Critical treatment issues in suicide among schizophrenics

The Importance of Suicide Risk Formulation in Schizophrenia

Suicide is a cause of early mortality in nearly 5% of patients with schizophrenia, and 25-50% of patients with schizophrenia attempt suicide in their lifetime. Evidence points to numerous individual, clinical, social, and psychological risk factors for suicide in patients with schizophrenia. Although recognizing suicidal risk factors in schizophrenia is extremely important in suicidal risk assessment, we have recently witnessed a change in suicide risk management that shifts the focus from suicide risk assessment to suicide risk formulation. Suicide risk formulation is dependent on the data gathered in the suicide risk assessment and assigns a level of suicide risk that is indispensable for the choice of treatment and the management of patients with a high suicidal risk. In this article, we extend the suicide risk formulation model to patients with schizophrenia. Suicide risk formulation results from four different areas that help clinicians collect as much information as possible for the management of suicidal risk. The four distinct judgments comprise risk status (the risk relating to the specific group to which the patient belongs), risk state (the risk for the person compared with his baseline or another reference point in the course of his life), available resources (on whom the person can count during a crisis) and foreseeable events (which can exacerbate the crisis). In schizophrenia, the suicide risk formulation model allows the clinician to evaluate in depth the clinical context of the patient, the patient's own history and patient-specific opportunities for better choosing and applying suicide prevention strategies.

Suicide in Schizophrenia: An Educational Overview

Suicide is an important public health problem. The most frequent psychiatric illnesses associated with suicide or severe suicide attempt are mood and psychotic disorders. The purpose of this paper is to provide an educational overview of suicidal behavior in individuals with schizophrenia. A lifetime suicide rate in individuals with schizophrenia is approximately 10%. Suicide is the largest contributor to the decreased life expectancy in individuals with schizophrenia. Demographic and psychosocial factors that increase a risk of suicide in individuals with schizophrenia include younger age, being male, being unmarried, living alone, being unemployed, being intelligent, being well-educated, good premorbid adjustment or functioning, having high personal expectations and hopes, having an understanding that life’s expectations and hopes are not likely to be met, having had recent (i.e., within past 3 months) life events, having poor work functioning, and having access to lethal means, such as firearms. Throughout the first decade of their disorder, patients with schizophrenia are at substantially elevated suicide risk, although they continue to be at elevated suicide risk during their lives with times of worsening or improvement. Having awareness of symptoms, especially, awareness of delusions, anhedonia, asociality, and blunted affect, having a negative feeling about, or non-adherence with, treatment are associated with greater suicide risk in patients with schizophrenia. Comorbid depression and a history of suicidal behavior are important contributors to suicide risk in patients with schizophrenia. The only reliable protective factor for suicide in patients with schizophrenia is provision of and compliance with comprehensive treatment. Prevention of suicidal behavior in schizophrenia should include recognizing patients at risk, delivering the best possible therapy for psychotic symptoms, and managing comorbid depression and substance misuse.

The Role of Demoralization and Hopelessness in Suicide Risk in Schizophrenia: A Review of the Literature

Background and Objectives: Demoralization has been defined by hopelessness and helplessness attributable to a loss of purpose and meaning in life. Demoralization is a meaningful mental health concern, frequently associated with suicide risk in medical and psychiatric patients. The aim of this systematic review was to synthesize the recent empirical evidence on demoralization in patients with schizophrenia and to better understand the relationship between demoralization and suicide risk in patients with schizophrenia. Methods: A comprehensive literature search using key words and subject headings was performed following PRISMA guidelines with several bibliographic databases, resulting in the identification of 27 studies. Results: The findings suggested that demoralization is prevalent in patients with schizophrenia and supported the hypothesis that the association between depression and suicide is moderated by hopelessness. In clinical practice, it is important to recognize symptoms of demoralization using appropriate psychological tools to better understand the suffering of patients with schizophrenia and to implement suicide prevention programs.

A comparison of correlates of suicidal ideation prior to initial hospitalization for first-episode psychosis with prior research on correlates of suicide attempts prior to initial treatment seeking

AIM

Individuals with first-episode psychosis, like those with chronic psychotic disorders, are at elevated risk for suicidal ideation and suicide attempts. However, relatively little is known about suicidality among first-episode patients prior to their initial presentation for treatment. This analysis was designed as a US-based examination of recent findings on prior suicide attempts from Dublin, Ireland, here focusing on prevalence and correlates of suicidal ideation during the weeks prior to initial treatment-seeking.

METHODS

Participants included 109 first-episode inpatients with primary psychotic disorders in public-sector settings that serve an urban, low-income, socially disadvantaged, predominantly African American population. Eligible patients had received <3 months of prior antipsychotic treatment and had not been hospitalized for psychosis >3 months prior to the index admission, though most were completely treatment naïve. Assessments included the Positive and Negative Syndrome Scale, Calgary Depression Scale for Schizophrenia, Birchwood Insight Scale, and a rigorous method for determining age at onset of first psychotic symptoms and duration of untreated psychosis.

RESULTS

Disconcertingly, nearly one quarter of patients (23%) endorsed a history of suicidal ideation in the 2 weeks prior to first admission. In the model designed to replicate the prior study in Ireland, Calgary Depression score (calculated omitting hopelessness and suicidal ideation as these were separate variables in the analysis) was a predictor of suicidal ideation (P < 0.01). In separate bivariate analyses analogous to the original study, two domains of insight were associated with suicidal ideation.

CONCLUSIONS

Findings suggest that depression, insight, and suicidality should be carefully monitored among first-episode patients initiating treatment and during the early course of illness. As insight improves, coping strategies should be enhanced with a goal of minimizing depression and preventing suicidality.

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.

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.

Life events and suicidality in adolescents with schizophrenia

OBJECTIVE

Suicide is the leading cause of premature death in patients with schizophrenia. Studies have shown a weaker association between suicidal behavior and stressful life events in schizophrenic than in nonschizophrenic subjects. The aim of the present study was to further investigate the complicated relationship of suicide attempts and life events in adolescent schizophrenic patients.

METHODS

Forty adolescents with a diagnosis of schizophrenia, including 20 who had attempted suicide and 20 who had not, were compared with 20 age-matched subjects with no psychiatric history. The instruments used for the assessment were the Life Events Checklist, the Suicidal Risk Scale, the Sexual Abuse in Childhood Questionnaire, and the Beck Depression Inventory.

RESULTS

Control subjects reported fewer life events in general, and fewer negative events, events of sexual abuse, and events associated with impaired family functioning than the schizophrenic patients. Within the schizophrenic group, the suicidal patients reported fewer life events than the nonsuicidal patients, but there was no difference between the groups in the number of negative or sexual-abuse events. However, the proportion of negative life events out of total life events was higher in the suicidal group, and their perceived impact was stronger. Levels of depression and suicidality were higher in the suicidal schizophrenic patients than in the nonsuicidal patients.

CONCLUSIONS

In adolescent patients with schizophrenia, suicidal behavior is associated less with the number of life events and more with their perception of the events as negative and the impact of these events on the individual.

Assessment and intervention for the suicidal patient with schizophrenia

The risk for suicidal behavior in schizophrenia is high with 10-15% committing suicide and 20-40% making suicide attempts. Due to the chronicity and complexity of schizophrenia and the multi-determined nature of suicidal behavior, the clinician must utilize a biopsychosocial approach to assessment and intervention. Clinical factors such as psychosis, depression and substance abuse increase the risk for suicidal behavior in schizophrenia. Social factors such as social adjustment and social supports also play a critical role. Ongoing assessment and intervention of suicidal behavior, clinical symptomatology, social environment and treatment issues are essential. Prediction and prevention of suicidal behavior are not always possible however. Treatment focused on the reduction of symptomatology and maintenance of an effective social environment may attenuate the risk for suicidal behavior in schizophrenia.

Depression in schizophrenia: current guidelines to treatment

Depressive symptoms and syndromes in schizophrenia are common but heterogeneous with respect to etiology, presentation, course, and treatment. Based on a comprehensive differential diagnosis that identifies ten clinical subgroups, the authors review relevant treatment studies and offer current treatment guidelines. The clinical recommendations focus on addressing underlying problems such as medication side effects and substance abuse, attempting to identify and treat medication-responsive syndromes, and preventing suicide. The categories and treatments presented here are expected to evolve as researchers continue to elucidate clinically meaningful syndromes and to develop specific treatments. Nevertheless, current knowledge suggests that many schizophrenics with depression and depression-like symptoms can be treated effectively.