by jumping (61.2, 95% CI = 48.3-76.3).

CONCLUSIONS

Patients with schizophrenia had higher suicide rates for all methods than did the general population. Suicide method differed based on sex. Patients with SUDs exhibit a high SMR for each suicide method and warrant intensive clinical attention.

Suicidality and social problem-solving skills among individuals with first-episode psychosis participating in Coordinated Specialty Care

AIM

Although suicidal ideation may decrease over the course of participation in specialized clinical programmes for first-episode psychosis (FEP), it is unclear whether such improvements exceed those that occur during treatment as usual. Clarifying the mechanisms underlying reductions in suicidal ideation and behaviour among individuals with first-episode psychosis may highlight important strategies through which specialized clinical programmes can increase the potency of their services to reduce suicidality among this high-risk population. Thus, the goal of this study is to evaluate the longitudinal relationships between suicidality and social problem-solving skills among individuals with FEP participating in Coordinated Specialty Care.

METHODS

Within-subject mediational and moderational models were applied to explore the interrelationships and longitudinal course of suicidality, social problem-solving and duration of untreated psychosis (DUP).

RESULTS

Over the first 6 months of care, individuals with FEP experienced improvements in social problem-solving skills that were found to mediate concurrent reductions in suicidality. Although longitudinal changes in social problem-solving skills were moderated by DUP, these results should be interpreted cautiously as they may stem in part from a relatively limited number of participants with longer durations of illness.

CONCLUSIONS

Improvements in social problem-solving skills during participation in CSC may facilitate reductions in suicidality. Treatments targeting suicidality among individuals with FEP may thus benefit from working to enhance social problem-solving skills among these individuals. Further research is needed to clarify if and how DUP may influence the magnitude of change in social problem-solving skills during participation in CSC.

The processing of angry faces in schizophrenia patients with a history of suicide: An fMRI study examining brain activity and connectivity

BACKGROUND

The high rate of suicidal behaviours (SBs) in psychiatric populations remain an important preoccupation to address. The literature reveals emotional instability as an important risk factor for SBs. However, the neural mechanisms underpinning this risk factor have never been investigated in schizophrenia patients with SBs. The following study implemented a task-based emotional processing functional magnetic resonance imaging (fMRI) paradigm to evaluate the activation and connectivity differences exhibited by schizophrenia patients with a history of suicide attempt (SA).

METHOD

A sample of 62 schizophrenia patients with and without SA and 22 controls completed an fMRI emotional processing task, which included the visualization of dynamic angry facial expressions. Task-based connectivity was assessed using generalized psychophysical interaction analyses.

RESULTS

During the processing of angry faces, suicidal schizophrenia patients displayed increased activation of the left median cingulate gyrus, left middle frontal gyrus, and left precuneus when compared to nonsuicidal schizophrenia patients and healthy controls. Whole-brain connectivity analyses yielded an increased coupling of the right amygdala and right superior frontal gyrus, as well as between the left precuneus and median cingulate gyrus, in suicidal schizophrenia patients. Schizophrenia patients' hostility scores on the Positive and Negative Symptom Scale (PANSS) were significantly and positively correlated with the activity of the left median cingulate gyrus.

CONCLUSION

When exposed to angry faces, suicidal schizophrenia patients demonstrate elevated activation of brain regions associated to executive functioning and self-processing, as well as aberrant fronto-limbic connectivity involved in emotion regulation. Our results highlight the neglected role of anger when investigating the neural alterations underpinning SBs in schizophrenia.

Suicidal ideation in schizophrenia: A cross-sectional study in a tertiary mental hospital in North-East India

INTRODUCTION

Suicide is a leading cause of mortality in schizophrenia. The study attempts to find an association of suicidal ideation, a less studied entity than suicide attempt, with various sociodemographic and clinical profiles in patients with schizophrenia.

MATERIALS AND METHODS

It is a cross-sectional study involving 140 patients diagnosed as schizophrenia. Sociodemographic and clinical profiles were collected using a semi-structured proforma. Positive and Negative Syndrome Scale, Calgary Depression Scale for Schizophrenia, InterSePT Scale for Suicidal Thinking, and Drug Attitude Inventory-10 were applied to assess psychopathology, depressive symptoms, suicidal ideas, and attitude toward psychotropics, respectively. The analysis was done using appropriate statistics.

RESULTS

Majority of the study sample were Hindus, male, unmarried, literate, unemployed, and belonging from lower socioeconomic class. About 25.7% attempted suicide earlier and 29.3% currently have suicidal ideation. A previous suicide attempt, family history of psychiatric illness and that of suicide and comorbid substance use, significantly predicted (p < 0.05) a current suicidal ideation. Ideation has also been found to be significantly correlated to comorbid depression and the positive, negative, emotional, and excitement domains of schizophrenic psychopathology.

CONCLUSION

The current study shows suicidal ideations in schizophrenia patients to be significantly related to schizophrenic psychopathology and comorbid depression, thus calling for a holistic management in preventing a fatal outcome.

Non-pharmacological strategies for self-directed and interpersonal violence in people with severe mental illness: a rapid overview of systematic reviews

INTRODUCTION

Self-directed and interpersonal violence among people with severe mental illness has become a health priority. Though non-pharmacological interventions have been investigated, to our knowledge, no summary of all systematic reviews on this topic has been reported. We will conduct a rapid overview of reviews to synthesise evidence available by identifying systematic reviews on non-pharmacological interventions for self-directed or interpersonal violence in people with severe mental illness.

METHODS AND ANALYSIS

This is a protocol for a rapid overview of reviews. The overview will include any systematic reviews (with or without meta-analyses) of randomised controlled trials (RCTs) or cluster RCTs that examine the effect of non-pharmacological interventions on self-directed or interpersonal violence in people with severe mental illness. This protocol applies the Preferred Reporting Items for Systematic Review and Meta-Analysis (PRISMA) Protocols, the criteria for conducting overviews of reviews in the Cochrane Handbook of Systematic Reviews of Interventions and the criteria for the Cochrane Rapid Reviews. To identify studies, a search will be performed in the following databases: PubMed, EMBASE, PsycINFO, CINAHL, LILACS, SciELO, Web of Science, Scopus, ProQuest, the Cochrane Database of Systematic Reviews through the Cochrane Library and the Epistemonikos database of systematic reviews. The searches date from inception to September 2020. The study selection process will be described using a PRISMA flow diagram, we will assess the quality of evidence in systematic reviews included and the quality of the systematic reviews themselves and the main results will be summarised in categories to provide a map of the evidence available.

ETHICS AND DISSEMINATION

No patients or other participants will be involved in this study. The results will be presented at mental health conferences and for publication in a peer-reviewed journal.

REGISTRATION DETAILS

The protocol was registered on the Open Science Framework (https://osf.io/myzd9/).

Incidence and risk factors of suicide among patients diagnosed with bladder cancer: A systematic review and meta-analysis

BACKGROUND

Patients with bladder cancer have a high risk of suicide. This study aimed to assess how bladder cancer increases suicide risk and to identify the demographic and clinical factors associated with suicidal death among patients with bladder cancer.

METHODS

Literature search of MEDLINE, PsycINFO, Embase, Web of Sciences and Cochrane Library databases was conducted up to April 2020 to identify eligible studies related to the incidence and risk factors of suicide after bladder cancer diagnosis. Summary multivariate-adjusted risk estimates and their associated 95% confidence intervals (CIs) were calculated using inverse variance method with random or fixed-effect modeling.

RESULTS

Five retrospective cohorts comprising 563,680 patients with bladder cancer were included. Higher risk of suicide by 1.90-fold was observed among patients with bladder cancer (hazard ratio, HR = 1.90, 95% CI: 1.29-2.81; P = 0.001; I² = 81.2%), especially in those aged 70 years or older (HR = 1.36, 95% CI: 1.29-1.43; P < 0.001; I² = 0%), unmarried (HR = 1.72, 95% CI: 1.61-1.83; P < 0.001; I² = 0%), and those with regional bladder cancer (HR = 1.88, 95% CI: 1.10-3.21; P = 0.021; I² = 96.3%), compared with those without bladder cancer. Furthermore, gender and race were not associated with increased suicide risk among patients with bladder cancer.

CONCLUSIONS

Suicide risk is increased among patients with bladder cancer, particularly those aged 70 years or older, unmarried and those with regional bladder cancer. Hence, early psychological support must be provided during the follow-up period of these special populations with a high suicide risk.

Psychological resilience to suicidal thoughts and behaviours in people with schizophrenia diagnoses : A systematic literature review

PURPOSE

Suicide deaths are a major concern in people with schizophrenia diagnoses. However, many people with such diagnoses do not attempt suicide, nor die by suicide, suggesting that some individuals are resilient to the impact of suicide triggers. This systematic literature review aimed to (1) appraise the evidence for psychological factors which confer resilience to suicidal thoughts and behaviours, and (2) categorize these psychological factors into broader psychological constructs which characterize resilience.

METHODS

The review was conducted in accordance with the PRISMA guidelines for the reporting of systematic reviews. A literature search of four electronic databases (Web of Science, PubMed, PsycINFO, and MEDLINE) was conducted. A quality evaluation of the included studies was carried out by two independent researchers using a quality assessment tool.

RESULTS

Psychological factors from 27 studies were categorized into four constructs: (1) perceived social support, (2) holding religious and spiritual beliefs, (3) identifying reasons for living, and (4) perceived positive personal skills and attributes.

CONCLUSIONS

The limited literature showed that resilience is important in understanding suicidal thoughts and behaviours in people with schizophrenia diagnoses. There is a need for prospective research that investigates moderating effects of psychological resilience in the pathways to suicidal thoughts and behaviours in people with schizophrenia diagnoses.

PRACTITIONER POINTS

Novel evidence for four psychological constructs which may confer resilience to suicidal thoughts and behaviours in people with schizophrenia diagnoses. Strong evidence for the impact of perceived social support and appraisals of personal skills and attributes on the severity of suicidal experiences in people with schizophrenia diagnoses. There was equivocal evidence for the effect of holding religious and spiritual beliefs on suicide attempts. Clinical practice would benefit from assessing perceived personal attributes and levels of social support from significant others and health professionals.

Prevalence and Factors Associated with Suicidal Ideation in Institutionalized Patients with Schizophrenia

Purpose

The shorter life expectancy and increased risk of suicide in patients with schizophrenia have been well documented. However, study outcomes on suicidality in this special population have been few to date. This study investigated the prevalence and factors associated with suicidal ideation in a population of institutionalized patients with schizophrenia.

Methods

Two hundred fifty-six patients with schizophrenia between the age of 18 and 65 years were randomly recruited. This cross-sectional study utilised the Calgary Depression Scale for Schizophrenia (CDSS), the Positive and Negative Syndrome Scale (PANSS) and the Psychotic Symptom Rating Scale (PSYRATS-AH). Univariate analysis was performed using an independent t-test or chi-square test, followed by binary logistic regression to determine the factors associated with increased suicidal risks.

Results

The socio-demographic factors associated with suicidal ideation included level of education (p=0.039); secondary-level education (OR=5.76, 95% CI:1.49, 22.34, p=0.011) and tertiary-level education (OR=9.30, 95% CI: 1.80, 48.12, p=0.008) posed a greater risk. A history of attempted suicide (OR=2.09, 95% CI: 1.01, 4.36, p=0.049) and the presence of co-morbid physical illnesses (OR=2.07, 95% CI: 1.02, 4.21, p=0.044) were also found to be associated with a suicidal ideation. Other significant factors associated with suicidal thoughts were concurrent depression (OR=9.68, 95% CI: 3.74, 25.05, p<0.001) and a higher PSYRATS score in emotional characteristics of auditory hallucinations (OR=1.13, 95% CI: 1.06, 1.21, p<0.001).

Conclusion

Suicide in schizophrenia appears to be more closely associated with certain socio-demographic factors and affective symptoms. Appropriate screening and treatment addressing these challenges must be emphasized if suicidal thoughts and actions are to be reduced.

An 18-month longitudinal study of suicidality in patients diagnosed with schizophrenia

BACKGROUND

Suicide kills over 30,000 people annually in the US. Schizophrenia increases the risk, even in psychiatric populations. Identifying high-risk groups within this patient population is central to suicide prevention. We tested the effects of known and putative risk factors for suicide in a clinically recognizable population with symptoms of schizophrenia and unstable illness.

METHODS

We studied 1439 subjects with schizophrenia participating in the NIMH-funded Clinical Antipsychotic Treatment for Intervention Effectiveness (CATIE) trial and followed for 18 months. The dependent variable was moderate to severe self-reported suicidal thinking and self-reported suicide attempts. The independent variables comprised potential risk factors for suicidality including measures of clinical change during follow-up. Proportional hazards models of time to first suicidality generated bivariate and multivariate hazard ratios (HRs).

RESULTS

Altogether 96 patients (7.6%) experienced moderate to severe suicidality in the course of 18 months. Multivariate analyses showed that baseline moderate or severe suicidality was the strongest correlate of subsequent moderate or severe suicidality (HR 5.1). An increase in a subject's depression score during follow-up was also independently and strongly associated with suicidality (HR 3.5). A change in psychotic symptoms was not.

CONCLUSIONS

Depression and despair may be more important risk factors for suicidality among people with schizophrenia than psychotic decompensation. Strategies for prevention that seek to identify groups at high risk of suicide should focus on these variables, as well as the effect of prior suicidality.

Performance in Practice: Practice Assessment Tool for the Care of Patients With Schizophrenia

Schizophrenia is associated with significant health, social, occupational, and economic burdens, including increased mortality. Despite extensive and robust research on the treatment of individuals with schizophrenia, many individuals with the illness do not currently receive evidence-based pharmacological and nonpharmacological treatments. The American Psychiatric Association Practice Guideline for the Treatment of Patients With Schizophrenia, Third Edition, aims to enhance knowledge and increase the appropriate use of interventions for schizophrenia, thereby improving the quality of care and treatment outcomes. To this end, this evidence-based Performance in Practice tool can facilitate the implementation of a systematic approach to practice improvement for the care of individuals with schizophrenia. This practice assessment activity can also be used in partial fulfillment of Continuing Medical Education and Maintenance of Certification, part IV, requirements, which can also satisfy requirements for the Centers for Medicare & Medicaid Services Merit-based Incentive Payment System program.

The American Psychiatric Association Practice Guideline for the Treatment of Patients With Schizophrenia

(Reprinted with permission from The American Journal of Psychiatry 2020; 177:868-872).

Scoping review protocol on non-pharmacological interventions for interpersonal and self-directed violence in adults with severe mental illness

INTRODUCTION

Violence committed by people with mental illness has implications for mental health policy and clinical practice. Several strategies to reduce the risk of aggressive and violent behaviour have been proposed, and these include non-pharmacological interventions. There is, however, a need to identify which of these interventions are effective, and as a first step, we will conduct a scoping review to identify non-pharmacological interventions for self-directed or interpersonal violence in adults with severe mental illness across different conditions and settings.

METHODS AND ANALYSIS

This is a scoping review protocol. The review will include any randomised controlled trials (RCTs) and cluster RCTs that assess the efficacy of interventions on self-directed or interpersonal violence with no restrictions on the control treatment in people with severe mental illness in any setting. No restrictions will be applied in terms of language or date of publication. To identify studies, a search will be performed in the following databases: Embase, MEDLINE (via PubMed), PsycINFO, CINAHL, LILACS, SciELO, Cochrane Library, Web of Science, Scopus, ProQuest, Epistemonikos and databases of clinical trials. The Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) statement will be followed for reporting the findings, including the use of a PRISMA flow diagram. A standardised form will be used to extract data from studies. The findings will be classified using conceptual categories that will be specified in detail and a descriptive summary of the main results will be created. Moreover, it will be assessed whether the studies identified have been included in systematic reviews or meta-analyses and the results will be used to generate a conceptual map.

ETHICS AND DISSEMINATION

No patients or other participants will be involved in this study. We will prepare a manuscript for publication in a peer-reviewed journal and the results will be presented at mental health conferences.

Sex, Gender, and Suicidal Behavior

This chapter reviews gender differences in suicide, commonly known as the gender paradox in suicide. While men are more likely to complete suicide, suicide attempts are more frequent in women. Although there are exceptions, this paradox occurs in most countries over the world, and it is partially explained by the preference of men for more lethal methods. Nevertheless, there are differences in the known risk factors for suicide between men and women, and this chapter summarizes the more relevant findings for the gender paradox. Apart from previous attempts, which still is the strongest predictor of death by suicide, with a higher rate in males than in females, we will emphasize in the role of male depression. It is commonly recognized that over 90% of people who die by suicide had a psychiatric diagnosis, mostly depression, and male depression seems to be a distinct clinical phenotype challenging to recognize, which might contribute to the gender paradox. Finally, in light of all the information reviewed, some recommendations on prevention of suicide from a gender perspective in the clinical setting will be made.

Predictors of suicide at time of diagnosis in schizophrenia spectrum disorder: A 20-year total population study in Ontario, Canada

BACKGROUND

Suicide is a major cause of mortality for individuals with schizophrenia spectrum disorders (SSD). Understanding the risk factors for suicide at time of diagnosis can aid clinicians in identifying people at risk.

METHODS

Records from linked administrative health databases in Ontario, Canada were used to identify individuals aged 16 through 45 years who received a first lifetime diagnosis of SSD (schizophrenia, schizoaffective disorder, psychotic disorder not otherwise specified (NOS)) using a validated algorithm between 01/01/1993 and 12/31/2010. The main outcome was death by suicide following cohort entry until 12/31/2012.

OUTCOMES

75,989 individuals with a first SSD diagnosis (60.1% male, 39.9% female) were followed for an average of 9.56 years. During this period, 1.71% of the total sample (72.1% male, 27.9% female) died by suicide, after an average of 4.32 years. Predictors of suicide death included male sex (HR 2.00, 95% CI 1.76-2.27), age at diagnosis between 26 and 35 (HR 1.27, 95% CI 1.10-1.45) or 36-45 (HR 1.34, 95% CI 1.16-1.54), relative to 16-25, and suicide attempt (HR 2.23, 95% CI 1.86-2.66), drug use disorder (HR 1.21, 95% CI 1.04-1.41), mood disorder diagnosis (HR 1.32, 95% CI 1.17-1.50), or mental health hospitalization (HR 1.30 95% CI 1.13-1.49) in the 2 years prior to SSD diagnosis.

INTERPRETATION

Death by suicide occurs in 1 out of every 58 individuals and occurred early following first diagnosis of SSD. Psychiatric hospitalizations, mood disorder diagnoses, suicide attempts prior to SSD diagnosis, as well as a later age at first diagnosis, are all predictors of suicide and should be integrated into clinical assessment of suicide risk in this population.

Painful insight vs. usable insight in schizophrenia. Do they have different influences on suicidal behavior?

BACKGROUND

Suicidal behavior is highly prevalent in schizophrenia. Among the risk factors, insight has been little studied and has yielded contradictory results. In addition, it has been studied neglecting relevant psychological aspects, such as beliefs about illness and coping styles.

METHOD

We assessed 133 outpatients diagnosed with schizophrenia according to ICD-10 criteria. Evaluation included sociodemographic, general clinical, psychopathological, psychological and suicidal behavior variables.

RESULTS

Neither insight nor insight coupled with negative beliefs and/or coping styles were associated with suicidal behavior. Nevertheless, insight coupled with negative beliefs and/or coping styles was associated with greater hopelessness and depression, internalized stigma, worse control over illness and greater global severity as compared to insight coupled with positive beliefs and coping styles. Suicide attempt and suicidal ideation groups showed greater depression and hopelessness, worse global beliefs and worse control over illness, higher socio-economic level, and greater number of previous psychiatric admissions compared to the non-suicidal group.

CONCLUSIONS

Insight coupled with negative beliefs and/or coping style was not associated with suicidal behavior. Nevertheless, it was associated with greater depression and hopelessness, both of which are firmly established risk factors for suicide in schizophrenia. Prospective studies with long-term follow-up and large samples are needed to clarify this issue. Clinicians should assess these psychological features associated with insight, both in patients with insight and in those with poor insight when promoting it.

Suicide attempts in people with schizophrenia before and after participating in an intensive case managed community program: A 20-year follow-up

Lack of treatment compliance in patients with schizophrenia is a risk factor that leads to illness-relapse, hospitalization and potentially strengthens suicidal behavior. The purpose of this investigation was to assess treatment adherence, reasons for treatment discharge, suicidal behaviour and impact of route of antipsychotics administration in a group of patients with schizophrenia treated in a comprehensive, community-based, intensive case managed program for people with severe mental illness. And to compare it to previous standard treatment received in mental health units (MHU). An observational, longitudinal, mirror-image study of patients with severe schizophrenia (N = 344) was carried out: ten years of follow-up (Program) and ten years retrospective (MHU). Reasons for treatment discharge, suicide attempts and antipsychotic (AP) medication were recorded. Treatment adherence during the Program was higher than in MHU (abandonment of treatment: 12.2% vs. 84.3% of patients). Forty patients died during follow-up, five of them due to suicide. Suicidal attempts significantly decreased during Program treatment compared to the standard one (7.6% vs. 38.9% of patients). Long-acting injectable (LAI) AP medication was significantly related to this outcome. A combination of intensive case-managed and LAIAP treatment helped to improve compliance and to reduce suicidal behavior compared to standard treatment in patients with severe schizophrenia.

Hope and belonging in patients with schizophrenia: A phenomenological study

PURPOSE

The aim of this study was to examine in depth the senses of hope and belonging in patients with schizophrenia and factors which affect these.

DESIGN AND METHODS

The data were collected through the phenomenological interview method and interpreted using Strauss and Corbin's approach to qualitative data analysis.

FINDINGS

Patients with schizophrenia reported that having hope and feeling a sense of belonging were very important to them and patients with the same diagnosis, and that being accepted by society, being employed and being productive increased their senses of both hope and belonging.

PRACTICE IMPLICATIONS

For the rehabilitation of patients with schizophrenia, which is a chronic disease, psychiatric nurses should carry out activities which increase their senses of hope and belonging.

Multi-institutional survey of suicide death among inpatients with schizophrenia in comparison with depression

Suicide is a major cause of death among inpatients with schizophrenia. However, there are only a limited number of surveys of suicide among such patients, especially in Asia. Therefore, we conducted a multi-institutional survey on suicide death among inpatients with schizophrenia in Japan. We investigated the characteristics of patients with schizophrenia who died by suicide during hospitalization in psychiatric wards, and simultaneously, those of patients with depression. Forty-five suicides of patients with schizophrenia occurred in 27 hospitals, and 46 suicides of patients with depression occurred in 33 hospitals. Hanging was the most common suicide method in both diagnostic groups. More than half of the patients with schizophrenia had histories of suicide attempts, although there was no significant difference in previous suicide attempts or self-harm between both diagnostic groups. Medical staff should confirm whether inpatients with schizophrenia have such histories. In this study, there was no significant difference in characteristics between inpatients with schizophrenia or depression. In order to prevent suicides of patients with schizophrenia during hospitalization, nonspecific suicide attempt prevention needs to be undertaken, such as ensuring comprehension of the general risk factors of suicide among medical staff.

From depressive symptoms to suicide risk: Roles of sense of belongingness and acquired capability for suicide in patients with mental disorders

In order to prevent suicides in patients with mental disorders, it was critical to recognize the risk factors and explore the mechanism. Based on depressive symptoms, which were common in patients with mental disorders in consolidation period in China, we constructed a moderated mediating model under the framework of Integrated Motivational-Volitional Model of suicidal behaviour, and examined the mechanism of how depressive symptoms, thwarted belongingness, and acquired capability for suicide influenced suicide risk. In this study, data were collected from 164 patients through four questionnaires, and analyzed with PROCESS macro for SPSS (Hayes, 2008). The result showed that in the predictive effects of depressive symptoms on suicide risk, thwarted belongingness was a partial mediating variable, while acquired capability for suicide played a moderating role in the partial mediating model. Specifically, the predictive effects of depressive symptoms and thwarted belongingness, both as motivation variables, on suicide risk both occurred in the case of the high acquired capability of suicide, which was a volition variable. The research pointed out the interdependence of depressive symptoms and a sense of belongingness, and clarified the critical role of acquired capability for suicide. The integrated perspective could enhance the interpretation of reality, and enlightened those carrying out the practice of suicide intervention to patients with mental disorders.

Feasibility and Preliminary Effects of Implementing Acceptance and Commitment Therapy for Inpatients With Psychotic-Spectrum Disorders in a Clinical Psychiatric Intensive Care Setting

The aim of this study was to adapt Acceptance and Commitment Therapy for Inpatients (ACT-IN) for implementation in a typical hospital setting to prepare for a larger clinical trial. The sample consisted of 26 inpatients diagnosed with psychotic-spectrum disorders. Using an open trial design, patients received individual and group ACT-IN sessions during their stay. We assessed the feasibility/acceptability of ACT-IN and preliminary changes on patient outcomes at baseline, discharge, and 4-month follow-up. We successfully recruited and retained participants as planned. Patients reported satisfaction with treatment, and routine hospital staff showed adoption and fidelity to the intervention. Relative to baseline, patients demonstrated significant improvements in symptoms and functioning across the 4-month follow-up. The current study shows that ACT-IN may be feasible and acceptable for inpatients with psychotic disorders in a psychiatric intensive care setting and should be tested in a future effectiveness-implementation trial.

Suicides in Greece before and during the period of austerity by sex and age group: Relationship to unemployment and economic variables

BACKGROUND

There is disagreement on the specific mechanism through which the economic recession increased suicides in Greece. Unemployment is considered by many authors to be the determining factor but the data are inconclusive and often negative, especially concerning the temporal relationship between onset of increase in unemployment and increase in suicides AIMS: The aim of this paper was to clarify the specific role of unemployment as well as of other socioeconomic variables on specific age-by-gender groups concerning the increase in suicides.

METHODS

Data of the Hellenic Statistical Authority ELSTAT (www.

STATISTICS

gr) were analyzed with Linear Regression Analysis and Bonferroni correction for multiple testing RESULTS: Unemployment correlates with suicide rates only in males aged 20-24, 50-54 and 60-64 years (p < 0.001). Unemployment could held responsible for an additional 148 male deaths during the period 2009-2015, which accounts for 5.3% of the total (29 additional deaths per year). The changes in all the socioeconomic conditions could held responsible for 317 cases of suicide or 9.4% of total CONCLUSIONS: The results of the current study suggest that there was a 33% increase in deaths by suicide in Greece during the early years of recession (2009-2015); one third could be directly attributed to unemployment, one third to other consequences of recession while another third is of unknown origin. The effect of unemployment is specifically restricted to males at the beginning of their working career (20-24 years old) and to middle aged (45-49 and 55-59 years old).