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Schizophrenia, Other Psychotic Disorders, and Suicidal Behaviour
Abstract
IntroductionSuicide in Psychotic DisordersThe Risk of Suicide and Other Psychotic DisordersRelationship with Other Suicide and Socio-Demographic CharacteristicsCharacteristics of Psychotic Illness in SuicideInsight into Psychotic IllnessPsychopathology, Personality Traits, and Family History of Suicidal BehaviourTreatment of Chronic Psychotic Disorders: Implications for Suicide RiskConclusion
References
... Previous research has suggested that the period of greatest risk for suicide in schizophrenia is early in the course of the disorder (McGirr & Turecki, 2011). However, many in Group 6 -which was characterized by long-term schizotypal, schizophrenia, and delusional disorders -had diagnoses that were originally made 20 or more years prior to suicide and in only one case was the diagnosis made within 5 years of death. ...
Background: People who have mental illness are at increased risk of suicide. Therefore, identifying "typical" trajectories to suicide in this population has the potential to improve the effectiveness of suicide prevention strategies. Aim: The aim of this study was to explore the pathways to suicide among a sample of Victorians with a diagnosed mental illness. Method: Victorian Suicide Register (VSR) data were used to generate life charts and identify typical life trajectories to suicide among 50 Victorians. Results: Two distinct pathways to suicide were identified: (1) where diagnosis of mental illness appeared to follow life events/stressors; and (2) where diagnosis appeared to precede exposure to life events/stressors. Some events acted as distal factors related to suicide, other events were more common as proximal factors, and still others appeared to act as both distal and proximal factors. Limitations: The data source might be biased because of the potential for incomplete information, or alternatively, the importance of some factors in a person's life may have been overstated. Conclusion: Strategies to reduce suicide need to consider the chronology of exposure to stressors in people's lives and clearly need to be different depending on whether proximal or distal risk factors are the target of a given strategy or intervention.
... In addition, other populations, for example those who have a significant physical illness, often have undiagnosed mental illness (Kelly & Turner, 2009). Evidence also suggests that among individuals with schizophrenia the period of greatest risk for suicide is early in the course of the disorder (McGirr & Turecki, 2011)-therefore it could be that some individuals simply did not have the opportunity to be diagnosed prior to their A. Clapperton et al. ...
Objective:
To determine whether people who died by suicide form groups based on demographic, psychosocial, mental and physical health factors and exposure to stressors.
Methods:
Retrospective case series review of persons who died by suicide in Victoria, Australia (2009-2013). A two-stage cluster analysis was performed.
Results:
The total sample comprised 2839 persons. Diagnosis of mental illness was present in 52% of cases. Initial analysis determined two groups with the main predictor of group membership being presence of diagnosed mental illness. Further analysis identified four subgroups within the mental illness group and two within the non-mental illness group.
Conclusions:
Suicide does not always occur in the context of mental illness; people who die by suicide cannot be considered a homogenous group.
... Autonomic cognitive impairments have specifically been linked to a protection against suicide in high-risk groups. A reduced ability to concentrate has been found to correlate with less suicidality among schizophrenics (Hawton et al., 2005;McGirr & Turecki, 2011), and deficits in concentration and decisiveness may also protect depressives (McGirr et al., 2007). Why these associations should occur is unclear, and they may anyway be evidentially ambiguous for the purpose of this enquiry, but it would make intuitive sense that a certain level of intellectual impairment may be protective for those at suicide risk McGirr et al., 2007). ...
Suicidality most likely evolved as an unfortunate side effect of two important primary adaptations in the human species, “pain and brain”: the aversive emotional experience of pain, which is biologically designed to aid self-preservation by motivating adaptive escape action, combined with a cognitive sophistication that offers most mature humans the means to escape pain maladaptively by self-killing. Suicide may thus be categorized alongside other major fitness costs of human cognition and encephalization, such as obstetric complications arising from the parturition of large-skulled infants and the necessity for human young to remain dependent on carers for many years while the brain develops, adaptive problems of such severity that they drove the natural selection of complex physiological and behavioral solutions to control their costs. Equally, the notion of suicidality as a costly by-product implies that countermeasures would expectably have evolved to prevent mature humans from using self-extinction to escape from pain. Inferences are made concerning the likely timing of the emergence of these countermeasures during human prehistory.
"THE MOST IMPORTANT THEORY OF SUICIDE IN THE CURRENT LITERATURE" [Review by Riadh Abed, FRCPsych, Former (Founding) Chair of the Evolutionary Psychiatry Special Interest Group at the Royal College of Psychiatrists (UK)].
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"This is an important book setting out ground-breaking ideas about the roots of suicide. I have read Cas Soper’s new book as well as his previous book, both of which are based on his PhD thesis proposing a new evolutionary theory of suicide. In my view Cas’ ‘Pain and Brain’ theory of suicide is the best explanation for suicide in the current literature, evolutionary or otherwise. His new book is aimed at the general public and goes further in developing the consequences and implications of his theory that provides a theory to explain the origins of happiness, love and religion as well as functional mental disorders (this bit, some psychiatrists may find controversial).
"The theory Cas presents is rigorously argued and he meticulously references research findings and other relevant literature. The book should be of interest to evolutionists from diverse fields including psychology and psychiatry, suicidologists, mental health professionals as well as anyone interested in understanding the human condition.
It is unfortunate that the hardback of his first book was priced out of reach of many potential readers but this one should hopefully get the attention it deserves."
(February 2021)
This chapter looks for psychological and behavioral phenomena that match the design specification of keepers detailed in the preceding chapter. If they exist, they should not be hard to find because of the predicted strangeness of keeper responses: triggered by intense and chronic emotional pain, keepers should reduce the motivation for suicide by moderating the aversiveness of the experience, and/or they should impair the capability to carry out suicide by attenuating psychomotor energy, decision-making, and other general intellectual faculties. The components and signature outcomes of the keeper specification are observed in a number of compulsive human responses to emotional pain, in symptoms of depression, addiction, psychotic delusions, self-harm, and other common mental disorders (CMDs), states that occur alongside heightened suicide risk. The closeness of the fit between the a priori design and observed form suggests that some CMD symptoms may, in fact, be evolved anti-suicide mechanisms.
Het onderzoek naar suïcidaliteit omvat distale (langdurige en statische) en proximale (vlak voorafgaande) risicofactoren. In dit hoofdstuk wordt het systematisch onderzoek van de suïcidaliteit beschreven. Belangrijk daarbij is het bespreken van de wanhoop en de plannen die mensen hebben gemaakt om een einde aan hun leven te maken. Enkele vragenlijsten en vragenschema’s die hierbij kunnen helpen, worden besproken.
Approximately 50% of patients with schizophrenia or schizoaffective disorder attempt suicide, and approximately 10% die of suicide. Study results suggest that clozapine therapy significantly reduces suicidal behavior in these patients.
METHODS:
A multicenter, randomized, international, 2-year study comparing the risk for suicidal behavior in patients treated with clozapine vs olanzapine was conducted in 980 patients with schizophrenia or schizoaffective disorder, 26.8% of whom were refractory to previous treatment, who were considered at high risk for suicide because of previous suicide attempts or current suicidal ideation. To equalize clinical contact across treatments, all patients were seen weekly for 6 months and then biweekly for 18 months. Subsequent to randomization, unmasked clinicians at each site could make any interventions necessary to prevent the occurrence of suicide attempts. Suicidal behavior was assessed at each visit. Primary end points included suicide attempts (including those that led to death), hospitalizations to prevent suicide, and a rating of "much worsening of suicidality" from baseline. Masked raters, including an independent suicide monitoring board, determined when end point criteria were achieved.
RESULTS:
Suicidal behavior was significantly less in patients treated with clozapine vs olanzapine (hazard ratio, 0.76; 95% confidence interval, 0.58-0.97; P =.03). Fewer clozapine-treated patients attempted suicide (34 vs 55; P =.03), required hospitalizations (82 vs 107; P =.05) or rescue interventions (118 vs 155; P =.01) to prevent suicide, or required concomitant treatment with antidepressants (221 vs 258; P =.01) or anxiolytics or soporifics (301 vs 331; P =.03). Overall, few of these high-risk patients died of suicide during the study (5 clozapine vs 3 olanzapine-treated patients; P =.73).
CONCLUSIONS:
Clozapine therapy demonstrated superiority to olanzapine therapy in preventing suicide attempts in patients with schizophrenia and schizoaffective disorder at high risk for suicide. Use of clozapine in this population should lead to a significant reduction in suicidal behavior.
There is substantial evidence suggesting that suicide aggregates in families. However, the extent of overlap between the liability to suicide and psychiatric disorders, particularly major depressive disorder, remains an important issue. Similarly, factors that account for the familial transmission of suicidal behavior remain unclear. Thus, through direct and blind assessment of first-degree relatives, the authors conducted a family study of suicide by examining three proband groups: probands who committed suicide in the context of major depressive disorder, living depressed probands with no history of suicidal behavior, and psychiatrically normal community comparison probands.
Participants were 718 first-degree relatives from 120 families: 296 relatives of 51 depressed probands who committed suicide, 185 relatives of 34 nonsuicidal depressed probands, and 237 relatives of 35 community comparison subjects. Psychopathology, suicidal behavior, and behavioral measures were assessed via interviews.
The relatives of probands who committed suicide had higher levels of suicidal behavior (10.8%) than the relatives of nonsuicidal depressed probands (6.5%) and community comparison probands (3.4%). Testing cluster B traits as intermediate phenotypes of suicide showed that the relatives of depressed probands who committed suicide had elevated levels of cluster B traits; familial predisposition to suicide was associated with increased levels of cluster B traits; cluster B traits demonstrated familial aggregation and were associated with suicide attempts among relatives; and cluster B traits mediated, at least in part, the relationship between familial predisposition and suicide attempts among relatives. Analyses were repeated for severity of attempts, where cluster B traits also met criteria for endophenotypes of suicide.
Familial transmission of suicide and major depression, while partially overlapping, are distinct. Cluster B traits and impulsive-aggressive behavior represent intermediate phenotypes of suicide.
The purpose of this study was to investigate the prevalence and comorbidity of current mental disorders defined by DSM-III-R among a random sample of suicide victims from a nationwide suicide population.
Using a psychological autopsy method, the authors collected comprehensive data on all suicide victims in Finland during 1 year. Retrospective axis I-III consensus diagnoses were assigned to 229 (172 male, 57 female) victims.
One or more diagnoses on axis I were made for 93% of the victims. The most prevalent disorders were depressive disorders (59%) and alcohol dependence or abuse (43%). The prevalence of major depression was higher among females (46%) than among males (26%). Alcohol dependence was more common among the males (39% versus 18% for females). A diagnosis on axis II was made for 31% and at least one diagnosis on axis III for 46% of the cases. Only 12% of the victims received one axis I diagnosis without any comorbidity.
The majority of suicide victims suffered from comorbid mental disorders. Comorbidity needs to be taken into account when analyzing the relationship between suicide and mental disorders and in planning treatment strategies for suicide prevention in clinical practice.
The authors examined the clinical characteristics of suicide victims with schizophrenia in the general population of Finland.
As part of the nationwide National Suicide Prevention Project in Finland, all suicides over a 12-month period of persons with DSM-III-R schizophrenia were investigated by using the psychological autopsy method. Clinical characteristics and their variation with age, sex, and illness duration were examined.
Among all suicide victims, 7% (N = 92) were identified as having suffered schizophrenia. Suicides occurred throughout the course of schizophrenia. Both active illness (78%) and depressive symptoms (64%) were highly prevalent immediately before suicide, and a history of suicide attempts (71%) was also common. Women were more likely than men to have committed suicide during an acute exacerbation of the illness. Marked variation in depressive symptoms, alcoholism, and suicide methods was found among sexes and age groups. Alcoholism was most common among middle-aged men (45%), whereas middle-aged women had a high rate of depressive symptoms (88%). Younger male subjects most often used violent suicide methods.
Suicide may occur at any point during the course of schizophrenia. The results indicate clinically important variation in depression, alcoholism, and suicide methods among suicide victims with schizophrenia. This suggestion of age- and sex-specific risk factors for suicide in schizophrenia needs further investigation.
Previous analyses of the personal and social adjustment of outpatients with schizophrenia have either relied on the assessment of unrepresentative patients who survived without relapse or used analyses that included relapse assessments, a potential confound when different rates of relapse existed among treatment conditions. The authors' goal was to conduct a study of the effects of personal therapy on outcome that was designed to take into consideration the effects of relapse.
They evaluated the effectiveness of personal therapy over 3 years after hospital discharge among 151 patients with schizophrenia or schizoaffective disorder. The patients were randomly assigned to receive personal therapy or contrasting therapies in one of two concurrent trials. One trial included patients who were living with family (N = 97); the other included patients who were living independent of family (N = 54). Patients were assessed at 6-month intervals over 3 years of treatment on measures of personal and social adjustment; patients who relapsed and restabilized and those who did not relapse were included.
Personal therapy had positive effects on broad components of social adjustment (role performance) but had few differential effects on symptoms, and patients receiving personal therapy remained more anxious than patients who received family or supportive therapy. For patients who were living with family, personal therapy led to better outcomes in overall performance than did the other treatments. Although family therapy had only one positive effect on patients' social adjustment, the personal adjustment (residual symptoms) of patients who received family therapy appeared to improve more than that of patients receiving personal or supportive therapy. For patients not living with family, personal therapy was more successful than supportive therapy in improving work performance and relationships out of the home. Longitudinal effects of personal therapy on symptoms were similar to those of family and supportive therapies, particularly in the first 2 years, but personal therapy effect sizes increased over time on measures of social adjustment.
Personal therapy has pervasive effects on the social adjustment of patients with schizophrenia that are independent of relapse prevention. Supportive therapy, with or without family intervention, produces adjustment effects that peak at 12 months after discharge and plateau thereafter. However, personal therapy, a definitive psychosocial intervention, continues to improve the social adjustment of patients in the second and third years after discharge. Brief treatment would appear to be less effective than a long-term, disorder-relevant intervention for schizophrenia.
The study of individual psychotherapeutic approaches to the treatment of schizophrenia has yielded equivocal findings, partly because of methodologic problems. Further, the ability of psychosocial treatments to prevent psychotic relapse appears to lessen over time. The authors' goal was to develop and test a demonstrably effective individual therapy for schizophrenia.
Using a study design that addressed previous methodologic issues, the authors evaluated personal therapy specifically designed to forestall late relapse in patients with schizophrenia. They evaluated the effectiveness of personal therapy over a period of 3 years after hospital discharge among 151 patients with schizophrenia or schizoaffective disorder diagnosed according to Research Diagnostic Criteria. The patients were randomly assigned to receive either personal therapy or contrasting therapies in one of two concurrent trials. One trial studied patients who were living with family (N = 97); the other studied patients who were living independent of family (N = 54).
All of the patients had extensive psychiatric histories, but only 44 (29%) experienced recurrent psychotic episodes over the 3-year study period, and only 27 (18%) prematurely terminated the study; most of those who left the study were in the no-personal-therapy conditions. Among patients living with family, personal therapy was more effective than family and supportive therapies in preventing psychotic and affective relapse as well as noncompliance. However, among patients living independent of family, those who received personal therapy had significantly more psychotic decompensations than did those who received supportive therapy.
Personal therapy had a positive effect on adverse outcomes among patients who lived with family. However, personal therapy increased the rate of psychotic relapse for patients living independent of family. The application of personal therapy might best be delayed until patients have achieved symptom and residential stability.
Psychiatric history, familial history of suicide attempts, and certain traumatic life events are important predictors of suicidal thoughts and behaviour. We examined the epidemiology and genetics of suicidality (i.e. reporting persistent suicidal thoughts or a plan or suicide attempt) in a large community-based sample of MZ and DZ twin pairs.
Diagnostic telephone interviews were conducted in 1992-3 with twins from an Australian twin panel first surveyed in 1980-82 (N = 5995 respondents). Data were analysed using logistic regression models, taking into account twin pair zygosity and the history of suicidality in the respondent's co-twin.
Lifetime prevalence of suicidal thoughts and attempts was remarkably constant across birth cohorts 1930-1964, and across gender. Major psychiatric correlates were history of major depression, panic disorder, social phobia in women, alcohol dependence and childhood conduct problems. Traumatic events involving assault (childhood sexual abuse, rape or physical assault) or status-loss (job loss, loss of property or home, divorce), and the personality trait neuroticism, were also significantly associated with suicide measures. Prevalence of serious suicide attempts varied as a function of religious affiliation. After controlling for these variables, however, history of suicide attempts or persistent thoughts in the respondent's co-twin remained a powerful predictor in MZ pairs (odds ratio = 3.9), but was not consistently predictive in DZ pairs. Overall, genetic factors accounted for approximately 45% of the variance in suicidal thoughts and behaviour (95% confidence interval 33-51%).
Risk of persistent suicidal thoughts and suicide attempts is determined by a complex interplay of psychiatric history, neuroticism, traumatic life experiences, genetic vulnerability specific for suicidal behaviour and sociocultural risk or protective factors.
The assumption that psychotic patients assigned to placebo in clinical trials of antipsychotics are exposed to substantial morbidity and mortality is not based on data about what actually happens to such patients. This study assesses symptoms and risks of suicide and suicide attempts in psychotic patients assigned to receive placebo in clinical trials.
The authors used the Food and Drug Administration database to assess suicides, suicide attempts, and psychotic symptom reduction in clinical trials of three new antipsychotics.
Among 10,118 participating patients, 26 committed suicide and 51 attempted suicide. Rates of suicide and attempted suicide did not differ significantly between the placebo-treated and the drug-treated groups. Annual rates of suicide and attempted suicide based on patient exposure years were 1.8% and 3.3%, respectively, with placebo; 0.9% and 5.7% with an established antipsychotic; and 0.7% and 5.0% with a new antipsychotic. Symptom reduction was 16.6% with new antipsychotics (N=1,203), 17.3% with established antipsychotics (N=261), and 1.1% with placebo (N=462).
These data may help inform discussions about the use of placebo in antipsychotic clinical trials.
Suicide risk was addressed in relation to the joint effect of factors regarding family structure, socioeconomics, demographics, mental illness, and family history of suicide and mental illness, as well as gender differences in risk factors.
Data were drawn from four national Danish longitudinal registers. Subjects were all 21,169 persons who committed suicide in 1981-1997 and 423,128 live comparison subjects matched for age, gender, and calendar time of suicide by using a nested case-control design. The effect of risk factors was estimated through conditional logistic regression. The interaction of gender with the risk factors was examined by using the log likelihood ratio test. The population attributable risk was calculated.
Of the risk factors examined in the study, a history of hospitalization for psychiatric disorder was associated with the highest odds ratio and the highest attributable risk for suicide. Cohabiting or single marital status, unemployment, low income, retirement, disability, sickness-related absence from work, and a family history of suicide and/or psychiatric disorders were also significant risk factors for suicide. Moreover, these factors had different effects in male and female subjects. A psychiatric disorder was more likely to increase suicide risk in female than in male subjects. Being single was associated with higher suicide risk in male subjects, and having a young child with lower suicide risk in female subjects. Unemployment and low income had stronger effects on suicide in male subjects. Living in an urban area was associated with higher suicide risk in female subjects and a lower risk in male subjects. A family history of suicide raised suicide risk slightly more in female than in male subjects.
Suicide risk is strongly associated with mental illness, unemployment, low income, marital status, and family history of suicide. The effect of most risk factors differs significantly by gender.
The authors compared the characteristics of suicide attempters with and without comorbid psychiatric and personality disorders to identify factors that explain the high suicide risk associated with psychiatric comorbidity.
A representative group of 111 patients who had attempted suicide (72 female and 39 male) was assessed for psychiatric and personality disorders according to ICD-10 criteria. The characteristics of patients with both types of disorder were compared with those of patients without comorbid disorders. A semistructured interview schedule and standardized questionnaires were used to investigate patients' background characteristics, the circumstances of the suicide attempts, psychological characteristics, and outcome after 12-20 months.
Comorbidity of psychiatric and personality disorders was present in 49 patients (44%). More patients with comorbid disorders had made previous suicide attempts (N=41 [84%] versus N=28 [45%]) and repeated attempts during the follow-up period (N=25 [51%] versus N=9 [15%]). Differences in precipitants and motives for the index episode were also found: patients with comorbid disorders were more depressed and hopeless, reported more episodes of aggression, were more impulsive, and had lower self-esteem and poorer problem-solving skills. Differences in self-esteem and problem-solving skills distinguished between the groups in a stepwise discriminant function analysis. More of the patients with comorbid disorders reported not being loved by their parents and parental suicidal behavior.
Suicide attempters with comorbid psychiatric and personality disorders show marked differences from those without both of these disorders. Comorbidity may contribute to greater suicide risk. Some of the characteristics of patients with comorbid disorders pose major clinical challenges that should be addressed in an effort to reduce suicide risk.
The topic of insight in schizophrenia and related disorders has become a major focus of research in psychiatry and psychology, and has important clinical implications in terms of outcome, treatment adherence, competence, and forensic issues. This resource examines the role of 'insight' within the mentally ill and presents a broad range of interdisciplinary work, including chapters on neuropsychology, neuroimaging, violence and stigma, legal and consumer views.
Objective: The suicide rate in schizophrenia is high, with the risk being highest early in the course. The rate of suicide attempts before treatment onset is also high and is often the event leading up to first treatment contact. A previous report showed that the duration of untreated psychosis can be reduced through an early detection program, and that the reduction was associated with lower symptom levels at treatment initiation. Treatment programs that bring first-episode patients into treatment at lower symptom levels can have the potential to reduce risk for suicide attempts. Method: The authors examined consecutive patients with nonorganic, nonaffective psychosis who sought initial treatment at psychiatric treatment units in four catchment areas: two that had an early detection program and two that did not. Results: The rate of severe suicidality (plans or attempts) was significantly higher in subjects from communities without the early detection program relative to those from early detection communities, even after adjustments for known predictors of suicidality. Conclusion: Early detection programs that bring patients into treatment at lower symptom levels may reduce suicidality risk at first treatment contact.
Chapter 1 briefly reviews the history of the use of the term “insight” in psychiatry, followed by a review of current methods and challenges related to its assessment, considers the relationship between insight and symptoms of psychosis before moving on to suggest the unique role of poor insight in schizophrenia. It concludes by discussing the etiological factors underlying the development of deficits in illness awareness, or poor insight, and discusses the implications for therapeutic strategies designed to either improve insight and/or remedy the serious problems created by it (e.g., nonadherence to treatment and services and estrangement from caregivers).
• To investigate the contribution of genetic and environmental factors in the etiology of mood disorders, a study was initiated to examine the frequency of psychiatric disorders in the biological and adoptive relatives of adult adoptees with mood disorders and in matched normal adoptees. Psychiatric evaluations of the relatives were made on the basis of independent blind diagnoses based on mental hospital and other official records. Analysis of the data showed an eightfold increase in unipolar depression among the biological relatives of the index cases and a 15-fold increase in suicide among the biological relatives of the index cases. These data demonstrate a significant genetic contribution to unipolar depression and suicide. They fail to disclose a significant contribution of family-associated transmission in the genesis of the mood disorders.
Background
Approximately 50% of patients with schizophrenia or schizoaffective disorder attempt suicide, and approximately 10% die of suicide. Study results suggest that clozapine therapy significantly reduces suicidal behavior in these patients.Methods
A multicenter, randomized, international, 2-year study comparing the risk for suicidal behavior in patients treated with clozapine vs olanzapine was conducted in 980 patients with schizophrenia or schizoaffective disorder, 26.8% of whom were refractory to previous treatment, who were considered at high risk for suicide because of previous suicide attempts or current suicidal ideation. To equalize clinical contact across treatments, all patients were seen weekly for 6 months and then biweekly for 18 months. Subsequent to randomization, unmasked clinicians at each site could make any interventions necessary to prevent the occurrence of suicide attempts. Suicidal behavior was assessed at each visit. Primary end points included suicide attempts (including those that led to death), hospitalizations to prevent suicide, and a rating of "much worsening of suicidality" from baseline. Masked raters, including an independent suicide monitoring board, determined when end point criteria were achieved.Results
Suicidal behavior was significantly less in patients treated with clozapine vs olanzapine (hazard ratio, 0.76; 95% confidence interval, 0.58-0.97; P = .03). Fewer clozapine-treated patients attempted suicide (34 vs 55; P = .03), required hospitalizations (82 vs 107; P =.05) or rescue interventions (118 vs 155; P = .01) to prevent suicide, or required concomitant treatment with antidepressants (221 vs 258; P = .01) or anxiolytics or soporifics (301 vs 331; P =.03). Overall, few of these high-risk patients died of suicide during the study (5 clozapine vs 3 olanzapine-treated patients; P = .73).Conclusions
Clozapine therapy demonstrated superiority to olanzapine therapy in preventing suicide attempts in patients with schizophrenia and schizoaffective disorder at high risk for suicide. Use of clozapine in this population should lead to a significant reduction in suicidal behavior.
Background:
While previous studies have shown an increased rate of suicidal behavior in the relatives of suicide victims, it is unclear if this is attributable merely to increased familial rates of psychiatric disorders. Therefore, we conducted a family study of adolescent suicide victims (suicide probands) and community control probands (controls) to determine if the rates of suicidal behavior were higher in the relatives of adolescent suicide probands even after adjusting for differences in the familial rates of psychiatric disorders.
Method:
The relatives of 58 adolescent suicide probands and 55 demographically similar controls underwent assessment for Axis I and II psychiatric disorders, lifetime history of aggression, and history of suicidal behavior (attempts and completions) using a combination of family study and family history approaches.
Results:
The rate of suicide attempts was increased in the first-degree relatives of suicide probands compared with the relatives of controls, even after adjusting for differences in rates of proband and familial Axis I and II disorders (odds ratio, 4.3; 95% confidence intervals, 1.1-16.6). On the other hand, the excess rate of suicidal ideation found in the relatives of suicide probands was explained by increased familial rates of psychiatric disorders. Among suicide probands, higher ratings of aggression were associated with higher familial loading for suicide attempts.
Conclusions:
Liability to suicidal behavior might be familially transmitted as a trait independent of Axis I and II disorders. The transmitted spectrum of suicidal behavior includes attempts and completions, but not ideation, and the transmission of suicidal behavior and aggression are related.
• Suicide appears to cluster in fanmilies, suggesting that genetic factors may play a role in this behavior. We studied 176 twin pairs in which one or both twins had committed suicide. Seven of the 62 monozygotic twin pairs were concordant for suicide compared with two of the 114 dizygotic twin pairs (11.3% vs 1.8%). The presence of psychiatric disorder in the twins and their families was examined in a subsample of 11 twin pairs, two of whom were concordant for suicide. Eleven of these 13 twin suicide victims had been treated for psychiatric disorder, as had eight of their nine surviving cotwins. In addition, twins in 10 pairs had other first- or second-degree relatives who had been treated for psychiatric disorder. Thus, these twin data suggest that genetic factors related to suicide may largely represent a genetic predisposition for the psychiatric disorders associated with suicide. However, they leave open the question of whether there may be an independent genetic component for suicide.
• The prevalence of mental disorders (DSM-III-R Axes I and II) among adolescent suicide victims (n = 53) was investigated in a nationwide psychological autopsy study in Finland. The data were collected comprehensively through interviews of the victims' relatives and attending health care personnel and from official records. Following independent assessment by two psychiatrists, the DSM-III-R diagnoses were assigned in consensus meetings. A large majority of the victims (94%) suffered from a mental disorder. The most prevalent disorders were depressive disorders (51%) and alcohol abuse or dependence (26%). The prevalence of adjustment disorders (21%) was higher than in most studies from other countries. Personality disorder was diagnosed in 32% of the cases. Comorbidity was found in 51% of the victims. The results indicate a strong relatedness between adolescent suicide and the presence of depression, antisocial behavior, and alcohol abuse.
Background Cognitive—behavioural therapy (CBT) improves persistent psychotic symptoms.
Aims To test the effectiveness of added CBT in accelerating remission from acute psychotic symptoms in early schizophrenia.
Method A 5-week CBT programme plus routine care was compared with supportive counselling plus routine care and routine care alone in a multi-centre trial randomising 315 people with DSM—IV schizophrenia and related disorders in their first (83%) or second acute admission. Outcome assessments were blinded.
Results Linear regression over 70 days showed predicted trends towards faster improvement in the CBT group.
Uncorrected univariate comparisons showed significant benefits at 4 but not 6 weeks for CBTv. routine care alone on Positive and Negative Syndrome Scale total and positive sub-scale scores and delusion score and benefits v. supportive counselling for auditory hallucinations score.
Conclusions CBT shows transient advantages over routine care alone or supportive counselling in speeding remission from acute symptoms in early schizophrenia.
The lifetime risks of suicide are generally quoted as 15% for affective disorder and alcoholism and 10% for schizophrenia, based on data from 1921-1975 and on calculations performed before computerised modelling techniques became available. This study recalculates the risk using contemporary data and modern techniques.
Twenty-seven mortality studies provided data for affective disorder, 27 for alcohol dependence and 29 for schizophrenia. The proportion of the cohort who had died was plotted against the proportion of deaths from suicide. Modelling techniques fitted curves through the data points extrapolating them to cohort extinction, thus estimating the lifetime risk of suicide for each disorder.
The lifetime risk was estimated at 6% for affective disorder. 7% for alcohol dependence and 4% for schizophrenia.
The lifetime suicide risk figures often quoted in the literature appear to be too high.
Suicide is the single major cause of death among patients with schizophrenia. Despite great efforts in the prevention of such deaths, suicide rates have remained alarming, pointing to the need for a better understanding of the phenomenon. The present sample comprised 20 male patients with schizophrenia who committed suicide and who were investigated retrospectively for a large number of characteristics. Controls were 20 living patients with schizophrenia. The results suggest that suicide attempts, hopelessness and self-devaluation were the three variables most strongly associated with completed suicide. However, a number of variables were identified which may constitute risk factors, some of which have not been identified in the past: agitation and motor restlessness (OR = 3.66; 95%CI = 0.95/14.02), self-devaluation (OR = 28.49; 95%CI = 3.15/257.40), hopelessness (OR = 51.00; 95%CI = 7.56-343.72), insomnia (OR = 12.66; 95%CI = 0.95/14.02), mental disintegration (OR = 3.66; 95%CI = 0.95/14.02), and suicide attempt (OR = 3.66; 95%CI = 1.40/114.41). Poor adherence to medications was also predictive of completed suicide in our sample of schizophrenia patients, primarily because the suicide victims showed very low adherence.
Suicide rate among schizophrenia patients may vary for several reasons, one of the most important being the time point of the suicide during the illness process. However, prospective studies on suicide risk in population-based cohort of individuals with new-onset schizophrenia have been lacking.
The data were collected for 10,934 individuals alive in Finland at the age of 16 from the genetically homogenous, population-based Northern Finland 1966 Birth Cohort ascertained already during mid-pregnancy. The Finnish Hospital Discharge Register was used until the end of 1997 (age 31) to identify cases with mental disorder. Case records were scrutinized and diagnoses were re-checked for DSM-III-R criteria. One hundred subjects met the DSM-III-R criteria for schizophrenia. Deaths by the end of year 2005 (age 39) were ascertained from death certificates.
Suicides (n = 7) accounted for 50% of all the deaths at age from 16 to 39. Seven (7.0%) subjects with schizophrenia had committed suicide; suicide rate being 2.9% (1/35) for women and 9.2% (6/65) for men. Furthermore, 71% of suicides in schizophrenia occurred during the first 3 years after onset of illness.
The suicide rate for patients with new-onset schizophrenia followed until the age of 39 was high and accounted for half of the deaths. Great majority of the suicides took place during the first years of the illness.
This study examined Drake's model that individuals with schizophrenia with good premorbid adjustment and insight into their illness are more vulnerable to becoming demoralized and therefore suicidal. One hundred sixty-four patients with schizophrenia (N = 115) or schizoaffective disorder (N = 49) were assessed for depressive symptoms and DSM-III-R depression, premorbid functioning, insight and suicidal behavior using The Diagnostic Interview for Genetic Studies and the Premorbid Adjustment Scale. Premorbid adjustment, insight and past MDE did not discriminate attempters from nonattempters, contrary to the model. However, consistent with the model, the interaction between good premorbid adjustment and insight predicted severity of depressive symptoms, and the psychological symptoms of depression significantly differentiated attempters from nonattempters, whereas the somatic symptoms did not. This study provides support for some aspects of the demoralization model.
Previous reports regarding risk factors for suicide in schizophrenia have been inconclusive. We performed a matched case-control study of in-patient-treated schizophrenia patients in order to assess the suicide risk associated with socioeconomic, demographic, and psychiatric factors. The cases were 84 patients who died by suicide within five years after diagnosis in a cohort of all patients discharged for the first time from psychiatric hospitals in Stockholm County, Sweden, with a diagnosis of schizophrenia, schizophreniform disorder or schizoaffective disorder between the years 1984 and 2000. One control was individually and randomly matched with each case from the same cohort by date (+/-1 year) and age (+/-5 years) at index diagnosis. Data were retrieved from clinical records of the case-control pairs in a blind fashion. Of the suicides, 54% were men and 46% were women. In multivariate analyses, higher educational attainment (odds ratio [OR] 3.0, 95% confidence interval [CI] 1.03-8.0), age >or=30 years at onset of symptoms (OR 4.8, CI 1.1-21.2), and a history of a suicide attempt requiring non-psychiatric medical treatment (OR 5.0, CI 1.6-15.4) were found to be significantly associated with an increased suicide risk. Gender did not significantly affect the suicide risk, nor did a history of self-discharge, compulsory in-patient treatment, substance-use disorder or a family history of mental disorders or suicide. In schizophrenia, certain suicide risk factors may differ from those in the general population. Clinical suicide risk assessment for schizophrenia patients should be performed taking this into account.
Neurocognitive enhancement therapy (NET) is a remediation program for the persistent and function-limiting cognitive impairments of schizophrenia. In a previous study in veterans, NET improved work therapy outcomes as well as executive function and working memory. The present study aimed to determine whether NET could enhance functional outcomes among schizophrenia and schizoaffective patients in a community mental health center receiving community-based vocational services.
Patients (N=72) participated in a hybrid transitional and supported employment program (VOC) and were randomized to either NET+VOC or VOC only. NET+VOC included computer-based cognitive training, work feedback and a social information information-processing group. VOC only also included two weekly support groups. Active intervention was 12 months with 12 month follow-up. Follow-up rate was 100%.
NET+VOC patients worked significantly more hours during the 12 month follow-up period, reached a significantly higher cumulative rate of competitive employment by the sixth quarter, and maintained significantly higher rates of employment.
NET training improved vocational outcomes, suggesting the value of combining cognitive remediation with other rehabilitation methods to enhance functional outcomes.
By reviewing causes of death among cohorts of various major disease entities or conditions, one may infer that a large majority of suicides are associated with a relatively small number of conditions. From the available follow-up studies, we might estimate that the following percentage of affected individuals will die by suicide: primary (endogenous) depression, 15 per cent; reactive (neurotic) depression, 15 per cent; alcoholism, 15 per cent; schizophrenia, 10 per cent; psychopathic personality, 5 per cent; opiate addiction, 10 per cent or more. Rough estimates of the number of suicides per year in the United States attributable to each condition might be as follows (using low incidence figures): depression, 12,900; alcoholism, 6,900; schizophrenia, 3,800; psychopathy, 2,000 (?); drug addiction, 900.
This article reports suicide risk among 200 schizophrenic, 100 manic, and 225 depressive patients, and 160 surgical controls. The suicide experience of the study subjects was compared to that of the population of the state of Iowa, the geographical area and population from which the subjects were selected. The suicide experience of the surgical controls was not significantly different from that of the general population. On the other hand, increased risk of suicide was found in all psychiatric groups except female schizophrenics. Suicide appeared pronounced particularly in male patients with affective disorders during the first decade of the follow-up period.
A clinical study of 25 male and 17 female schizophrenic suicides is presented. Jumping from a height was the most common method used. The 42 suicidal schizophrenics in Taiwan were compared with both 84 sex- and age-matched and 60 5-year illness course non-suicidal schizophrenic control groups. The suicidal schizophrenics were not significantly different from the non-suicidal counterparts of both control groups with regard to age, sex, ethnicity, religion, educational background, the presence of suicide cases in the family history, and the presence of insight, but were significantly different in characteristics of a history of previous suicide attempts, presence of psychotic symptoms during their final month, depression during their final month, a history of depression, a history of previous psychiatric hospitalizations, and the number of hospitalizations. We discuss the findings from this study and others in the literature in the context of the different clinical and socio-cultural backgrounds of these Taiwanese schizophrenic suicides.
The prevalence of mental disorders (DSM-III-R Axes I and II) among adolescent suicide victims (n = 53) was investigated in a nationwide psychological autopsy study in Finland. The data were collected comprehensively through interviews of the victims' relatives and attending health care personnel and from official records. Following independent assessment by two psychiatrists, the DSM-III-R diagnoses were assigned in consensus meetings. A large majority of the victims (94%) suffered from a mental disorder. The most prevalent disorders were depressive disorders (51%) and alcohol abuse or dependence (26%). The prevalence of adjustment disorders (21%) was higher than in most studies from other countries. Personality disorder was diagnosed in 32% of the cases. Comorbidity was found in 51% of the victims. The results indicate a strong relatedness between adolescent suicide and the presence of depression, antisocial behavior, and alcohol abuse.
Suicide appears to cluster in families, suggesting that genetic factors may play a role in this behavior. We studied 176 twin pairs in which one or both twins had committed suicide. Seven of the 62 monozygotic twin pairs were concordant for suicide compared with two of the 114 dizygotic twin pairs (11.3% vs 1.8%). The presence of psychiatric disorder in the twins and their families was examined in a subsample of 11 twin pairs, two of whom were concordant for suicide. Eleven of these 13 twin suicide victims had been treated for psychiatric disorder, as had eight of their nine surviving cotwins. In addition, twins in 10 pairs had other first- or second-degree relatives who had been treated for psychiatric disorder. Thus, these twin data suggest that genetic factors related to suicide may largely represent a genetic predisposition for the psychiatric disorders associated with suicide. However, they leave open the question of whether there may be an independent genetic component for suicide.
Suicide rates among schizophrenic individuals are disturbingly high. At present, suicide is the number one cause of premature
death among schizophrenics, with 10 to 13 percent killing themselves. Recent studies place the risk of suicide for persons
with schizophrenia at a level comparable to that for persons with affective disorder. Depression, especially the symptom of
self-reported or perceived hopelessness, is an important comorbidity factor in assessing this risk. Young white schizophrenic
men with high levels of premorbid functioning and high expectations are at particularly high risk. Schizophrenic women, unlike
women in the general population, behave more like men when it comes to choosing suicide. This article reviews recent studies
reporting suicide rates and risk factors for suicide among schizophrenic patients. Current issues concerning the prediction,
prevention, and treatment of suicidality among persons with schizophrenia are also discussed.
To investigate the contribution of genetic and environmental factors in the etiology of mood disorders, a study was initiated to examine the frequency of psychiatric disorders in the biological and adoptive relatives of adult adoptees with mood disorders and in matched normal adoptees. Psychiatric evaluations of the relatives were made on the basis of independent blind diagnoses based on mental hospital and other official records. Analysis of the data showed an eightfold increase in unipolar depression among the biological relatives of the index cases and a 15-fold increase in suicide among the biological relatives of the index cases. These data demonstrate a significant genetic contribution to unipolar depression and suicide. They fail to disclose a significant contribution of family-associated transmission in the genesis of the mood disorders.
Patients with command hallucinations (voices ordering particular acts, often violent or destructive ones) are commonly assumed to be at high risk for dangerous behavior. The authors reviewed 789 consecutive inpatient admissions. Of 151 patients with auditory hallucinations, 58 (38.4%) heard commands. The presence of auditory hallucinations was significantly associated with diagnosis, demographic variables, and use of maximal observation and seclusion. However, patients with command hallucinations were not significantly different from patients without commands on demographic and behavioral variables, including suicidal ideation or behavior and assaultiveness. These findings suggest that command hallucinations alone may not imply greater risk for acute, life-threatening behavior.
Although suicidal behavior frequently complicates the treatment of schizophrenia, there are no clear criteria for evaluating suicide risk among schizophrenics. This review summarizes and integrates the available empirical studies. Studies that focus on schizophrenics and provide adequate comparison groups are emphasized. The literature suggests that young, male schizophrenics are the most vulnerable to self-destruction, particularly during the early years of illness. A clinical course characterized by many exacerbations and remissions increases risk. These patients experience severe functional deterioration yet retain a non-delusional awareness of the effects of chronic illness. Changes in clinical course precipitate suicide, and the period of clinical improvement following relapse is a particularly vulnerable time. Suicide occurs more frequently during periods of depression and hopelessness than during episodes of intense psychosis. Signs of severe agitation and excessive treatment dependence during hospitalization are dangerous. Previous suicidal behavior also increases the risk of completing suicide. Problems with the current research, controversies within the literature, and recommendations for further research are discussed.
A matched controlled study of 30 chronic schizophrenic suicides is presented. Eighty per cent were male and committed suicide at a mean age of 25.8 years after a mean duration of illness of 4.8 years. Significantly more of the suicides had a chronic relapsing schizophrenic illness; 23.3 per cent committed suicide while in-patients, and 50 per cent of the out-patients committed suicide within three months of discharge from in-patient care. Significantly more of the suicides had a past history of depression (56.6 per cent), were depressed in the last episode of contract (53.3 per cent), had their last admission for depression or suicidal ideation (55.2 per cent) and were unemployed (80 per cent).
By means of the psychological autopsy method and a case-control design, the authors examined the association of specific mental disorders and comorbidity with suicide among young men.
Seventy-five men aged 18-35 years whose deaths were adjudicated as completed suicides by coroners of greater Montreal and Quebec City were matched to 75 living young men for age, neighborhood, marital status, and occupation. For each subject in both groups a key respondent best acquainted with the subject was interviewed by clinicians using standardized schedules. Information from the coroner and medical records was also collected. Two experienced psychiatrists, blind to outcome, established best-estimate DSM-III-R diagnoses.
Six-month prevalence rates for all axis I diagnoses for the suicide and comparison groups were 88.0% and 37.3%, respectively; major depression was present in 38.7% and 5.3%, alcohol dependence in 24.0% and 5.3%, psychoactive substance dependence in 22.7% and 2.7%. Borderline personality disorder was identified in 28.0% and 4.0%, respectively. Of the suicide subjects, 28.0% had at least two of the following disorders: major depression, borderline personality disorder, and alcohol or drug dependence; the rate was 0.0% among the comparison subjects.
In young men, completed suicide is linked to specific mental disorders, namely, major depression, borderline personality disorder, and substance abuse. Comorbidity involving any of these disorders is frequently associated with completed suicide.
The presence of command hallucinations in individuals with schizophrenia may result in an increase in clinical monitoring to reduce the perceived risk of violent behavior. However, the issue of whether command hallucinations hold any clinical relevance in relatively stable outpatient samples has not been established.
The clinical and research records of individuals with schizophrenia who participated in outpatient research protocols at the University of California, San Diego were reviewed for the presence of command hallucinations. Information on clinical characteristics was collected in a detailed chart review from 106 patient records.
Command hallucinations were reported by one half of all patients with auditory hallucinations, and these hallucinations often were violent in content. Yet, in over a third of the patients, these hallucinations had not been documented in their clinical charts, but instead were uncovered during a secondary source review. Patients with command hallucinations generally did not differ on prognostic or clinical course variables. However, the 2 patients who committed suicide during the study were patients with command hallucinations.
Although command hallucinations may be more frequent than clinicians generally note, in most cases they have minimal influence on the outcome of schizophrenia. However, in outpatients with schizophrenia who have a history of suicide attempts, suicidal command hallucinations should be taken seriously.
Suicide has been reported to occur in 9%-13% of schizophrenic patients. It has been suggested that neuroleptic-resistant or neuroleptic-intolerant schizophrenic patients are at higher risk for suicide than neuroleptic-responsive patients. Clozapine is the treatment of choice for neuroleptic-resistant patients, but its use has been greatly limited because of its ability to cause potentially fatal agranulocytosis. The purpose of this study was to compare the suicidality of neuroleptic-resistant and neuroleptic-responsive patients and to determine if clozapine treatment decreased suicidality in the former group.
Prior episodes of suicidality were assessed in a total of 237 neuroleptic-responsive and 184 neuroleptic-resistant patients with schizophrenia or schizoaffective disorder. Eighty-eight of the neuroleptic-resistant patients were treated with clozapine and prospectively evaluated for suicidality for periods of 6 months to 7 years.
There was no significant difference in prior suicidal episodes between neuroleptic-responsive and neuroleptic-resistant patients. Clozapine treatment of the neuroleptic-resistant patients during the follow-up period resulted in markedly less suicidality. The number of suicide attempts with a high-probability of success decreased from five to zero. This decrease in suicidality was associated with improvement in depression and hopelessness.
These results suggest a basis for reevaluation of the risk-benefit assessment of clozapine, i.e., that the overall morbidity and mortality of patients with neuroleptic-resistant schizophrenia are less with clozapine treatment than with typical neuroleptic drugs because of less suicidality. This conclusion also has implications for increasing the use of clozapine with neuroleptic-responsive patients.
An initial finding of heightened risk of suicidal ideation or behavior among individuals in a random community sample who met diagnostic criteria for panic disorder or panic attacks was not replicated in later studies of both general and specific groups of psychiatric outpatients. The present study represented another effort to validate the finding.
The participants included 209 outpatients who had attempted suicide or were at high risk for continued suicidal behavior or eventual suicide. All subjects were evaluated with a structured clinical interview for assigning DSM-III-R diagnoses, the Modified Scale for Suicidal Ideation, the suicidal ideation subscale of the Suicide Probability Scale, and the Beck Hopelessness Scale.
The findings indicated the relative complexity and importance of diagnostic comorbidity among these suicidal subjects. Mood disorders were the most frequent primary diagnoses, followed by phobias, posttraumatic stress disorder (PTSD), generalized anxiety disorder, and panic disorder. Panic disorder was not present as an isolated, independent diagnosis; on the contrary, all of the patients with panic disorder also received at least one additional comorbid diagnosis. Mean scores for suicidal ideation and hopelessness were greatest for patients with current comorbid primary mood disorder and panic disorder. However, a critical and equally important role was played by comorbid PTSD, generalized anxiety disorder, and phobias.
The findings represent another failure to validate, with a specific clinical group, panic disorder as an independent risk factor for suicidal ideation or behavior. However, they highlight the possibility that panic disorder and other anxiety disorders are risk factors when they co-occur with a primary mood disorder.
The aim of this study was to compare the prevalence and comorbidity patterns of psychiatric disorders in subjects making medically serious suicide attempts and in comparison subjects.
The association between mental disorders and the risk of a suicide attempt was examined in 302 consecutive individuals who made serious suicide attempts and 1,028 randomly selected comparison subjects. Each subject completed a semistructured interview, and a significant other underwent a parallel interview; best-estimate DSM-III-R diagnoses were then generated.
Of those who made serious suicide attempts, 90.1% had a mental disorder at the time of the attempt. Multiple logistic regression showed that those who made suicide attempts had high rates of mood disorders (odds ratio = 33.4, 95% confidence interval = 21.9-1.2); substance use disorders (odds ratio = 2.6, 95% confidence interval = 1.6-4.3); conduct disorder or antisocial personality disorder (odds ratio = 3.7, 95% confidence interval = 2.1-6.5); and nonaffective psychosis (odds ratio = 16.8, 95% confidence interval = 2.7-105.8). The relationship between psychiatric morbidity and suicide risk varied with age and gender. The incidence of comorbidity was high: 56.6% of those who made serious suicide attempts had two or more disorders. The risk of a suicide attempt increased with increasing psychiatric morbidity: subjects with two or more disorders had odds of serious suicide attempts that were 89.7 times the odds of those with no psychiatric disorder.
Individuals who made serious suicide attempts had high rates of mental disorders and of comorbid disorders. Subjects with high levels of psychiatric comorbidity had markedly high risks of serious suicide attempts.
Although indirect support can be found for the clinical benefits of work, it has not been studied in randomized designs, nor
have critical variables been manipulated. One such variable is pay incentive. The authors present a study of 150 subjects
with schizophrenia or schizoaffective disorder who were randomized into Pay ($3.40/hour) and No-Pay conditions and offered
6-month work placements within a Department of Veterans Affairs medical center. Subjects participated in a work-related support
group and were evaluated weekly on symptom measures. Results indicated that Pay subjects worked more hours and earned more
money than No-Pay subjects. Pay subjects showed more total symptom improvement at followup, and more improvement, particularly
on positive and emotional discomfort symptoms. They also had a significantly lower rate of rehospitalization than No-Pay subjects.
Participation in work activity was closely associated with symptom improvement. Participators showed more total symptom improvement
at followup than partial participators or nonparticipators, and more improvement, particularly on positive, hostility, and
emotional discomfort symptoms. We concluded that pay increased participation and that, in this study, participation in work
activity was primarily responsible for symptom reduction.
Seventy schizophrenia patients and 97 depressives were studied prospectively while in the hospital and at periodic follow-ups. Positive symptoms, negative symptoms, and post-hospital functioning were assessed at the 2-year follow-up; and suicidal activity, at the 7.5-year follow-up. The results support an interactive model of suicide risk. Psychotic symptoms (i.e., hallucinations, delusions) predict later suicidal activity only for the schizophrenia patients. Deficit symptoms (psychomotor retardation, concreteness) predict later suicidal activity only for the depressive group. Adequacy of overall functioning predicts later suicidal activity for both diagnostic groups and appears to mediate the effects of psychosis in the schizophrenia group.
While previous studies have shown an increased rate of suicidal behavior in the relatives of suicide victims, it is unclear if this is attributable merely to increased familial rates of psychiatric disorders. Therefore, we conducted a family study of adolescent suicide victims (suicide probands) and community control probands (controls) to determine if the rates of suicidal behavior were higher in the relatives of adolescent suicide probands even after adjusting for differences in the familial rates of psychiatric disorders.
The relatives of 58 adolescent suicide probands and 55 demographically similar controls underwent assessment for Axis I and II psychiatric disorders, lifetime history of aggression, and history of suicidal behavior (attempts and completions) using a combination of family study and family history approaches.
The rate of suicide attempts was increased in the first-degree relatives of suicide probands compared with the relatives of controls, even after adjusting for differences in rates of proband and familial Axis I and II disorders (odds ratio, 4.3; 95% confidence intervals, 1.1-16.6). On the other hand, the excess rate of suicidal ideation found in the relatives of suicide probands was explained by increased familial rates of psychiatric disorders. Among suicide probands, higher ratings of aggression were associated with higher familial loading for suicide attempts.
Liability to suicidal behavior might be familially transmitted as a trait independent of Axis I and II disorders. The transmitted spectrum of suicidal behavior includes attempts and completions, but not ideation, and the transmission of suicidal behavior and aggression are related.
This paper presents a structured review of the published information on the mortality of schizophrenia.
A meta-analysis of the literature.
Schizophrenia has a significantly increased mortality from natural and unnatural causes. Twenty-eight percent of the excess mortality is attributable to suicide and 12% to accidents. The rest of the excess mortality is from the same broad range of conditions which cause deaths in the general population. Further interpretation is hampered by confounding variables, wide confidence intervals and reservations about generalising from individual cohorts.
The available evidence suggests that schizophrenia is associated with a large increased mortality from suicide and a moderate increased mortality from natural causes. A number of possible interventions have been identified, but we do not yet have reliable means of detecting any changes in mortality which might result.
Suicide is the major cause of premature death in patients with schizophrenia. Among these patients, 40% report suicidal thoughts, 20% to 40% make unsuccessful suicide attempts, and 9% to 13% end their lives by suicide. Traditional antipsychotic drugs undertreat many schizophrenic patients and can produce serious side effects, such as tardive dyskinesia. Clozapine is the only antipsychotic drug that has been shown in controlled clinical trials to be effective in reducing both positive and negative symptoms in schizophrenic patients who fail to respond to typical neuroleptic drugs. The potential decrease in suicide among schizophrenic patients treated with clozapine is estimated to be as high as 85%. Treatment with clozapine is cost-effective, and the significant decrease in the risk of suicide far outweighs the very low risk of mortality from agranulocytosis. Clozapine should be considered for treatment of both neuroleptic-resistant and neuroleptic-responsive schizophrenic patients who have persistent suicidal thoughts or behavior.
This article presents an updated review of studies on the relation between command hallucinations and dangerous behavior. The author reviewed all studies published between 1966 and 1997 according to MEDLINE and between 1974 and 1997 according to PSYCLIT. Forty-one studies were found, of which 82.9 percent dealt with the relation between command hallucinations and dangerous behavior. Of these studies, 32.3 percent were controlled, and they were grouped into three partially overlapping classes: those concerned with violent behavior, those concerned with suicidal behavior, and those concerned with mediating variables. Most of these studies agreed on the non-existence of an immediate relation between command hallucinations and dangerous (violent or suicidal) behavior. Even though the studies were divided about the existence of a relation between severity/dangerousness of command content and compliance with the commands, there was agreement about the existence of a direct relation between compliance with commands and both benevolence and familiarity of commanding voice. It seems that the research and knowledge available to date on this subject is both scant and methodologically weak. Future study should probably concentrate on mediating factors, such as appraisal and coping attitudes and behaviors.
Cognitive Enhancement Therapy (CET) is a developmental approach to the rehabilitation of schizophrenia patients that attempts to facilitate an abstracting and "gistful" social cognition as a compensatory alternative to the more demanding and controlled cognitive strategies that often characterize schizophrenia as well as much of its treatment. Selected cognitive processes that developmentally underlie the capacity to acquire adult social cognition have been operationalized in the form of relevant interactive software and social group exercises. Treatment methods address the impairments, disabilities, and social handicaps associated with cognitive styles that appear to underlie the positive, negative, and disorganized symptom domains of schizophrenia. Style-related failures in secondary rather than primary socialization, particularly social cognitive deficits in context appraisal and perspective taking, are targeted goals. Illustrative examples of the techniques used to address social and nonsocial cognitive deficits are provided, together with encouraging preliminary observations regarding the efficacy of CET.
Suicide is the single largest cause of premature death among individuals with schizophrenia. Furthermore, epidemiological data indicate that nearly 80% of patients with the diagnosis of schizophrenia will experience a major depressive episode at some time during their lifetime. This report reviews recent findings relative to the risk of suicide in schizophrenia, including data from the Chestnut Lodge longitudinal study of schizophrenia subtypes and symptom domains. Paradoxically, those patients with schizophrenia who are most likely to recover or experience a good outcome are also those at greatest risk for suicide. The reduction of morbidity and mortality in schizophrenia should include depression and suicidality as targets for both psychopharmacological and psychosocial treatment.
Lifetime substance abuse comorbidity is frequent in schizophrenic patients, but the clinical correlates remain unclear. We have explored the chronological relations between substance abuse and course of schizophrenia, and compared several clinical characteristics and personality dimensions in 50 schizophrenic patients with or without lifetime substance abuse or dependence. Abuse occurred mainly after the first prodromal symptoms and just before the first psychotic episode. Substance-abusing patients were not different from non-substance-abusing patients on the Chapman Physical Anhedonia Scale, PANSS total score, negative subscore or depression item, CGI, treatment response and demographic variables. In contrast, substance-abusing patients had higher scores on the Barratt Impulsivity Scale (total, cognitive and non-planning scores) and had attempted suicide more often. In patients with schizophrenia, as in the general population, substance abuse or dependence appears associated with higher impulsivity and suicidality. High impulsivity could facilitate substance abuse as a maladaptive behavior in response to prodromal symptoms, precipitating the onset of a characterized psychosis.