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

Prevalence of and Risk Factors for Suicide Attempts Among Patients With Severe Psychiatric Disorders in Eastern Morocco

Background: Suicide attempts are common in patients with severe psychiatric disorders; however, they are rarely studied in this population. Aims: To investigate the prevalence and risk factors associated with suicide attempts among patients with severe psychiatric disorders. Method: This is a cross-sectional study of patients admitted to the Mohammed VI University Hospital of Psychiatry in Oujda, Morocco. Results: A total of 250 patients with a psychiatric disorder were recruited in this study. Among these, 78 cases (31.2%) had a personal history of suicide attempts. A personal history of suicide attempt was significantly higher among women compared to men (45.5% vs. 27.2%, p = .0099). The most common method of suicide attempts was jumping from heights (31%). Patients with a personal history of suicide attempts had a significantly higher prevalence of alcohol consumption (p = .0063), family history of psychiatric disorders (p = .002), family history of suicide attempt (p = .00004), and family history of suicide (p = .018) compared to those who had never made suicide attempts. Limitations: As suicidal behavior is highly stigmatized in Morocco, the number of patients who have made a suicide attempt may be underestimated. Conclusion: Our findings justify the need to provide specialized support to psychiatric patients with risk factors for suicide attempts.

Digit ratio as an endophenotype in a schizophrenia population

BACKGROUND

Schizophrenia is a debilitating mental health condition affecting the lives of many South Africans. The origins of the heterogeneity in the presentation of the illness remain uncertain.

AIM

This cross-sectional study performed a retrospective data analysis to determine the usefulness of digit ratio as an endophenotype in a South African schizophrenia population.

SETTING

A large genetic study in a South African schizophrenia population recruited patients from services in the Western and Eastern Cape.

METHODS

Complete clinical histories were captured for participants, including sets of images of the face and extremities. Software was utilised to measure the lengths of participants' digits from said images and digit ratios (2D:4D) were calculated. Descriptive analyses were performed on the ratios and statistical differences in digit ratio means were calculated between groups characterised by sex, age of onset and the presence vs absence of positive symptoms. Linear modelling was utilised to assess for correlates between 2D:4D and positive and negative symptom severity using scores obtained from the Positive and Negative Syndrome Scale (PANSS) and Scale for the Assessment of Negative Symptoms (SANS).

RESULTS

2D:4D in male participants did not significantly differ from female participants as in healthy populations. 2D:4D did not significantly correlate with the severity of positive or negative symptoms and 2D:4D means between groups did not significantly relate to age of onset.

CONCLUSION

2D:4D appears to be a possible endophenotype in schizophrenia in this population. 2D:4D, however, may not be as readily identifiable as certain minor physical anomalies and neurological soft signs significantly associated with schizophrenia in this population.

Prevalence of suicide attempts in individuals with schizophrenia: a meta-analysis of observational studies

AIMS

Suicide attempt is an important indicator of suicide and potential future mortality. However, the prevalence of suicide attempts has been inconsistent across studies. This meta-analysis aimed to examine the prevalence of suicide attempts in individuals with schizophrenia and associated correlates.

METHODS

Relevant publications in Embase, PsycINFO, PubMed, Web of science and Cochrane were systematically searched. Data on the prevalence of suicide attempts in individuals with schizophrenia were pooled using a random-effects model.

RESULTS

Thirty-five studies with 16 747 individuals with schizophrenia were included. The pooled lifetime prevalence of suicide attempts was 26.8% (95% CI 22.1-31.9%; I2 = 97.0%), while the 1-year prevalence, 1-month prevalence and the prevalence of suicide attempts from illness onset were 3.0% (95% CI 2.3-3.7%; I2 = 95.6%), 2.7% (95% CI 2.1-3.4%; I2 = 78.5%) and 45.9% (95% CI 42.1-49.9%; I2 = 0), respectively. Earlier age of onset (Q = 4.38, p = 0.04), high-income countries (Q = 53.29, p < 0.001), North America and Europe and Central Asia (Q = 32.83, p < 0.001) were significantly associated with a higher prevalence of suicide attempts.

CONCLUSIONS

Suicide attempts are common in individuals with schizophrenia, especially those with an early age of onset and living in high-income countries and regions. Regular screening and effective preventive measures should be implemented as part of the clinical care.

Age at onset mixture analysis and systematic comparison in schizophrenia spectrum disorders: Is the onset heterogeneity dependent on heterogeneous diagnosis?

A major obstacle to the identification of the neurobiological correlates of schizophrenia is the substantial diagnostic heterogeneity of this disorder. Dividing schizophrenia into "early" and "late" subtypes may reduce heterogeneity and facilitate identification of biomarkers related to this disease. Our objective was to assess the presence of different sub-groups in schizophrenia by age at onset analysis. The participants in this study were 612 unrelated patients with schizophrenia. Admixture analysis was applied in order to identify a model of separate normal distributions of age at onset characterized by different means, variances and population proportions to evaluate the effect of winter birth and ethnicity on early onset schizophrenia. The best-fitting model suggested three subgroups with means and standard deviations of 17.11 ± 2.09, 21.96 ± 3.43 and 30.02 ± 7.1 years, comprising 34.6%, 42.6% and 22.8% of the sample respectively. We considered as predictors of early onset schizophrenia: male gender, winter birth, white ethnicity and positive family history for psychiatric disorders. Earlier onset was significantly associated with male gender. We also compared our age at onset distribution with those published in other studies and we found significant differences with several studies suggesting heterogeneity in age at onset that is likely influenced by diagnostic heterogeneity in applying the DSM-IV criteria. Overall, our study showed that a typical early onset schizophrenia patient is more likely to be a white male with cannabis abuse and positive family history of psychiatric disorders. The heterogeneity in reporting age at onset across different studies suggests the application of more stringent criteria in diagnosing schizophrenia.

Suicide and suicide attempts in people with severe mental disorders in Butajira, Ethiopia: 10 year follow-up of a population-based cohort

BACKGROUND

People with severe mental disorders (SMD) are at higher risk of suicide. However, research into suicide attempts and completed suicide in people with SMD in low- and middle-income countries is mostly limited to patients attending psychiatric facilities where selection bias is likely to be high.

METHODS

A population-based cohort of 919 people with SMD from rural Ethiopia (who received standardized clinician diagnoses of schizophrenia (n = 358) major depressive disorder (n = 216) and bipolar I disorder (n = 345)) were followed up annually for an average of 10 years. The Longitudinal Interval Follow-up Evaluation chart was administered by psychiatrists and used to evaluate systematically suicidal behavior and risk factors, which may be amenable to intervention.

RESULTS

Over the follow-up period, the cumulative risk of suicide attempt was 26.3% for major depression, 23.8% for bipolar I disorder and 13.1% for schizophrenia, (p < 0.001). The overall incidence of completed suicide was 200.2/100,000 person-years (CI = 120.6, 312.5). Hanging was the most frequent method used (71.5%) for both attempters and completers. Most people who completed suicide were successful on the first attempt (84.2%), but the case-fatality rate for suicide attempt was 9.7%. In the adjusted logistic regression model, being currently married (Adjusted OR) =2.17, 95% CI = 1.21, 3.91), and having a diagnosis of bipolar I disorder (Adjusted OR = 2.59, 95% CI = 1.57, 4.26) or major depression (Adjusted OR = 2.71, 95% CI = 1.60, 4.58) were associated significantly with increased risk of suicide attempts.

CONCLUSION

In this sample of people with SMD from a rural setting, the rate of suicide was high. Initiatives to integrate mental health service into primary care need to focus on limiting access to suicide methods in people with SMD in addition to expanding access to mental health care.

Attempted suicide in a Xhosa schizophrenia and schizoaffective disorder population

Suicide risk behavior is a significant contributor to the mortality and morbidity of schizophrenia. We previously reported affected sibship status in a Xhosa schizophrenia or schizoaffective disorder sample to be protective in nature; given the counterintuitive nature of this finding, we expanded the sample size to seek further clarification. Subjects were assessed with the Diagnostic Interview for Genetic Studies and then stratified into two groups: with (n = 137) or without (n = 837) a previous suicide attempt. The presence of lifetime bizarre behavior (OR 1.5; 95% CI 1.12-1.87) or cannabis use or abuse (OR 1.2; 95% CI 10.01-1.47) was a significant predictor of suicide attempts, while a higher global alogia score (OR 0.84; 95% CI 0.74-0.96) was a protective factor. Our data seem to support that in this population, encouraging family members to report bizarre behavior and implementing dual diagnosis interventions for cannabis use or abuse could be an appropriate starting point toward developing a targeted suicide prevention program for further research.

Suicide and schizophrenia: a systematic review of rates and risk factors

Risk assessment is a core skill in psychiatry. Risk prediction for suicide in schizophrenia is known to be complex. We undertook a systematic review of all original studies concerning suicide in schizophrenia published since 2004. We found 51 data-containing studies (from 1281 studies screened) that met our inclusion criteria, and ranked these by standardized quality criteria. Estimates of rates of suicide and risk factors associated with later suicide were identified, and the risk factors were grouped according to type and strength of association with suicide. Consensus on the lifetime risk of suicide was a rate of approximately 5%. Risk factors with a strong association with later suicide included being young, male, and with a high level of education. Illness-related risk factors were important predictors, with number of prior suicide attempts, depressive symptoms, active hallucinations and delusions, and the presence of insight all having a strong evidential basis. A family history of suicide, and comorbid substance misuse were also positively associated with later suicide. The only consistent protective factor for suicide was delivery of and adherence to effective treatment. Prevention of suicide in schizophrenia will rely on identifying those individuals at risk, and treating comorbid depression and substance misuse, as well as providing best available treatment for psychotic symptoms.

Suicide in Blantyre, Malawi (2000-2003)

In an attempt to identify at risk individuals, we analysed available information for individuals who committed suicide in Blantyre, Malawi. A retrospective audit of suicides autopsied at the Queen Elizabeth Central Hospital and the University of Malawi College of Medicine mortuaries between January 2000 and December 2003 was analysed by age, sex, residential location, and mode of suicide. Eighty-four suicide cases (65 males, 19 females) represented 17% of all autopsies. The major mode of suicide in Blantyre was chemical poisoning using an agricultural pesticide, accounting for 66 cases (79%)-49 males (76%), 17 females (89%). There were no cases of poisoning by therapeutic medicines, self-immolation or incised wounds. The majority of cases were from one major urban area, Limbe, and one peri-urban area, Chileka. The demographics of suicide in Malawi differ from those reported for other African countries (e.g., lower proportion of females, no use of therapeutic medicine in poisoning, few gunshots). This audit highlights a need for investigations into the sale and use of agricultural pesticides. A prospective study of social and demographic factors around suicide should be undertaken to target groups at highest risk.