Risk factors for suicide among patients with schizophrenia

Alcohol use and suicide-related outcomes in people with a diagnosis of schizophrenia: a comprehensive systematic review and meta-analysis

Suicide is the leading cause of unnatural death among people with a diagnosis of schizophrenia. Alcohol use is a prevalent comorbid feature of schizophrenia and a modifiable risk factor for suicide. We conducted a prospectively registered (PROSPERO, CRD42022358214) systematic review and meta-analysis to quantify the relationship between alcohol use and suicide-related outcomes in schizophrenia.We searched Medline, Embase, and PsycINFO for cross-sectional, case-control and longitudinal studies using exhaustive terms from database inception to December 2022 inclusive. Computation of odds ratios (ORs) and hazard ratios (HRs) were performed using a random-effects model with DerSimonian-Laird estimation. We also evaluated publication bias, study quality, and performed subgroup analysis and meta-regression. Fifty studies, comprising 65 samples, met eligibility criteria. Overall, alcohol use was associated with suicide (OR 1.38, 95% CI 1.21-1.58; HR = 1.32, 95% CI 1.00-1.74), attempted suicide (OR 1.69, 95% CI 1.45-1.98), and suicidal ideation (OR 1.69, 95% CI 1.22-2.34). While there was no evidence of publication bias, between-sample heterogeneity was moderate in analyses of attempted suicide (I2 = 39.6%, p = 0.01) and suicidal ideation (I2 = 56.0%, p = 0.01). Summary effects were significant in all subgroups except for longitudinal studies of attempted suicide (OR 1.60, 95% CI 0.86-3.00) and studies of suicidal ideation using gender combined samples (OR 1.63, 95% CI 0.99-2.67). Alcohol use is significantly associated with suicide-related outcomes in schizophrenia. Clinicians should routinely inquire about alcohol use in mental health services to focus preventative treatment efforts.

Glutamine and GABA alterations in cingulate cortex may underlie alcohol drinking in a rat model of co-occurring alcohol use disorder and schizophrenia: an 1H-MRS study

Alcohol use disorder commonly occurs in patients with schizophrenia and significantly worsens the clinical course of the disorder. The neurobiological underpinnings of alcohol drinking are not well understood. Magnetic resonance spectroscopy (MRS) has been used to assess the neurochemical substrates that may be associated with alcohol drinking in patients; however, the causal impact of these findings remains elusive, highlighting the need for studies in animal models. This study performed MRS in the neonatal ventral hippocampal lesioned (NVHL) rat model, a model of co-occurring schizophrenia and substance use disorders. NVHL lesions (or sham surgeries) were performed on post-natal day 7 and animals were given brief exposure to alcohol during adolescence (10% v/v in a 2-bottle choice design). Animals were re-exposed to alcohol during adulthood (20% v/v) until a stable drinking baseline was established, and then forced into abstinence to control for the effects of differential alcohol drinking. Animals were scanned for MRS after one month of abstinence. NVHL rats consumed significantly more alcohol than sham rats and in the cingulate cortex showed significantly higher levels of GABA and glutamine. Significantly lower GABA levels were observed in the nucleus accumbens. No differences between the NVHL and sham animals were observed in the hippocampus. Correlation analysis revealed that GABA and glutamine concentrations in the cingulate cortex significantly correlated with the rats' alcohol drinking prior to 30 days of forced abstinence. These findings suggest that a potential dysfunction in the glutamate/GABA-glutamine cycle may contribute to alcohol drinking in a rat model of schizophrenia, and this dysfunction could be targeted in future treatment-focused studies.

Clinical features and psychiatric comorbidities in military veterans with schizophrenia with or without suicidality

Suicide is currently among the leading causes of death among individuals with schizophrenia. Reducing mortality from suicide remains a major clinical challenge in the care of veterans with schizophrenia. There is a need to increase our understanding of what elevates suicide risk in veterans with schizophrenia as a first step towards the future development of suicide prevention interventions. This study compared demographic and clinical features of military veterans with schizophrenia with vs. without suicidality to determine specific risk factors for suicidality. The sample consisted of two groups of veterans with schizophrenia: suicide ideators and/or attempters (SIA) and individuals without a history of suicidal ideation or attempts (no-SIA). Participants were interviewed using the Structured Clinical Interview for DSM-5 Axis I disorders (SCID-I), Positive and Negative Syndrome Scale for Schizophrenia (PANSS), Hamilton Depression Rating Scale (HDRS), and Schizotypal Personality Questionnaire (SPQ). In bivariate analyses, the PANSS-Positive Symptom scores, PANSS-General Psychopathology scores, HDRS total score, HDRS-Paranoid symptoms item score, and SPQ total scores were higher among SIA compared with no-SIA patients. In this unique clinical sample of veterans with schizophrenia, SIA patients were more likely to have mood disorders, post-traumatic stress disorder (PTSD), and/or alcohol use disorder in comparison to the no-SIA group. Logistic regression analysis indicated that the HDRS total score and presence/absence of comorbid mood disorder drive the difference between the groups. These results indicate that suicide risk assessment in veterans with schizophrenia should include identifying individuals with comorbid mood disorders/symptoms, PTSD, alcohol use disorder, marked positive symptoms, and schizotypal features.

Is suicidal behaviour a stronger predictor of later suicide than suicidal ideation? A systematic review and meta-analysis

OBJECTIVE

Suicidal ideation and suicidal behaviour are both regarded as important risk factors for suicide, but it is usually believed that suicidal ideation is less strongly linked to suicide than suicidal behaviours. In this study, we assessed and compared the strengths of the associations that suicidal ideation and suicidal behaviour have with later suicide using meta-analysis of primary studies reporting both these independent variables and the dependent variable of suicide.

METHODS

A total of 51 English language publications describing cohort or controlled studies that reported on both the association between suicidal ideation and suicide and the association between suicidal behaviours and suicide were located using searches for titles in PubMed containing variants of the word suicide (suicid*). Suicides were considered to include reported suicides and open verdicts from mortality registers. The strengths of the two associations were examined in separate random effects meta-analyses and were then compared using mixed effects meta-regression. Subgroups were examined according to study characteristics including the definitions of suicidal ideation or behaviour used, setting (psychiatric or non-psychiatric), diagnostic mix of the study population, study design (cohort or control) and study quality.

RESULTS

Suicidal ideation (odds ratio = 3.11, 95% confidence interval = 2.51, 3.86) and suicidal behaviours (odds ratio = 4.09, 95% confidence interval = 3.05, 5.49) were both significantly associated with suicide but there was no significant difference in the strengths of association (p = 0.14). Nor were there significant differences in the strengths of the two associations in multiple subgroup analyses.

CONCLUSION

Suicidal ideation and suicidal behaviour are both moderately associated with suicide. Existing data cannot conclusively demonstrate that suicidal behaviours are more strongly associated with suicide than suicidal ideation. Clinicians should not strongly prioritise suicidal behaviour over suicidal ideation when considering suicide risk.

Association between suicidal ideation and suicide: meta-analyses of odds ratios, sensitivity, specificity and positive predictive value

BACKGROUND

The expression of suicidal ideation is considered to be an important warning sign for suicide. However, the predictive properties of suicidal ideation as a test of later suicide are unclear.AimsTo assess the strength of the association between suicidal ideation and later suicide measured by odds ratio (OR), sensitivity, specificity and positive predictive value (PPV).

METHOD

We located English-language studies indexed in PubMed that reported the expression or non-expression of suicidal ideation among people who later died by suicide or did not. A random effects meta-analysis was used to assess the pooled OR, sensitivity, specificity and PPV of suicidal ideation for later suicide among groups of people from psychiatric and non-psychiatric settings.

RESULTS

There was a moderately strong but highly heterogeneous association between suicidal ideation and later suicide (n = 71, OR = 3.41, 95% CI 2.59-4.49, 95% prediction interval 0.42-28.1, I2 = 89.4, Q-value = 661, d.f.(Q) = 70, P ≤0.001). Studies conducted in primary care and other non-psychiatric settings had similar pooled odds to studies of current and former psychiatric patients (OR = 3.86 v. OR = 3.23, P = 0.7). The pooled sensitivity of suicidal ideation for later suicide was 41% (95% CI 35-48) and the pooled specificity was 86% (95% CI 76-92), with high between-study heterogeneity. Studies of suicidal ideation expressed by current and former psychiatric patients had a significantly higher pooled sensitivity (46% v. 22%) and lower pooled specificity (81% v. 96%) than studies conducted in non-psychiatric settings. The PPV among non-psychiatric cohorts (0.3%, 95% CI 0.1%-0.5%) was significantly lower (Q-value = 35.6, P < 0.001) than among psychiatric samples (3.9%, 95% CI 2.2-6.6).

CONCLUSIONS

Estimates of the extent of the association between suicidal ideation and later suicide are limited by unexplained between-study heterogeneity. The utility of suicidal ideation as a test for later suicide is limited by a modest sensitivity and low PPV.Declaration interestM.M.L. and C.J.R. have provided expert evidence in civil, criminal and coronial matters. I.B.H. has been a Commissioner in Australia's National Mental Health Commission since 2012. He is the Co-Director, Health and Policy at the Brain and Mind Centre (BMC) University of Sydney. The BMC operates an early-intervention youth services at Camperdown under contract to Headspace. I.B.H. has previously led community-based and pharmaceutical industry-supported (Wyeth, Eli Lily, Servier, Pfizer, AstraZeneca) projects focused on the identification and better management of anxiety and depression. He is a Board Member of Psychosis Australia Trust and a member of Veterans Mental Health Clinical Reference group. He was a member of the Medical Advisory Panel for Medibank Private until October 2017. He is the Chief Scientific Advisor to, and an equity shareholder in, InnoWell. InnoWell has been formed by the University of Sydney and PricewaterhouseCoopers to administer the $30 M Australian Government Funded Project Synergy. Project Synergy is a 3-year programme for the transformation of mental health services through the use of innovative technologies.

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

AIMS

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Behavioral predictors of alcohol drinking in a neurodevelopmental rat model of schizophrenia and co-occurring alcohol use disorder

Alcohol use disorder commonly occurs in patients with schizophrenia and contributes greatly to its morbidity. Unfortunately, the neural and behavioral underpinnings of alcohol drinking in these patients are not well understood. In order to begin to understand the cognitive and reward-related changes that may contribute to alcohol drinking, this study was designed to address: 1) latent inhibition; 2) conditioning; and 3) extinction of autoshaping in a neurodevelopmental rat model with relevance to co-occurring schizophrenia and alcohol use disorders, the neonatal ventral hippocampal lesioned (NVHL) rat. NVHL lesions (or sham surgeries) were performed on post-natal day 7 (PND7) and animals were given brief exposure to alcohol during adolescent (PND 28-42). Latent inhibition of autoshaping, conditioning and extinction were assessed between PND 72-90. On PND90 animals were given alcohol again and allowed to establish stable drinking. Latent inhibition of autoshaping was found to be prolonged in the NVHL rats; the NVHL rats pre-exposed to the lever stimulus were slower to acquire autoshaping than sham pre-exposed rats. NVHL rats that were not pre-exposed to the lever stimulus did not differ during conditioning, but were slower to extinguish conditioned responding compared to sham controls. Finally, the NVHL rats from both groups drank significantly more alcohol than sham rats, and the extent of latent inhibition predicted future alcohol intake in the pre-exposed animals. These findings suggest that the latent inhibition of autoshaping procedure can be used to model cognitive- and reward-related dysfunctions in schizophrenia, and these dysfunctions may contribute to the development of co-occurring alcohol use.

Effects of iloperidone, combined with desipramine, on alcohol drinking in the Syrian golden hamster

Alcohol use disorder in patients with schizophrenia dramatically worsens their clinical course, and few treatment options are available. Clozapine appears to reduce alcohol use in these patients, but its toxicity limits its use. To create a safer clozapine-like drug, we tested whether the antipsychotic iloperidone, a drug that combines a weak dopamine D2 receptor blockade and a potent norepinephrine alpha-2 receptor blockade would reduce alcohol drinking, and whether its effect on alcohol drinking could be increased if combined with an agent to facilitate norepinephrine activity. Syrian golden hamsters (useful animal model for screening drugs that reduce alcohol drinking in patients with schizophrenia) were given free access to water and alcohol (15% v/v) until stable drinking was established. Animals (n = 6-7/group), matched according to alcohol intake, were treated daily with each drug (iloperidone; clozapine; haloperidol; desipramine [norepinephrine reuptake inhibitor]; with idazoxan [norepinephrine alpha-2 receptor antagonist]) or with a two-drug (iloperidone + desipramine; iloperidone + idazoxan) combination for 14 days. Moderate doses of iloperidone (1-5 mg/kg) significantly reduced alcohol drinking (p < 0.05) in the hamster, whereas higher doses (10-20 mg/kg) did not. In addition, 5 mg/kg of iloperidone reduced alcohol drinking to the same extent as clozapine (8 mg/kg), whereas haloperidol (0.2 mg/kg) did not. Moreover, iloperidone's effects were enhanced via the addition of desipramine (3 mg/kg), but not idazoxan (1.5/3 mg/kg). In this animal model, iloperidone decreases alcohol drinking as effectively as clozapine, and desipramine appears to amplify this effect. The data suggest that iloperidone, alone or in combination with desipramine, should be tested in patients with schizophrenia and alcohol use disorder.

Clozapine reconstructed: Haloperidol's ability to reduce alcohol intake in the Syrian golden hamster can be enhanced through noradrenergic modulation by desipramine and idazoxan

BACKGROUND

Alcohol use disorder commonly occurs in patients with schizophrenia. Most antipsychotic drugs do not lessen alcohol use; although the atypical antipsychotic clozapine has been shown to reduce alcohol use in patients with schizophrenia, its toxicity severely limits its use in patients. With an eye toward creation of a safer clozapine-like drug, we have investigated the pharmacological basis of the clozapine's effects on alcohol drinking in the Syrian golden hamster. In this animal, as in patients with schizophrenia, clozapine reduces alcohol drinking while the typical antipsychotic haloperidol does not. We have suggested that clozapine decreases alcohol drinking due to its weak dopamine D2 receptor blockade, its potent norepinephrine α-2 receptor antagonism, as well as its ability to elevate plasma norepinephrine.

METHODS

We recreated a clozapine-like drug to reduce alcohol drinking in the Syrian golden hamster by combining low dose haloperidol with a norepinephrine α-2 receptor antagonist, idazoxan, and a norepinephrine reuptake inhibitor, desipramine. Hamsters were given free access to water and alcohol (15% v/v) and were treated daily with each drug or with the three-drug combination for 23 days.

RESULTS

The drug combination reduced alcohol drinking and preference significantly as compared to vehicle or to haloperidol, idazoxan or desipramine, while not altering food-intake or body-weight.

CONCLUSION

These findings suggest that that haloperidol, which does not reduce alcohol drinking in patients with schizophrenia or the hamster, if combined with idazoxan and desipramine (producing a drug combination that mimics aspects of clozapine's pharmacology) is able to reduce alcohol drinking in the hamster.

Meta-analysis of the association between suicidal ideation and later suicide among patients with either a schizophrenia spectrum psychosis or a mood disorder

OBJECTIVE

Recent studies of patients with a mix of psychiatric diagnoses have suggested a modest or weak association between suicidal ideation and later suicide. The aim of this study was to examine the extent to which the association between expressed suicidal ideation and later suicide varies according to psychiatric diagnosis.

METHOD

A systematic meta-analysis of studies that report the association between suicidal ideation and later suicide in patients with 'mood disorders', defined to include major depression, dysthymia and bipolar disorder, or 'schizophrenia spectrum psychosis', defined to include schizophrenia, schizophreniform disorder and delusional disorder.

RESULTS

Suicidal ideation was strongly associated with suicide among patients with schizophrenia spectrum psychosis [14 studies reporting on 567 suicides, OR = 6.49, 95% confidence interval (CI) 3.82-11.02]. The association between suicidal ideation and suicide among patients with mood disorders (11 studies reporting on 860 suicides, OR = 1.49, 95% CI 0.92-2.42) was not significant. Diagnostic group made a significant contribution to between-study heterogeneity (Q-value = 16.2, df = 1, P < 0.001) indicating a significant difference in the strength of the associations between suicidal ideation and suicide between the two diagnostic groups. Meta-regression and multiple meta-regression suggested that methodological issues in the primary research did not explain the findings. Suicidal ideation was weakly but significantly associated with suicide among studies of patients with mood disorders over periods of follow-up of <10 years.

CONCLUSION

Although our findings suggest that the association between suicidal ideation and later suicide is stronger in schizophrenia spectrum psychosis than in mood disorders this result should be interpreted cautiously due to the high degree of between-study heterogeneity and because studies that used stronger methods of reporting had a weaker association between suicidal ideation and suicide.

Suicide in schizophrenia

Suicide is recognised as the most devastating possible outcome of a schizophrenic illness. This study examined the characteristics of 15 schizophrenic patients who committed suicide. These patients were older and less socially isolated than noted in other research. Drowning was the commonest method of suicide and overall, the methods chosen were comparable to those reported among the general Irish population. A past history of deliberate self harm was common although no temporal relationship between such behaviour and suicide emerged. The findings are discussed in the light of the existing literature on this topic.

Preventing suicide among inpatients

OBJECTIVE

Inpatient suicide comprises a proportionately small but clinically important fraction of suicide. This study is intended as a qualitative analysis of the comprehensive English literature, highlighting what is known and what can be done to prevent inpatient suicide.

METHOD

A systematic search was conducted on the Cochrane Library, PubMed, Embase, Web of Knowledge, and a personal database for articles on cohort series, preferably controlled, of inpatient suicide (not deliberate self-harm or attempted suicide, unless they also dealt specifically with suicide data).

RESULTS

A qualitative discussion is presented, based on the findings of the literature searched.

CONCLUSIONS

The bulk of inpatient suicides actually occur not on the ward but off premises, when the patient was on leave or had absconded. Peaks occur shortly after admission and discharge. It is possible to reduce suicide risk on the ward by having a safe environment, optimizing patient visibility, supervising patients appropriately, careful assessment, awareness of and respect for suicide risk, good teamwork and communication, and adequate clinical treatment.

Risk factors for suicide behaviors in the observational schizophrenia outpatient health outcomes (SOHO) study

BACKGROUND

To identify risk factors for suicide using data from a large, 3-year, multinational follow-up study of schizophrenia (SOHO study).

METHODS

Baseline characteristics of 8,871 adult patients with schizophrenia were included in a logistic regression post-hoc analysis comparing patients who attempted and/or committed suicide during the study with those who did not.

RESULTS

384 (4.3%) patients attempted or committed suicide. Completed suicides were 27 (0.3%). The significant risk factors for suicide behaviors were previous suicidality, depressive symptoms, prolactin-related adverse events, male gender and history of hospitalization for schizophrenia.

CONCLUSIONS

In view of the observational design of the study and the post-hoc nature of the analysis, the identified risk factors should be confirmed by ad-hoc specifically designed studies.

Suicides during 7 years among a catchment area cohort of patients with psychoses

OBJECTIVE

To investigate a series of consecutive suicides at a psychosis clinic by using a psychological autopsy technique.

METHOD

The clinic serves an adult population of 225,000 individuals, of whom 0.5% have regular contact with the clinic. During a 7½-year period, 23 men and nine women committed suicide, which corresponds to an odds ratio of 14.

RESULTS

Most patients were schizophrenic, and 24 were outpatients. Suicide methods were violent in all but two cases. Nineteen had a history of at least one suicide attempt, and 24 were known to have had suicidal ideation. More than half had no social contacts over the last year except with psychiatric staff. The median time between the last contact with the psychiatric services and the suicide was 4 days. No warning signs were noted. At the time of death, 3 of the 24 who were prescribed antipsychotics, and none of the 10 who were prescribed antidepressants had plasma levels of the corresponding drug.

CONCLUSION

Findings of special interest are the lack of forewarnings and the poor drug compliance. Patients appear to have played "business as usual" with the care-givers, and did it well. Is it a sign of health and despair, or illness?

Significant relationship between lifetime alcohol use disorders and suicide attempts in an Australian schizophrenia sample

OBJECTIVE

Suicide and attempted suicide are common in individuals with schizophrenia, and evidence exists for a link between substance use disorders and suicidality in this disorder. However, alcohol has not been consistently implicated. We examined the relationship between substance use disorders and suicide attempts in schizophrenia.

METHODS

We recruited a schizophrenia sample in Australia (n = 821) for genetic analyses. We analysed demographic and clinical variables, including substance use disorders, and their relationship to suicide attempts using generalised equation modelling.

RESULTS

A significant association was identified between lifetime alcohol abuse/dependence and suicide attempts (OR = 1.66; 95% CI, 1.23 to 2.24; p = 0.001) after adjustment for potential confounders, but not between cannabis abuse/dependence and suicide attempts, nor between other illicit drug abuse/dependence and suicide attempts. Polysubstance abuse/dependence was also not implicated.

CONCLUSIONS

These results suggest that the presence of alcohol abuse/dependence may be a risk factor for suicide attempts in individuals with schizophrenia, independent of comorbid substance abuse/dependence.

Internet pathways in suicidality: a review of the evidence

The general aim of this study was to review the scientific literature concerning the Internet and suicidality and to examine the different pathways by which suicidal risks and prevention efforts are facilitated through the Internet. An online literature search was conducted using the MEDLINE and Google Scholar databases. The main themes that were investigated included pathological Internet use and suicidality, pro-suicide websites, suicide pacts on the Internet, and suicide prevention via the Internet. Articles were screened based on the titles and abstracts reporting on the themes of interest. Thereafter, articles were selected based on scientific relevance of the study, and included for full text assessment. The results illustrated that specific Internet pathways increased the risk for suicidal behaviours, particularly in adolescents and young people. Several studies found significant correlations between pathological Internet use and suicidal ideation and non-suicidal self-injury. Pro-suicide websites and online suicide pacts were observed as high-risk factors for facilitating suicidal behaviours, particularly among isolated and susceptible individuals. Conversely, the evidence also showed that the Internet could be an effective tool for suicide prevention, especially for socially-isolated and vulnerable individuals, who might otherwise be unreachable. It is this paradox that accentuates the need for further research in this field.

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

Currently there is a lack of strong epidemiological evidence for violent offending and intelligence quotient (IQ) level as predictors of suicide risk among people with schizophrenia. We interlinked several Swedish routinely collected national registers, including the Hospital Discharge, Crime, Conscript, Migration and Cause of Death Registers, to identify 13,804 patients admitted at least twice with a schizophrenia diagnosis during 1973-2004. All deaths by specific cause were ascertained and suicides identified, and rate ratios were estimated using Poisson regression models with adjustment for age and period effects. There were 871 suicides: 6.3% of the cohort. Almost 80% of these cases were aged 20-39 years, and 80% occurred within 10 years of second discharge, with almost a quarter taking place within a year. The following risk factors were identified: younger age, 15-19 versus 40 years and older (rate ratio 3.18, 95% confidence interval 1.82-5.56), male sex (rate ratio 1.37, 1.18-1.59) and history of violent offending (rate ratio 1.45, 1.21-1.73). Intelligence quotient data were unavailable for women, but in men, lower IQ appeared protective compared to those of average or higher levels of intelligence (rate ratio 0.71, 0.58-0.86). Further stratified analyses to identify effect modification indicated that the elevated risk associated with past violent offending was restricted to males, and specifically to those with a lower IQ. Further research is needed to identify additional risk and protective factors for suicide that may be unique to people diagnosed with schizophrenia, and also other modifiers of the increased risk linked with violent offending.

Suicidal behavior in the older patient with schizophrenia

Little is known about treating elderly suicidal patients with schizophrenia. The purpose of this article is to review the literature dealing with this population and to discuss what is required to advance this field. Most available studies from middle-aged and older individuals suggest that risk factors include hopelessness, lower quality of life, past traumatic events, depressive symptoms, lifetime suicidal ideation and past attempts; it is not clear whether these findings are generalizable to geriatric populations. Although little treatment research has been performed in older suicidal patients with schizophrenia, an integrated psychosocial and pharmacologic approach is recommended. In addition, one recent study augmented antipsychotic treatment with an SSRI (i.e., citalopram) in a sample of middle-aged and older individuals with schizophrenia with subsyndromal depression; in that study, serotonin selective reuptake inhibitor augmentation reduced depressive symptoms and suicidal ideation. More research is required to better understand suicidal behavior in older patients with schizophrenia.

Managing suicide risk in patients with schizophrenia

The management of suicide risk in patients with schizophrenia poses many challenges for clinicians. Compared with the general population, these patients have an 8.5-fold greater risk of suicide. This article reviews the literature dealing with the treatment of at-risk patients with schizophrenia. An integrated psychosocial and pharmacological approach to managing this population of patients is recommended. Although there is at least modest evidence suggesting that antipsychotic medications protect against suicidal risk, the evidence appears to be most favourable for second-generation antipsychotics, particularly clozapine, which is the only medication approved by the US FDA for preventing suicide in patients with schizophrenia. In addition, treating depressive symptoms in patients with schizophrenia is an important component of suicide risk reduction. While selective serotonin receptor inhibitors (SSRIs) ameliorate depressive symptoms in patients with schizophrenia, they also appear to attenuate suicidal thoughts. Further research is needed to more effectively personalize the treatment of suicidal thoughts and behaviours and the prevention of suicide in patients with schizophrenia.

Treatment With Acamprosate in Patients With Schizophrenia Spectrum Disorders and Comorbid Alcohol Dependence

OBJECTIVE

Alcohol use disorders and schizophrenia frequently co-occur with rates higher than in the general population. There is no consensus on the best treatment for patients with these comorbid conditions. Several clinical trials have shown that acamprosate is superior to placebo in reducing drinking and is particularly effective in sustaining abstinence. No study to date has examined the efficacy of acamprosate in patients with alcohol dependence and comorbid schizophrenia. The aims of this study are to assess the efficacy of acamprosate when compared to placebo in reducing drinking and to examine its effects on schizophrenic symptoms.

METHODS

This was a double-blind, randomized, 12-week treatment trial of acamprosate versus placebo. Twenty-three recently abstinent patients with diagnosed alcohol dependence and comorbid schizophrenia, schizoaffective disorder, or psychosis not otherwise specified were included in this study.

RESULTS

All participants significantly decreased their drinking during medication treatment, although acamprosate was not superior to placebo in increasing consecutive days of abstinence. There was a significant difference favoring the acamprosate group on obsessive thoughts of drinking but no significant group X time interaction. Overall, medication treatment significantly reduced positive symptoms of schizophrenia, but there were no group differences.

CONCLUSIONS

Acamprosate was not more effective than placebo in reducing drinking or symptoms of schizophrenia. It can be safely used in patients with alcohol dependence and comorbid schizophrenia spectrum disorders.

Attempted suicide predicts suicide risk in schizophrenia spectrum psychosis

BACKGROUND

People with schizophrenia have an increased risk of suicide and attempted suicide is suggested to be an important risk factor.

AIM

Our objective was to assess the cumulative survival, predictive values and odds ratios of attempted suicide for suicide in a long-term cohort of patients with schizophrenia spectrum psychosis with and without previous attempted suicide.

METHOD

Inpatients (n=224) hospitalized with schizophrenia spectrum psychosis were followed for a mean of 25 years. All patients were followed up for causes of death. Information on suicide attempt before the end of the observation period was retrieved from medical records.

RESULTS

Eight percent died by suicide during the follow-up. Eighteen percent of suicide attempters died by suicide. Two percent of non-attempters died by suicide. There was a strong association between previous suicide attempt and suicide in men and women. Odds ratio for attempters vs. non-attempters was 10. Suicide risk was almost three times higher in male than female suicide attempters.

CONCLUSION

Previous attempted suicide is an important risk factor for suicide in both men and women with schizophrenia spectrum psychosis, particularly in male suicide attempters. The suicide risk remains high over a long period. Continuous assessment of risk factors and appropriate treatment are crucial for this patient group to prevent suicide.

Toward a New Prevention of Suicide in Schizophrenia

Suicide is the primary cause of death among schizophrenic patients; follow-up studies suggested that 10-13% of schizophrenic patients die by suicide. Preventive measures based on early recognition of risk factors and the establishment of drug treatment protocols are no doubt of great help but have not resulted in a significant reduction of the number of suicides among these patients. Schizophrenia is a chronic disorder affecting all aspects of the individual's life. Prevention should therefore be addressed to various areas. This paper overviews studies dealing with major fields of interest in the prevention of suicide among patients with schizophrenia. The authors focus on the role of pharmacological treatment, psychosocial interventions and psychotherapy, the struggle against stigmatization and the role of GPs. Prevention of suicide among inpatients with schizophrenia is also analysed. It is concluded that those integrated strategies already in use and the implementation of less known interventions should constitute a more effective prevention of self-inflicted deaths among these patients.

Subjective experience and suicidal ideation in schizophrenia

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

Suicide risk in schizophrenia: learning from the past to change the future

Suicide is a major cause of death among patients with schizophrenia. Research indicates that at least 5-13% of schizophrenic patients die by suicide, and it is likely that the higher end of range is the most accurate estimate. There is almost total agreement that the schizophrenic patient who is more likely to commit suicide is young, male, white and never married, with good premorbid function, post-psychotic depression and a history of substance abuse and suicide attempts. Hopelessness, social isolation, hospitalization, deteriorating health after a high level of premorbid functioning, recent loss or rejection, limited external support, and family stress or instability are risk factors for suicide in patients with schizophrenia. Suicidal schizophrenics usually fear further mental deterioration, and they experience either excessive treatment dependence or loss of faith in treatment. Awareness of illness has been reported as a major issue among suicidal schizophrenic patients, yet some researchers argue that insight into the illness does not increase suicide risk. Protective factors play also an important role in assessing suicide risk and should also be carefully evaluated. The neurobiological perspective offers a new approach for understanding self-destructive behavior among patients with schizophrenia and may improve the accuracy of screening schizophrenics for suicide. Although, there is general consensus on the risk factors, accurate knowledge as well as early recognition of patients at risk is still lacking in everyday clinical practice. Better knowledge may help clinicians and caretakers to implement preventive measures. This review paper is the result of a joint effort between researchers in the field of suicide in schizophrenia. Each expert provided a brief essay on one specific aspect of the problem. This is the first attempt to present a consensus report as well as the development of a set of guidelines for reducing suicide risk among schizophrenia patients.

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.

Investigation of A218C tryptophan hydroxylase polymorphism: association with familial suicide behavior and proband's suicide attempt characteristics

According to WHO, suicide accounts for about 1,000,000 deaths worldwide every year. In view of these dramatic data, several studies have tried to identify possible biological mechanisms and markers of suicide. Genes encoding for proteins involved in the serotonergic transmission are major candidates in association studies of suicidal behavior. The gene that codes for tryptophan hydroxylase (TPH), the rate-limiting enzyme in the biosynthesis of serotonin, is one of these candidates. Two polymorphisms in intron 7 of this gene (A218C and A779C) have been described, but their role in suicidal behavior remains uncertain. TPH A218C polymorphism was analyzed in a sample of 248 psychiatric patients and 63 healthy controls. In addition, at least one close relative member was interviewed to assess family suicidal behavior history. Our research confirmed that a positive history of suicide attempts in a family member is associated with the chance of an individual to attempt suicide. Furthermore, we demonstrated that familial suicide attempts are more lethal and frequently more violent. We were not able to find significant differences of the TPH genotype frequencies between patients and controls. The TPH A218C genotypes were not associated with a history of suicide attempt and the lethality of the most lethal lifetime suicide attempt and suicide attempt method. The authors conclude that the A218C polymorphism of the TPH gene may not be a susceptibility factor for suicidal behavior in this group of psychiatric patients but confirm that a family suicidal behavior history increases the proband's suicide attempt risk.

Where schizophrenic patients commit suicide: a review of suicide among inpatients and former inpatients

OBJECTIVE

To review the literature on suicide of inpatients with schizophrenia, to identify suicide risk factors as well as typical patterns of behavior and to suggest a rationale and strategies for future interventions.

METHOD

A computerized MedLine, Excerpta Medica and PsycLit search supplemented by an examination of cross-references and reviews.

RESULTS

Up to half the suicides among patients with schizophrenia occur during inpatient admission. Inpatient suicides were found among those of a young age group who were predominantly single, childless and socially isolated. The vast majority experienced an illness characterized by long duration and prolonged psychiatric hospitalizations or multiple admissions and discharges. Up to 50% of the suicides occurred in the first few weeks and months following discharge from the hospital. The paranoid subtype of schizophrenia, where positive symptoms prevail and negative symptoms are few, is associated with a suicide risk that is three times greater than that associated with nonparanoid subtypes and eight times greater than the risk associated with the deficit subtype.

CONCLUSIONS

Treatment of suicide is a major problem among inpatients with schizophrenia. Evidence suggests that suicide is generally carried-out by patients who have been recently discharged or by those who manage to get away from the hospital. Strategies aimed at preventing this phenomenon have been introduced to the medical personnel, but suicide in these patients does not seem to have been reduced. We emphasize the need to establish guidelines for the prevention of suicide in hospitalized patients with schizophrenia.

Schizophrenia and suicide: systematic review of risk factors

BACKGROUND

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

AIMS

To identify risk factors for suicide in schizophrenia.

METHOD

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

RESULTS

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

CONCLUSIONS

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

Suicide among patients with schizophrenia: a consideration of risk and protective factors

BACKGROUND

The elevated rate of suicide among patients with schizophrenia is well documented and thus frequently researched. The majority of research has focused solely on the identification of risk factors that predispose patients to attempt or commit suicide. This review serves to expand on the literature pertaining to suicide risk factors by additionally outlining how protective factors may shield against suicide within this unique patient population.

METHODS

A literature review of English-language publications pertaining to suicide among people with schizophrenia was completed using PsychINFO and MEDLINE databases between the years of 1960-2004 and 1950-2004 respectively. Special emphasis was given to studies of risk factors and protective factors for suicide.

RESULTS

Commonly supported risk factors for suicide were identified: previous attempts, severity of illness, comorbidity, social isolation, temporal relationships, and demographic characteristics. Risk factors such as a history of violence, the presence of command hallucinations, and recent tragic loss were found to warrant future study. Social support, positive coping skills, life satisfaction, and resiliency emerged as protective factors that may mitigate suicide.

CONCLUSIONS

Understanding why some patients wish to end their lives but also why some desire to live allows for more comprehensive suicide prevention.

Suicide attempts in an African schizophrenia population: an assessment of demographic risk factors

This study investigated demographic variables, including affected sibling pair status, as risk factors for suicidal behavior in schizophrenia patients of African (Xhosa) descent. Xhosa subjects with schizophrenia were interviewed with the Diagnostic Interview for Genetic Studies (DIGS) and then stratified into two groups: those with ( n = 90) and those without ( n = 364) a history of previous suicide attempts. Demographic parameters (including gender, age, and social circumstances, sib ship) were then compared across these groups. Demographic predictors of suicide included sib ship status ( p = 0.038; OR = 1.7) and age of onset of illness ( p = 0.008; OR = 2.5). On further analysis of suicide in siblings, only a minority of sib pairs was found to be concordant for a lifetime history of suicide attempts (3%). These findings raise the possibility that affected sib pair status may be protective in nature. Given the counter-intuitive nature of this finding, further work is needed to replicate it, and to explore possible underlying mechanisms.

The Psychology and Neurobiology of Suicidal Behavior

Suicide is a leading cause of death, but it is not well understood or well researched. Our purpose in this review is to summarize extant knowledge on neurobiological and psychological factors involved in suicide, with specific goals of identifying areas particularly in need of future research and of articulating an initial agenda that may guide future research. We conclude that from both neurobiological and psychological perspectives, extant research findings converge on the view that two general categories of risk for suicide can be identified: (a) dysregulated impulse control; and (b) propensity to intense psychological pain (e.g., social isolation, hopelessness), often in the context of mental disorders, especially mood disorders. Each of these categories of risk is underlain at least to some degree by specific genetic and neurobiological factors; these factors in general are not well characterized, though there is emerging consensus that most if not all reside in or affect the serotonergic system. We encourage future theorizing that is conceptually precise, as well as epistemically broad, about the specific preconditions of serious suicidal behavior, explaining the daunting array of suicide-related facts from the molecular to the cultural level.

Dual Diagnosis: Impact of Family History

Psychiatric outpatients with severe and persistent mental illness and a current or past substance use disorder (N = 89) were interviewed. Information from the Family Informant Schedule and Criteria was configured in three ways to capture the degree of familial substance abuse: biological parents only, all first-degree biological relatives, and all caregivers. All three configurations predicted the severity of lifetime drug abuse on the Inventory of Drug Use Consequences, controlling for any gender and non-substance-related Axis I diagnosis. Differences in means represent low to very low substance abuse severity for those without family history and low to medium severity for those with family history. The clinical implications are discussed.

Familial suicide behaviour: association with probands suicide attempt characteristics and 5-HTTLPR polymorphism

OBJECTIVE

There is compelling evidence that a serotonergic dysfunction may play a major role in suicide behaviour and it has also been demonstrated that suicide is, at least partially, genetically determined. Thus, the serotonin-related genes are the major candidates. Previously a functional polymorphism in the promoter region of the serotonin transporter gene (5-HTTLPR) was identified and the presence of the short allele (S) was found to be associated with a lower level of expression of the gene and lower levels of 5-HT uptake when compared with the long allele (L). The purpose of this study was to evaluate the association between family suicide behaviour history and probands' suicide attempt (SA) history, SA characteristics and 5-HTTLPR genotype.

METHOD

We genotyped 237 probands (major depressed or schizophrenic patients) and used a semistructured interview to determine probands' SA characteristics and first- and second-degree family suicidal behaviour.

RESULTS

An association between suicidal family history and proband's SA but not with SA characteristics and probands genotype was found.

CONCLUSION

Our results suggest that multiple biological and environmental factors underlie familial transmission of suicidal behaviour.

Clozapine reduces alcohol drinking in Syrian golden hamsters

Alcohol abuse contributes substantially to the overall morbidity of schizophrenia. While typical antipsychotic medications do not limit alcohol use in patients with schizophrenia, emerging data suggest that the atypical antipsychotic clozapine does. To further elucidate the effects of these antipsychotics on alcohol use, we initiated a study in alcohol-preferring rodents. Syrian golden hamsters were given free-choice, unlimited access to alcohol. Nine days of treatment (s.c. injection) with clozapine (2-4 mg/kg/day), but not haloperidol (0.2-0.4 mg/kg/day), reduced alcohol drinking. Clozapine reduced alcohol drinking by 88% (from 11.3+/-1.7 to 1.4+/-0.2 g/kg/day) while increasing both water and food intake. Alcohol drinking gradually (during 24 days) returned toward baseline in the clozapine-treated animals when vehicle was substituted for clozapine. Further increasing the doses of haloperidol (0.6-1.0 mg/kg/day) had no effect on alcohol drinking; moreover, very low doses of haloperidol (0.025-0.1 mg/kg/day) tested in separate groups of hamsters also had no effect on alcohol drinking. This study demonstrates that clozapine, but not haloperidol, can effectively and reversibly decrease alcohol consumption in alcohol-preferring hamsters. The results are compatible with the observations that clozapine, but not haloperidol, limits alcohol use in patients with schizophrenia. These data further suggest that clozapine may serve as a prototype for developing novel treatments for alcohol abuse.

First episode schizophrenia-related psychosis and substance use disorders: acute response to olanzapine and haloperidol

BACKGROUND

Co-occurring substance use disorders, mostly involving alcohol, cannabis or cocaine, occur commonly in patients with schizophrenia and are associated with increased morbidity and mortality. Available but limited data suggest that substance use disorders (especially cannabis use disorders) may also be common in first-episode patients and appear linked to a poor outcome in these patients. Strategies to curtail substance use form an important dimension of the treatment program for both first-episode and chronic patients. We report on rates of co-occurring substance use disorders in patients within their first episode of schizophrenia-related psychosis from a multicenter, international treatment trial of olanzapine vs. haloperidol.

METHODS

The study involved 262 patients (of 263 who were randomized and who returned for a post-randomization evaluation) within their first episode of psychosis (schizophrenia, schizoaffective disorder or schizophreniform disorder) recruited from 14 academic medical centers in North America and Western Europe. Patients with a history of substance dependence within 1 month prior to entry were excluded.

RESULTS

Of this sample, 97 (37%) had a lifetime diagnosis of substance use disorder (SUD); of these 74 (28% of the total) had a lifetime cannabis use disorder (CUD) and 54 (21%) had a lifetime diagnosis of alcohol use disorder (AUD). Patients with SUD were more likely to be men. Those with CUD had a lower age of onset than those without. Patients with SUD had more positive symptoms and fewer negative symptoms than those without SUD, and they had a longer duration of untreated psychosis. The 12-week response data indicated that 27% of patients with SUD were responders compared to 35% of those without SUD. Patients with AUD were less likely to respond to olanzapine than those without AUD.

DISCUSSION

These data suggest that first-episode patients are quite likely to have comorbid substance use disorders, and that the presence of these disorders may negatively influence response to antipsychotic medications, both typical and atypical antipsychotics, over the first 12 weeks of treatment.

Predicting suicidal risk in schizophrenic and schizoaffective patients in a prospective two-year trial

BACKGROUND

Enhanced ability to reliably identify risk factors for suicidal behavior permits more focused decisions concerning treatment interventions and support services, with potential reduction in lives lost to suicide.

METHODS

This study followed 980 patients at high risk for suicide in a multicenter prospective study for 2 years after randomization to clozapine or olanzapine. A priori predictors related to diagnosis, treatment resistance, and clinical constructs of disease symptoms were evaluated as possible predictors of subsequent suicide-related events.

RESULTS

Ten baseline univariate predictors were identified. Historical predictors were diagnosis of schizoaffective disorder, history or current use at baseline of alcohol or substance abuse, cigarette smoking, number of lifetime suicide attempts, and the number of hospitalizations in the previous 36 months to prevent suicide. Predictive clinical features included greater baseline scores on the InterSePT scale for suicidal thinking, the Covi Anxiety Scale, the Calgary Depression Scale (CDS), and severity of Parkinsonism. Subsequent multivariate analysis revealed the number of hospitalizations in the previous 36 months, baseline CDS, severity of Parkinson's, history of substance abuse, and lifetime suicide attempts. Clozapine, in general, was more effective than olanzapine in decreasing the risk of suicidality, regardless of risk factors present.

CONCLUSIONS

This is the first prospective analysis of predictors of suicide risk in a large schizophrenic and schizoaffective population judged to be at high risk for suicide. Assessment of these risk factors may aid clinicians in evaluating risk for suicidal behaviors so that appropriate interventions can be made.

A 20-year follow-up study on schizophrenia in Singapore

OBJECTIVE

To assess the outcome and predictors of patients with schizophrenia 20 years later.

METHOD

The patients, aged 15-39 years, with diagnosis of schizophrenia and first admitted to a national mental hospital in Singapore in 1975 were included. In 1980, 1985, 1990 and 1995, their hospital records were examined and the patients were interviewed to determine their working and treatment status. Possible predictors of good outcome and suicide data were determined.

RESULTS

A total of 402 patients were included. Over 20 years, there was lower percentage of patients working full time and proportionately more patients were receiving out-patient treatment. Overall, about two-third of the patients had a good/fair outcome. Shorter illness duration before admission was significantly associated with a good outcome. The suicide rate was the highest in the first 10 years.

CONCLUSION

Most patients with schizophrenia had a good/fair outcome at 20 years.

Suicide attempts among patients with psychosis in a Chinese rural community

OBJECTIVE

To explore the characteristics of psychotic patients with suicide attempts in a Chinese rural community.

METHOD

An epidemiological investigation of psychotic patients with suicide attempts among 123,572 population (over 15 years of age) was conducted in Xinjin County, Chengdu.

RESULTS

The rate of suicide attempts was found to be 8.17% among all the psychotic patients (906 cases). Patients with affective psychosis showed a significantly higher rate of suicidal attempts (15.3%) than those with schizophrenia (7.5%) (P < 0.005). Suicide attempts were significantly associated with depression and hopelessness in both schizophrenia and affective psychosis (P < 0.001). Patients with suicide attempts were younger and had an earlier age of onset than those without suicide attempts (P < 0.05). Patients with schizophrenia and affective disorders were the major patients with suicide attempts.

CONCLUSION

The rate of suicide attempts in psychotic patients may be largely influenced by the illness itself. Community-based services should be necessary for these patients.

Clinical variables related to suicide attempts in schizophrenic patients: a retrospective study

In this study, we investigated the possible association between clinical or pharmacological variables and suicidal behavior in a sample of chronic schizophrenia or schizoaffective disorder patients. One hundred and three patients with a DSM-III-R diagnosis of chronic schizophrenia or schizoaffective disorder were studied. The sample was subdivided in two subsamples according to the presence/absence of suicidal attempts lifetime. The main demographic and clinical variables retrospectively collected were analyzed and compared between the two groups. Attempters had a significantly higher rate of nicotine abuse or dependence (chi-square=3.900, df=1, p<0.05, Odds Ratio (O.R.)=3.4), were more likely to have or have had lifetime major depressive episodes (chi-square=10.258, df=1, p<0.002, O.R.=6.5), were more likely to have a duration of untreated psychosis (DUP) > or =1 year (chi-square=6.228, df=1, p<0.02, O.R.=12.5), and were more frequently prescribed typical antipsychotics (chi-square=3.979, df=1, p<0.05, O.R.=6.5) than patients without suicidal attempts lifetime. Further investigations on larger samples and with prospective designs are warranted, particularly with respect to the role of early intervention and atypical antipsychotic treatment in reducing suicide risk in schizophrenic patients.

Suicidal behaviour of psychiatric in-patients

OBJECTIVE

The study aimed to examine suicidal behaviour before and during in-patient care in a psychiatric state hospital.

METHOD

Based upon a psychiatric basic documentation system prevalence and risk factors of in-patient suicides, suicide attempts and suicidal thoughts were investigated over an 11-year period from 1989 until 1999.

RESULTS

A total of 30 in-patient suicides were found among 21 062 patients. According to the multivariate logistic regression analysis the risk of hospital suicide increases for patients with schizophrenia, higher cumulative length of stay, previous suicide attempt, part-time employment and training/retraining. Predictors of suicide attempt during hospitalization are suicide attempt on admission, personality disorder, suicidal thoughts on admission, schizophrenia and affective disorder.

CONCLUSION

As Schizophrenics represent the high-risk group of in-patient suicide, suicide prevention should be a major goal in their treatment. More frequent suicide risk assessment is recommended particularly before granting a leave or an outing.

Serotonergic function and suicidal behavior in schizophrenia

Recent studies suggest that altered serotonergic (5-HT) function, as assessed by lower prolactin (PRL) response to fenfluramine (FEN), a specific 5-HT releaser and uptake inhibitor, is associated with suicidal behavior in either depressed and personality disordered patients. The purpose of this study was to investigate, in schizophrenic patients, the relationship between suicidal behavior and PRL response to D-fenfluramine (D-FEN). A D-FEN test was performed in 18 healthy controls and 33 drug-free DSM-IV schizophrenic patients (12 with a history of suicide attempts, 21 without it). Schizophrenic patients with a history of suicide attempts showed a lower PRL response to D-FEN (Delta PRL) compared to schizophrenic patients without such history (P<0.04) and also compared to healthy controls (P<0.0003). Delta PRL did not differentiate schizophrenic patients without suicide attempts and controls. These findings could not be explained by PRL basal hormonal levels, age, sex, menstrual status, demographic or clinical characteristics. These results suggest that PRL response to D-FEN is a marker of suicidal tendencies also in schizophrenia, supporting the hypothesis that a dysfunction in serotonergic function is associated with suicidal behavior regardless of the psychiatric diagnosis.

Suicide and schizophrenia

Suicide and suicide attempts occur at a significantly greater rate in schizophrenia than in the general population. Common estimates are that 10% of people with schizophrenia will eventually have a completed suicide, and that attempts are made at two to five times that rate. Demographically associated with suicidality in schizophrenia are being young, being early in the course of the illness, being male, coming from a high socioeconomic family background, having high intelligence, having high expectations, not being married, lacking social supports, having awareness of symptoms, and being recently discharged from the hospital. Also associated are reduced self-esteem, stigma, recent loss or stress, hopelessness, isolation, treatment non-compliance and substance abuse. Clinically, the most common correlates of suicidality in schizophrenia are depressive symptoms and the depressive syndrome, although severe psychotic and panic-like symptoms may contribute as well. This review specifically explores the issue of depression in schizophrenia, in relation to suicide, by organizing the differential diagnosis of this state and highlighting their potentially treatable or correctable causes. This differential diagnosis includes both acute and chronic disappointment reactions, the prodrome of an acute psychotic episode, neuroleptic induced akinesia and akathisia, the possibility of direct neuroleptic-induced depression, negative symptoms of schizophrenia, and the possible co-occurrence of an independent depressive diathesis. The potential beneficial roles of 'atypical' antipsychotic agents, including both clozapine and more novel agents, and adjunctive treatment with other psychopharmacological medications are considered, and the important roles of psychosocial factors and interventions are recognized.

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

BACKGROUND

Estimations about the lifetime risk of suicide in schizophrenia vary between 4 and 10%. At present, there does not exist a suicide risk scale developed particularly for schizophrenic patients. The aims of the present study were to: (1) develop a clinically useful semi-structured scale for the estimation of short-term suicide risk among schizophrenic patients, and (2) to carry out an initial validation of the scale.

METHODS

A 25-item Schizophrenia Suicide Risk Scale (SSRS) was constructed on the base of the literature. The SSRS scores of 69 living schizophrenic patients (LS group) were compared with the scores of 69 schizophrenic suicides (SS group) whose data had been collected previously from The Finnish nationwide and representative psychological autopsy study. Internal consistency of the SSRS was evaluated with Cronbach alpha. The most important SSRS items predicting suicide were identified with a logistic regression analysis. Sensitivity, specificity, positive predictive value, and negative predictive value of the SSRS in predicting suicide with various cut-off scores were calculated.

RESULTS

In the final logistic regression model, the following SSRS items significantly predicted suicide: suicide plans communicated to someone during the past 3 months; one or more previous suicide attempts; loss of professional skills demanding job; depression observed during an interview; and suicide plans communicated during an interview. With high cut-off scores the specificity of the SSRS became satisfactory, but the sensitivity dropped below 32%. Internal consistency of the anamnestic history of the SSRS was low, which suggests that anamnestic risk factors for suicide in schizophrenia are multifactorial. Internal consistency of the interview-based items was high, and present state risk factors seemed to consist of two separate factors, depression-anxiety and irritability.

CONCLUSIONS

The SSRS may be clinically useful in identifying schizophrenic patients with a particularly high risk for suicide. However, the SSRS seems not to be a practical screening instrument for suicide risk in schizophrenia, and it is probably impossible to construct a suicide risk scale with both high sensitivity and high specificity in this disorder.

Substance misuse, offending and mental illness: a review

The literature concerning the associations between violence, mental disorder, comorbidity and substance misuse are discussed in this review, which focuses on the findings of several international studies that demonstrate significantly higher rates of violence in substance misuse and dual diagnosis (when compared with 'single' diagnosis groups). The need for the development of an effective psychiatric nursing response in terms of assessment, liaison and joint clinical management approaches to those with a dual diagnosis is discussed in the context of United Kingdom Government legislation and policy in both forensic mental health services, and in statutory substance misuse services.

Completed suicide: an update for the general psychiatrist

Objectives: To review the most recent information on completed suicide for the general adult psychiatrist.

Methods: Literature review.

Results: Suicide is the result of a complex interaction of multiple variables. Prediction is highly dependent on clinical evaluation. Predictive factors identify groups better than individuals. Prevention has both clinical and political implications.

Conclusions: Reduced access to lethal methods (historically, from barbiturates to modified vehicle exhaust systems and paracetamol), attention to social factors (such as alcohol availability and employment levels) and clinical vigilance, coupled with adequate treatment of psychiatric disorders and close follow-up, should help to reduce suicide rates. Wider cultural issues (eg. religion) are poorly understood and require further research.

Predictors of suicide in psychiatric hospital

OBJECTIVE

About 5% of all suicides occur in psychiatric hospitals. The aim of this study was to look for potential characteristics common to patients who committed suicide in psychiatric hospital.

METHOD

All patients who committed suicide in University Psychiatric Hospital in Ljubljana, Slovenia, in the period 1984-1993 were included. The suicidal patients (SP) with schizophrenia (SCH) and affective psychoses (AP) were compared to an age-, sex- and diagnosis-matched control group. Data from files and (in control patients) patient interviews were gathered. Multivariate logistic regression analysis was used.

RESULTS

A total of 79 patients (34 males and 45 females) committed suicide. The majority of them had SCH (n = 36) and AP (n = 23). The predictors of suicide among patients with AP and SCH were depression and lack of insight and, in addition in patients with SCH, past suicidal behaviour and poor relationships with family members.

CONCLUSION

This study provides the clinician with information on risk factors for in-patient suicide.

Schizophrenia, substance use, and brain morphology

The high rate of comorbid substance abuse in schizophrenia and the consistently poor outcome of this comorbidity are well established findings in the research literature. However, the reasons for the high rate of comorbidity are not adequately understood, and the question of why some patients with schizophrenia abuse substances and others do not remains unanswered. There is widespread agreement about the clinical heterogeneity of schizophrenia, and there is some evidence suggesting that the heterogeneous clinical presentation may reflect a parallel underlying heterogeneity of brain morphology. We were interested in examining the possibility that the high rate of substance abuse and the characteristically poor outcome may be associated with the underlying brain morphology. Our hypothesis was that study subjects with schizophrenia and substance abuse would have higher rates of gross brain abnormalities than subjects with only schizophrenia. In an attempt to explore this possibility, we looked at qualitative differences in magnetic resonance imaging scans for a large sample (n = 176) of schizophrenia patients. In the group of patients who abused both alcohol and drugs, we found the rate of gross brain abnormalities to be slightly less than half the rate found among the patients with no history of alcohol or substance abuse (8 vs. 19). Although these results are not statistically significant, they reflect a trend that is compatible with previous findings, suggesting that substance abuse history may be accompanied by less impairment in certain areas, which in turn may be reflected in a better premorbid adjustment. However, our findings are not compatible with previous findings that show substance abuse to be associated with more severe symptoms and a poorer outcome in schizophrenia.