Article

Suicidal Ideation and Schizophrenia: Contribution of Appraisal, Stigmatization, and Cognition

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Abstract

Objective: To predict suicidal ideation in people with schizophrenia, certain studies have measured its relationship with the variables of defeat and entrapment. The relationships are positive, but their interactions remain undefined. To further their understanding, this research sought to measure the relationship between suicidal ideation with the variables of loss, entrapment, and humiliation. Method: The convenience sample included 30 patients with schizophrenia spectrum disorders. The study was prospective (3 measurement times) during a 6-month period. Results were analyzed by stepwise multiple regression. Results: The contribution of the 3 variables to the variance of suicidal ideation was not significant at any of the 3 times (T1: 16.2%, P = 0.056; T2: 19.9%, P = 0.117; T3: 11.2%, P = 0.109). Further analyses measured the relationship between the variables of stigmatization, perceived cognitive dysfunction, symptoms, depression, self-esteem, reason to live, spirituality, social provision, and suicidal ideation. Stepwise multiple regression demonstrated that the contribution of the variables of stigmatization and perceived cognitive dysfunction to the variance of suicidal ideation was significant at all 3 times (T1: 41.7.5%, P = 0.000; T2: 35.2%, P = 0.001; T3: 21.5%, P = 0.012). Yet, over time, the individual contribution of the variables changed: T1, stigmatization (β = 0.518; P = 0.002); T2, stigmatization (β = 0.394; P = 0.025) and perceived cognitive dysfunction (β = 0.349; P = 0.046). Then, at T3, only perceived cognitive dysfunction contributed significantly to suicidal ideation (β = 0.438; P = 0.016). Conclusion: The results highlight the importance of the contribution of the variables of perceived cognitive dysfunction and stigmatization in the onset of suicidal ideation in people with schizophrenia spectrum disorders.

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... Given the high risk of suicide in schizophrenia (Heilä et al., 2005) and its elevated risk among individuals in FEP (Ayesa-Arriola et al., 2015;Melle et al., 2006;Lopez-Morinigo et al., 2019), there remains critical interest and value in examining the role of depression, positive and negative symptoms, cognition, and clinical insight in relation to suicidal ideation among the schizophrenia spectrum population. While greater characterization of these features and their relationships have been demonstrated among individuals with schizophrenia-spectrum disorders (Villa et al., 2018;Barrett et al., 2011;Delaney et al., 2012;Stip et al., 2017), relatively less is known about them in earlier phases of illness with few studies focusing specifically on individuals in FEP. Accordingly, this study aims to examine the relationships between positive and negative symptoms, symptoms of depression, clinical insight, cognitive functioning, and suicidal ideation among a first-episode sample of participants with psychosis. ...
... The risk of suicide is markedly elevated among individuals experiencing FEP (Austad et al., 2015;Barrett et al., 2010;Chang et al., 2014), particularly when compared to individuals with in longerphases of schizophrenia spectrum disorder illness (Villa et al., 2018;Stip et al., 2017;Delaney et al., 2012;Barrett et al., 2011). Consistent with prior literature of adults with schizophrenia (Bornheimer, 2016;Montross et al., 2005;Tarrier et al., 2014;Bornheimer and Jaccard, 2017;Siris, 2001), our results suggest that individuals with FEP experiencing greater depression and positive symptoms at baseline had greater odds of experiencing suicidal ideation post-baseline. ...
Article
Background Suicide is a leading cause of death for individuals with psychosis. Although factors influencing suicide risk have been studied in schizophrenia, far less is known about factors that protect against or trigger increased risk during early-stage and first episode of psychosis. This study examined whether depression, psychotic symptoms, clinical insight, and cognition were associated with suicide ideation among individuals with first-episode psychosis. Methods Data were obtained from the Recovery After an Initial Schizophrenia Episode (RAISE) project. Participants (n = 404) included adults between ages 15 and 40 in a first episode of psychosis. Measurement included the Positive and Negative Syndrome Scale, Brief Assessment of Cognition in Schizophrenia, and Calgary Depression Scale for Schizophrenia. A logistic regression model evaluated clinical and cognitive variables as predictors of suicidal ideation. Results Greater positive symptoms (OR = 1.085, p < .01) and depression (OR = 1.258, p < .001) were associated with increased likelihood of experiencing suicidal ideation during the RAISE project. Meanwhile, stronger working memory (OR = 0.922, p < .05) and impaired clinical insight (OR = 0.734, p < .05) were associated with a decreased likelihood of experiencing suicidal ideation. Conclusion The likelihood of experiencing suicidal ideation was significantly increased when positive and depressive symptoms were present, and significantly decreased when clinical insight was poorer and working memory stronger. These findings have important implications for the role of cognition and insight in risk for suicide ideation in early-stage psychosis, which may aid in improving the prediction of suicide behaviors and inform clinical decision-making over the course of the illness.
... 74 Insight into illness, 70,75-80 avoidant personality traits, 81 and coping strategies, 82 loneliness, 83 and resilience 84 moderated the relationship with depression and self-esteem mediated the effects of self-stigma on hope. 85 Self-stigma mediated the effects of perceived cognitive dysfunction and experienced stigma on suicidality 86,87 and QoL. 88 Self-stigma was negatively associated with QoL (n = 41), self-esteem (n = 44), self-efficacy (n = 13), well-being (n = 9), life satisfaction (n = 8), empowerment (n = 11), resilience (n = 7), stigma resistance (n = 11), and personal recovery (n = 22). ...
... Mixed results were found for self-stigma stability over time with no specific intervention. 86,[102][103][104] Attending psychiatric rehabilitation was associated with significant reductions in self-stigma extent (from a mean total ISMI score of 2.31 on admission to 1.96 at discharge; 38 107 ) and in the proportion of participants with high self-stigma (ISMI > 2.5 from 37% to 13.7%; 38 reduction in ISMI levels at follow up > 25% in 38% of the participants with mean self-stigma > 2 103 ). Not receiving disability benefits during psychiatric rehabilitation was associated with a greater reduction in self-stigma. ...
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Article
Self-stigma is associated with poor clinical and functional outcomes in Serious Mental Illness (SMI). There has been no review of self-stigma frequency and correlates in different cultural and geographic areas and SMI. The objectives of the present study were: (1) to review the frequency, correlates, and consequences of self-stigma in individuals with SMI; (2) to compare self-stigma in different geographical areas and to review its potential association with cultural factors; (3) to evaluate the strengths and limitations of the current body of evidence to guide future research. A systematic electronic database search (PubMed, Web of Science, PsycINFO, Scopus, and Ovid SP Cumulative Index to Nursing and Allied Health Literature [CINAHL]) following PRISMA guidelines, was conducted on the frequency, correlates, and consequences of self-stigma in SMI. Out of 272 articles, 80 (29.4%) reported on the frequency of self-stigma (n = 25 458), 241 (88.6%) on cross-sectional correlates of self-stigma and 41 (15.0%) on the longitudinal correlates and consequences of self-stigma. On average, 31.3% of SMI patients reported high self-stigma. The highest frequency was in South-East Asia (39.7%) and the Middle East (39%). Sociodemographic and illness-related predictors yielded mixed results. Perceived and experienced stigma—including from mental health providers—predicted self-stigma, which supports the need to develop anti-stigma campaigns and recovery-oriented practices. Increased transition to psychosis and poor clinical and functional outcomes are both associated with self-stigma. Psychiatric rehabilitation and recovery-oriented early interventions could reduce self-stigma and should be better integrated into public policy.
... showed the strongest association with suicide. Schizophrenia showed the highest association with suicide both in the age group of 35 Table 5, schizophrenia showed high associations with the risk of suicide in for age groups of 20-34, 35-49, and 50-65 years. On the contrary, for age group of more than 65 years or less than 19 years, there was no significant association between schizophrenia and suicide. ...
... Previous studies have indicated perceived cognitive dysfunction and stigmatization in the onset of suicidal ideation in people with schizophrenia. 35 Significant associations between regional suicide rates and the intention to seek informal help, self-stigma, and shame have been reported in previous studies. 36 Therefore, prejudice and misconception might have affected suicide risk in adults with schizophrenia belonging to age groups of 35-49 and 50-65 years in South Korea. ...
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Article
Objective: Suicide is the leading cause of death in 10-39-year-olds in South Korea, and the second highest rate among the OECD countries. However, few studies have investigated the particularity of completed suicide in South Korea. Methods: Study subjects consisted of 2,838 suicide cases and 56,758 age and sex matched living controls from a national representative sample of 1,025,340 South Koreans. They were obtained from the Korean National Health Insurance Service-National Sample Cohort (NHIS-NSC) with follow-up up to 12 years. We obtained information on primary diagnosis of any ICD-10 disorder along with suicide cases during their lifetime. Results: Among ICD-10 disorders, depression was the most common disorder (19.10%, n=542), found in victims of completed suicides except for common medical disorders such as hypertensive crisis, respiratory tract infection or arthropathies. After adjusting for sex, age, economic status, disability, and disorders, schizophrenia showed the strongest association with suicide (AOR: 28.56, 95% CI: 19.58-41.66) among all ICD-10 disorders, followed by psoriasis, multiple body injury, epilepsy, sleep disorder, depression, and bipolar disorder. For age groups, ≤19 years was associated with anxiety disorder (AOR=80.65, 95% CI: 13.33-487.93), 20-34 years with epilepsy (AOR=134.92, 95% CI: 33.69-540.37), both 35-49 years (AOR=108.57, 95% CI: 37.17-317.09) and 50-65 years (AOR=189.41 95% CI: 26.59-1349.31), with schizophrenia, and >65 years (AOR=44.7, 95% CI: 8.93-223.63) with psoriasis. Conclusion: Psychiatric and physical disorders carried greatly increased risks and numbers of suicides in South Korea. Schizophrenia was the strongest risk factor, especially 35-65 years, and depression was the most common in suicide victims among ICD-10 disorders in South Korea.
... If individuals at risk are identified early, appropriate preventive interventions can be offered. Suicidal ideation has mostly been investigated in individuals living with a psychiatric disease (Fagiolini et al. 2004, Harris & Barraclough 1997, Stip et al. 2017 but there is much less known about suicide ideation in young individuals who are currently not in treatment for any disease. ...
Article
Background: Suicidal ideation is not restricted to psychiatric patients. To the contrary, it is not uncommon in the general population and constitutes a precursor for suicide attempts and completed suicides. While risk factors for suicidality have extensively been described, much less attention has been devoted to the investigation of protective factors. In the current study we investigated two of such potential protective factors in combination, namely trait emotional intelligence (EI) and resilience in a sample of university students. Subjects and methods: We recruited 277 university students without an active physical or mental disorder requiring medical attention via an online questionnaire and assessed lifetime and four-week suicidal ideation. Resilience was measured with the Connor-Davidson Resilience Scale, EI with the Self-report Emotional Ability Scale and stressful life events with the Social Readjustment Rating Scale. Logistic regression was used to investigate the effect of EI and resilience on lifetime and four-week suicidal ideation. Results: Resilience as well as intrapersonal trait EI factors were significantly lower in individuals who reported lifetime suicidal ideation. The regression analysis revealed the EI facet "Regulation of one's own emotions" and the resilience factor "Control" to be significant predictors of lifetime and/or four-week suicidal ideation. Neither trait EI nor resilience had a moderating effect on the relationship between life events and suicidality. Conclusions: Low intrapersonal EI and low resilience are associated with lifetime and, in part, four-week suicidal ideation.
... L'auto-stigmatisation est un des médiateurs entre un insight préservé et la survenue d'une dépression [74], [264][265][266][267][268]. De même, l'insight en lien avec la présence de troubles cognitifs contribuerait, via l'auto-stigmatisation, à un risque suicidaire accru et à une altération de la qualité de vie [232], [269], [270]. La réalisation précoce de programmes de psychoéducation orientés vers le rétablissement (TIPP ; [271] ; TCC-P ; [272]) pourrait permettre de réduire le stress lié à la stigmatisation et de prévenir l'auto-stigmatisation [42], [241]. ...
Thesis
L’auto-stigmatisation est fréquente chez les personnes avec Troubles Psychiques Sévères et Persistants (TPSP), dont elle altère le devenir clinique et fonctionnel. L’objectif de ce travail était de définir plus précisément l’auto-stigmatisation dans les TPSP et de mieux identifier les moyens d’y faire face. Il comporte plusieurs étapes : i) une 1ère revue systématique de littérature pour mieux appréhender les mécanismes cognitifs et neurobiologiques potentiels sous-tendant les effets de la stigmatisation; ii) une 2nde revue systématique de littérature sur la prévalence, les prédicteurs et les conséquences de l’auto-stigmatisation dans les TPSP ; iii) l’étude de la fréquence de l’auto-stigmatisation et de la résistance à la stigmatisation et des corrélats d’une auto-stigmatisation ou d’une résistance élevée à la stigmatisation dans la cohorte nationale des centres référents de réhabilitation psychosociale (REHABase), décrite dans un 1er article ; iv) l’adaptation française du programme de thérapie cognitive et de renforcement narratif (NECT) et un essai randomisé contrôlé évaluant son efficacité sur le fonctionnement social dans les TPSP, débutant au 1er trimestre 2020. L’auto-stigmatisation est un problème majeur de santé publique, et ce quelque soit l’aire géographique et culturelle, la pathologie ou le stade évolutif considérés. Environ 1/3 des participants de la cohorte REHABase ont une auto-stigmatisation élevée, celle-ci étant associée aux stades précoces du rétablissement et à un bien être et une satisfaction dans les relations sociales altérés. La résistance à la stigmatisation concerne plus de 50% des participants et est favorisée par la satisfaction dans les relations familiales. Ce travail a plusieurs implications cliniques et pour la recherche, discutées de façon approfondie
... In addition, some studies still fail to find any association between the factors of suicide and cognition; therefore, the association is still under speculation. For example, Stip et al. (2017) measured suicidal ideation and cognitive ability in 30 patients with schizophrenia and found that suicidal ideation was associated with cognitive dysfunction. This is in direct opposition to the association with increased cognitive performance found in other studies (see Villa et al. 2018;Vrbova et al. 2017b). ...
Chapter
Early thinking about cognitive process and suicidal behaviors tended to focus on the immediate situation surrounding the individual - typically the underlying psychiatric condition that was seen as leading to his or her distress. However, we now know that the cognitive processes involved in a range of suicidal thoughts and behaviors can exert a significant impact on the expression or development of these behaviors, even without an environmental stressor or psychiatric condition. In this chapter, we summarize theoretical perspectives that led to this realization and explore the current understanding of the link between cognition and suicide from recent research and clinical findings. We present these findings first by psychiatric disorder, then by cognitive domains, and finally by specific suicidal construct in order to highlight the importance of these factors in determining the role of cognition in the suicidal process.Within and across psychiatric disorders, certain cognitive processes - negativistic thinking, impulsivity, cognitive rigidity, and altered emotional processing - are frequently found to be linked to suicidal thoughts and behaviors. Overall cognitive performance, decreased processing speed, executive dysfunction, and negative biases in memory and attention have also been linked to suicidal thoughts and behaviors. However, these findings do not hold true for all populations. There seems to be a role both for cognitive distortions (such as hopelessness) and neurocognitive deficits (such as poor overall cognitive performance, slower processing speed, and executive dysfunction) in the suicidal process, which warrant further exploration both separately and together.
... Six studies did not report participants' stage of illness, one study included participants with chronic illness (of more than 14 years), one included participants in a second episode of psychosis or later, one included participants with a median 6 years of illness, and seven included participants who were in an early or first-episode phase of illness. Studies on risk and protective factors for suicide tend to include participants with longer illness duration and chronic psychotic symptoms (46)(47)(48)(49), and it is apparent that the psychosocial intervention literature is increasingly investigating the population experiencing a first episode in relation to suicide, which is particularly important given a higher risk of suicide among these individuals compared with individuals with longer duration of illness (50,51). It was encouraging to observe that subgroup analysis of studies focusing only on participants in an early or first-episode stage of illness reported an overall statistically significant treatment effect, which provides preliminary support for the use of psychosocial interventions for suicidal intervention among these patients. ...
Article
Objective: Suicide ideation, plan, attempt, and death are significant and prevalent concerns among individuals with psychosis. Previous studies have focused on risk factors, but few have systematically evaluated the effect of psychosocial interventions on these experiences among individuals with psychosis. This study evaluated the effectiveness of psychosocial interventions in reducing suicide ideation, plan, attempt, and death among individuals with psychotic symptoms. Methods: Eight electronic databases were systematically searched from inception until June 30, 2019. Identified studies included both randomized controlled trials and controlled trials without randomization that examined psychosocial interventions for suicide ideation, plan, attempt, and death among individuals with psychotic symptoms. A random-effects model was used to pool the effect sizes for synthesis. Results: Eleven studies with 14 effect sizes (N=4,829 participants) were analyzed. The average age of participants ranged from 21 to 51, and most participants identified as male and non-Hispanic Caucasian or Chinese and were in an early or first-episode stage of illness. On average, participants who received psychosocial interventions were less likely than their counterparts in the control group to report suicide ideation, plan, and attempt and die by suicide (odds ratio [OR]=0.57, 95% confidence interval [CI]=0.41-0.78). Subgroup analyses further revealed significant reductions in suicide ideation (OR=0.73, 95% CI=0.55-0.97) and suicide death (OR=0.45, 95% CI=0.30-0.68) among intervention participants. Conclusions: Preliminary evidence indicated that psychosocial interventions are effective in reducing suicide ideation, plan, attempt, and death among individuals with psychotic symptoms. Intervention characteristics, however, varied across studies, which suggests a lack of consensus on best clinical practices.
... *p < .05. respectively. Three studies investigated the association between negative beliefs and suicidal ideation or risk over periods between 6 and 18 months, but no significant relationships were reported (Hutton et al., 2019;Pyle, Stewart, et al., 2015;Stip, et al., 2017). However, small samples in two of these studies likely limited power (n = 45-68). ...
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Article
Objective Emotional distress, including depression and anxiety, is commonly reported amongst individuals experiencing psychosis. The beliefs individuals hold about the meaning of their psychosis may explain the distress they experience. The current meta‐analysis aimed to review the association between beliefs about psychosis experiences and emotional distress. Method Three electronic databases (PsycINFO, MEDLINE, and CINAHL) were searched using keywords and controlled vocabulary (e.g., Medical Subject Headings) from date of inception to August 2019. A total of 19 eligible papers were identified. Results Our random‐effects meta‐analysis revealed that depression and anxiety held moderate association with psychosis beliefs, with perceptions concerning a lack of control over experiences having the strongest association with distress. Longitudinal studies suggest that negative beliefs at baseline are associated with depressive symptoms at follow‐up. Conclusions The results suggest that the endorsement of negative beliefs about psychosis is associated with current level of depression and anxiety. The results are consistent with theories of emotional distress in psychosis. However, the small number of longitudinal papers limits what can be concluded about the direction or other temporal characteristics of these relationships. Therapies that target unhelpful beliefs about psychosis may beneficial. Practitioner points • Negative beliefs about experiences of psychosis are associated with greater emotional distress such as depression and anxiety. • Beliefs about a lack of control over experiences had the strongest association with distress. • Interventions that aim to modify or prevent the formation of unhelpful beliefs about psychosis may be beneficial for this population.
... Likewise, Westheide et al. (2008) compared inpatient groups with MDD based on suicidal ideation (mean age of 34.3 years with suicidal ideation, and 40.4 years without suicidal ideation), and found impaired executive function in those inpatients with suicidal ideation, compared to those without (Westheide et al., 2008). The studies from Pu et al. (2017), Marzuk et al. (2005) and Westheide et al. (2008) as well as this current study, further validate the importance of cognitive function, and value of cognitive testing and modelling (Stip et al., 2017) in regard to collaborative, integrated, and personalized care. Clinically speaking, neurocognitive dysfunction could be helpful in establishing contributing factors to certain clinical domains, in this instance, suicidal ideation. ...
Article
Neuropsychological assessments have provided the field of psychiatry with important information about patients. As an assessment tool, a neuropsychological battery can be useful in a clinical setting; however, implementation as standard clinical care in an inpatient unit has not been extensively evaluated. A computerized cognitive battery was administered to 103 current young adult inpatients (19.2 ± 3.1 years; 72% female) with affective disorder. Neurocognitive tasks included Verbal Recognition Memory (VRM), Attention Switching (AST), Paired Association Learning (PAL), and Rapid Visual Processing (RVP). Patients also completed a computerized self-report questionnaire evaluating subjective impressions of their cognition. Hierarchical cluster analysis determined three neurocognitive subgroups: cluster 1 (n = 17) showed a more impaired neurocognitive profile on three of the four variables compared to their peers in cluster 2 (n = 59), and cluster 3 (n = 27), who had the most impaired attentional shifting. Two of the four neurocognitive variables were significantly different between all three cluster groups (verbal learning and sustained attention). Overall group results showed an association between poorer sustained attention and increased suicidal ideation. These findings strengthen the idea that neurocognitive profiles may play an important role in better understanding the severity of illness in young inpatients with major psychiatric disorders.
Article
Objectives Depression has long been considered a significant feature of schizophrenia and is associated with more frequent psychotic episodes, increased service utilisation, substance misuse, poor quality of life and completed suicide. However, there is a distinct lack of literature on this comorbidity from low- and middle-income countries or non-western cultural backgrounds. Methods This is a cross-sectional analysis of baseline data from a large randomised controlled trial, examining the prevalence of depression and suicidal ideation in patients with schizophrenia spectrum disorder. A total of 298 participants were recruited from inpatient and outpatient psychiatric units in Karachi, Pakistan. Participants completed the Calgary Depression Scale for Schizophrenia (CDSS), Positive and Negative Syndrome Scale (PANSS), Euro Qol (EQ-5D) and Social Functioning Scale (SFS). Results Data indicate that 36% of participants in the study were depressed and 18% endorsed suicidal ideation. Depression was associated with higher positive symptom scores and reduced quality of life, but no significant difference in negative symptoms and social functioning. Conclusions Depression and suicidal ideation are prevalent in Pakistani patients diagnosed with schizophrenia spectrum disorder. Evaluation of depressive symptoms in this group may help identify individuals at higher risk of completed suicide, allowing for targeted interventions to improve outcomes. • Key points • To our knowledge, this is the first study describing the prevalence of depression and suicidal ideation in individuals with schizophrenia from Pakistan. • Our data indicate that 36% of individuals with schizophrenia in our sample were depressed and 18% endorsed suicidal ideation. • Depression in schizophrenia was associated with poorer quality of life and higher positive symptom burden. • This study adds to the scarce literature from low- and middle-income countries where the burden of mental illness is great and where the majority of suicide deaths occur. • Addressing social inequality, food insecurity, high rates of unemployment and low levels of literacy in these settings may have a profound effect on population mental health and suicide risk.
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This study aimed to comprehensively evaluate psychosocial risk factors associated with suicidality in patients with schizophrenia in Korea. The study sample consisted of 84 hospitalized patients with schizophrenia. Suicidal thoughts and a clear desire to be dead within 2 weeks were defined as a current suicidal ideation. Socio-demographic and clinical variables, including family history of completed suicides and psychiatric illnesses, were collected, and the Positive and Negative Syndrome Scale (PANSS), Calgary Depression Scale for Schizophrenia (CDSS), Beck Depression Inventory (BDI), Simpson-Angus Scale (SAS), Scale to assess Unawareness of Mental Disorder (SUMD), and Alcohol Use Disorders Identification Test (AUDIT) were administered to identify factors associated with a current suicidal ideation. Forty-three subjects (51.2%) reported clear suicidal ideation. Multivariate analysis revealed that later age of illness onset, previous suicide attempt, family history of completed suicide, depression, or substance abuse, fewer than one family visitation to the hospital per month, and score on the CDSS were independently related to current suicidal ideation in these subjects. Age, education level, and scores on the SUMD were not significantly associated with current suicidal ideation in the multivariate analysis, but were associated with suicidal ideation in a univariate analysis on the level of p<0.1. The above clinical factors should be evaluated to predict and prevent suicidal risk in patients with schizophrenia. In particular, modifiable factors such as depression should be managed to reduce suicidality of hospitalized patients with schizophrenia.
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The suicide risk in psychotic disorders is highest in the early phases of illness. Studies have typically focused on suicidality from treatment start rather than actual onset of psychosis. This study explored the prevalence and characteristics of suicidality in patients with a first episode of psychosis (FEP) in two time intervals: 1) prior to study entry and 2) explicitly in the period of untreated psychosis. One hundred seventy FEP-patients were interviewed as soon as possible after treatment start. The interview included assessments of diagnoses, suicidality, symptoms, substance use, and premorbid functioning. Nearly 26% of the patients attempted suicide prior to study entry and 14% made suicide attempts during the period of untreated psychosis. Of the patients who had been suicidal (i.e. experienced suicidal ideation or attempts), 70% were suicidal during the period of untreated psychosis. Suicide attempts prior to study entry were associated with female gender, more depressive episodes, younger age at psychosis onset, and history of alcohol disorder. Suicide attempts during untreated psychosis were also associated with more depressive episodes and younger age at illness onset, in addition to drug use the last six months and longer duration of untreated psychosis (DUP). The prevalence of suicidality before and in the early phases of FEP is high, especially during untreated psychosis. As prolonged DUP is associated with suicide attempts during the period of untreated psychosis, reducing the DUP could have the effect of reducing the prevalence of suicide attempts in patients with FEP.
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Describes the rationale, development, and validation of the Scale for Suicide Ideation, a 19-item clinical research instrument designed to quantify and assess suicidal intention. In a sample with 90 hospitalized Ss, the scale was found to have high internal consistency and moderately high correlations with clinical ratings of suicidal risk and self-administered measures of self-harm. Furthermore, it was sensitive to changes in levels of depression and hopelessness (Beck Depression Inventory and Hopelessness Scale, respectively) over time. Its construct validity was supported by 2 studies by different investigators testing the relationship between hopelessness, depression, and suicidal ideation and by a study demonstrating a significant relationship between high level of suicidal ideation and "dichotomous" attitudes about life and related concepts on a semantic differential test. Factor analysis yielded 3 meaningful factors: Active Suicidal Desire, Specific Plans for Suicide, and Passive Suicidal Desire. (29 ref)
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The variable results of positive-negative research with schizophrenics underscore the importance of well-characterized, standardized measurement techniques. We report on the development and initial standardization of the Positive and Negative Syndrome Scale (PANSS) for typological and dimensional assessment. Based on two established psychiatric rating systems, the 30-item PANSS was conceived as an operationalized, drug-sensitive instrument that provides balanced representation of positive and negative symptoms and gauges their relationship to one another and to global psychopathology. It thus constitutes four scales measuring positive and negative syndromes, their differential, and general severity of illness. Study of 101 schizophrenics found the four scales to be normally distributed and supported their reliability and stability. Positive and negative scores were inversely correlated once their common association with general psychopathology was extracted, suggesting that they represent mutually exclusive constructs. Review of five studies involving the PANSS provided evidence of its criterion-related validity with antecedent, genealogical, and concurrent measures, its predictive validity, its drug sensitivity, and its utility for both typological and dimensional assessment.
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The objective of this study was to predict suicidality in people with schizophrenia. Ninety-six patients with recent-onset schizophrenia were rated every 2 weeks for 1 year to examine (1) the temporal course of suicidal ideation and suicide attempts and (2) the extent to which anxiety, depression, and mild suicidal ideation were followed by significant suicidal ideation or a suicide attempt. The severity of suicidality changed rapidly. Low levels of suicidal ideation increased the risk for significant suicidal ideation or a suicide attempt during the subsequent 3 months. Depression was moderately correlated with concurrent suicidality, but not independently associated with future suicidality. Therefore, low levels of suicidal ideation may predict future suicidal ideation or behavior better than depressed mood in individuals with schizophrenia.
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Risk factors for suicide attempts have rarely been studied comprehensively in more than one psychiatric disorder, preventing estimation of the relative importance and the generalizability of different putative risk factors across psychiatric diagnoses. The authors conducted a study of suicide attempts in patients with mood disorders, psychoses, and other diagnoses. Their goal was to determine the generalizability and relative importance of risk factors for suicidal acts across diagnostic boundaries and to develop a hypothetical, explanatory, and predictive model of suicidal behavior that can subsequently be tested in a prospective study. Following admission to a university psychiatric hospital, 347 consecutive patients who were 14-72 years old (51% were male and 68% were Caucasian) were recruited for study. Structured clinical interviews generated axis I and axis II diagnoses. Lifetime suicidal acts, traits of aggression and impulsivity, objective and subjective severity of acute psychopathology, developmental and family history, and past substance abuse or alcoholism were assessed. Objective severity of current depression or psychosis did not distinguish the 184 patients who had attempted suicide from those who had never attempted suicide. However, higher scores on subjective depression, higher scores on suicidal ideation, and fewer reasons for living were reported by suicide attempters. Rates of lifetime aggression and impulsivity were also greater in attempters. Comorbid borderline personality disorder, smoking, past substance use disorder or alcoholism, family history of suicidal acts, head injury, and childhood abuse history were more frequent in suicide attempters. The authors propose a stress-diathesis model in which the risk for suicidal acts is determined not merely by a psychiatric illness (the stressor) but also by a diathesis. This diathesis may be reflected in tendencies to experience more suicidal ideation and to be more impulsive and, therefore, more likely to act on suicidal feelings. Prospective studies are proposed to test this model.
Article
The well-known fact of suicides of psychiatric inpatients during psychiatric hospital treatment is discussed according to national and international suicide data. In our Baden-Württemberg (Germany) Psychiatric Inpatient Suicide Study an increase in suicide and suicide rates from 1970 to 1993 can be shown with an mostly impressive increase in the 1970s and a plateau formation in the 1980s and constant figures in the 1990s. The group of 585 suicides (59% men, 41% women) is composed of: 26% primarily depressives, 53% schizophrenics (ICD-9); where the following features were notable presuicidal syndrome with depressive mood (68%). insight into illness (63%). feelings of suffering (64%), failure (57%), hopelessness (54%) and helplessness (54%).
Chapter
Chapter 5 explains the basis of the theory of entrapment, which is a state that results from a person perceiving that they are defeated and/or humiliated, feeling that they must escape, and sensing that their present situation will continue indefinitely. Suicidal acts are viewed as a means of an individual escaping from this positionin detail, including how deficiencies in problem solving, related to abnormalities of autobiographical memory, may contribute to a person feeling entrapped, and how a tendency to experience hopelessness may add to this. It also considers how differential activation—that is the tendency for patterns of moods, thoughts and bodily sensations all to be activated by changes in a single modality—may explain why some people rapidly and repeatedly experience thoughts of suicidal behaviour. This model is a basis for proposing how mindfulness-based cognitive therapy, already shown to be effective in preventing relapse of mood disorders, might have a significant role to play in the prevention of repetition of suicidal acts.
Article
Suicide is the 10th leading cause of death in the United States and is the leading cause of death among individuals with schizophrenia. In order to prevent premature suicidal death and improve the quality of life among individuals with schizophrenia, conceptual models are needed to understand the mechanisms of suicide risk. This paper reviews the theoretical perspectives of schizophrenia, suicide, and the intersection of schizophrenia and suicide to develop a conceptual basis for future prevention and intervention efforts by health and mental health practitioners and researchers. A better explanation and understanding of risk factors for suicide has to potential to play a larger role in treatment and recovery of schizophrenia, and prevent premature suicidal death. As a result of the absence to date of theoretically driven and empirically testable models of suicidal behaviors tailored for individuals with schizophrenia, the current paper proposes a model of suicide risk specific to individuals with schizophrenia to increase understanding of risk and to inform prevention efforts.
Article
Among clients with schizophrenia, suicidality is associated with extreme personal distress, an increased number of inpatient hospitalizations, increased health care expenditures, and early mortality. This study attempted to identify risk factors for current suicidality in clients diagnosed with schizophrenia (N = 223). Results indicated that severity of depressive symptoms most strongly correlated with degree of suicidality. Younger age and recent traumatic stress each significantly predicted suicidality independent of depressive symptoms. Stepwise regression procedures showed that the combination of depression, younger age, and traumatic stress might provide a general prediction model for suicidality among clients diagnosed with schizophrenia. Counseling implications of these findings are outlined.
Article
Objectives. Life-events that precede the onset of unipolar depression usually involve an appraisal of loss; recent research has shown that where these events are also appraised as humiliating or involving entrapment and defeat (the absence of a way forward or failure to reaffirm an identity) they are especially potent in triggering depression. Depression in schizophrenia has not been studied from the cognitive or psychosocial perspectives, probably because of its confused nosological status. In a previous study we showed that patients' perceived loss of control and entrapment by psychotic illness (e.g. by recurring relapse) was strongly linked to depression. Design. In this study we follow up the original sample of 49 patients 2.5 years later to examine the hypotheses using more powerful prospective methodology. Two of the sample had died of natural causes and the remaining 47 agreed to be reinterviewed. Method. We used the same measures of patients' appraisal of their illness and symptoms in terms of the extent to which they perceive it as embodying loss, humiliation and entrapment. Results. It was found using multivariate analysis that perceived loss of autonomy and social role, particularly employment, were correlated with depression. The appraisal of entrapment in psychotic illness was found to have high cross-sectional and prospective predictive value independent of illness, symptom and treatment variables and was shown to be influenced by certain aspects of psychiatric treatment, particularly compulsory detention. Conclusion. We propose that episodes of depression in schizophrenia are triggered by psychosis-related events (relapse, compulsory admission, residual voices, loss of job, etc.) that signify the inability to overcome the loss of a cherished personal goal or social role and thereby to affirm an identity. Implications for psychological therapy are discussed.
Article
AimsTo investigate the relationship between internalized stigma, depression, social anxiety and unusual experiences in young people considered to be at risk of developing psychosis. MethodsA total of 288 participants meeting criteria for an at-risk mental state were recruited as part of a multisite randomized controlled trial of cognitive behavioural therapy for people meeting criteria for an at risk mental state (ARMS). The sample was assessed at baseline and 6 months using measures of at risk mental states, internalized stigma, depression and social anxiety. ResultsThe Personal Beliefs about Experiences Questionnaire was validated for use with an ARMS sample. Correlational analyses at baseline indicated significant relationships between internalized stigma and: (i) depression; (ii) social anxiety; (iii) distress associated with unusual psychological experiences; and (iv) suicidal thinking. Regression analysis indicates negative appraisals of unusual experiences contributed significantly to depression scores at 6-month follow up when controlling for baseline depression and unusual psychological experiences. Conclusions These findings suggest that internalized stigma may contribute to the development and maintenance of depression in young people at risk of psychosis.
Article
Background Depression in schizophrenia is a rather neglected field of study, perhaps because of its confused nosological status. Three course patterns of depression in schizophrenia, including post-psychotic depression (PPD), are proposed. Aims We chart the ontogeny of depression and psychotic symptoms from the acute psychotic episode over a 12-month period and test the validity of the proposed course patterns. Method One hundred and five patients with ICD-10 schizophrenia were followed up on five occasions over 12 months following the acute episode, taking measures of depression, positive symptoms, negative symptoms, neuroleptic exposure and side-effects. Results Depression accompanied acute psychosis in 70% of cases and remitted in line with the psychosis; 36% developed PPD without a concomitant increase in psychotic symptoms. Conclusions The results provided support for the validity of two of the three course patterns of depression in schizophrenia, including PPD. Post-psychotic depression occurs de novo without concomitant change in positive or negative symptoms.
Article
78 18–75 yr old women and 52 20–63 yr old men of French-Canadian background completed an adapted French version of the Scale for Suicide Ideation. Interitem correlations were calculated, a principal component analysis was performed, and correlations with selected personality variables were obtained. The adapted French form had a factorial structure that generally resembled that of the English original, and its correlational characteristics were in line with those reported in the literature. (French abstract) (PsycINFO Database Record (c) 2012 APA, all rights reserved)
Article
The development of assessment instruments have allowed clinicians to evaluate the potential overlap between psychosis and depression. Hence, the prevalence of depression in psychosis received acknowledgement and incorporation into diagnostic regimens, primarily as schizo-affective disorder and more recently as "post schizophrenic depression." Depression is now regarded as an integral part of the course of psychotic illness and a possible precursor to suicide if associated with hopelessness. Topics include: suicide in psychosis; predicting suicide; precursors of suicide; and cognitive appraisal of self, symptoms and illness. (PsycINFO Database Record (c) 2012 APA, all rights reserved)
Article
Objective. To further develop the Personal Beliefs about Illness Questionnaire (PBIQ), which reflects current constructs of social rank theory in relation to people experiencing psychosis. Method. Drawing on extensive clinical and research experience and after consultation with other mental health professionals and service users, 17 new items were added to 12 from the original 16 PBIQ questions. These made up five theoretical constructs (entrapment, loss, social marginalization, shame, and control). A total of 150 people who had just experienced a first episode of psychosis completed the newly devised PBIQ-R. To test the validity of its five subscales, a small sub-sample (N= 66) for whom follow-up data was available also completed measures of depression, insight, and other social rank appraisals. Results. All five subscales of the PBIQ-R were found to be reliable, valid, and sensitive to change. Conclusions. Although the PBIQ-R was not designed to produce an overall ‘personal beliefs about illness’ score, its five subscales provide a rapid and valid method to assess and measure common psychological reactions to a first episode of psychosis. It will have relevance for use in older, multiple episode samples although further validation may be needed.
Article
Objectives: This study aimed to examine the prevalence and correlates of lifetime suicide attempts and current suicidal ideation in community-dwelling schizophrenia patients in China. Method: A sample of 540 schizophrenia patients was randomly selected in Beijing, China. All subjects were interviewed using standardized assessment instruments and their basic socio-demographic and clinical data including history of suicide attempts were collected. Results: The prevalence of lifetime suicide attempts and the point prevalence of suicidal ideation were 12.0%, and 21.1%, respectively. In multiple logistic regression analyses, the presence of lifetime suicide attempt was independently associated with rural residence, having major medical conditions and better social functioning, while higher likelihood of current suicidal ideation was associated with past suicide attempt, the severity of overall psychopathology and depressive symptoms and lower psychological quality of life (QOL). Conclusion: Among Chinese outpatients with schizophrenia, increased current symptoms and poorer QOL were correlated with current suicidal ideation, while demographic factors and indicators of greater social support were mostly correlated with lifetime suicide attempts. This study may help to identify important subgroups of patients with schizophrenia at particularly high risk of suicidal behavior.
Article
Between 4 and 13% of people with schizophrenia commit suicide and between 25 and 50% make a suicide attempt, a reflection of the devastating toll this syndrome takes on the quality of life, that is, the subjective and objective sense of well-being. Many risk factors for suicide in schizophrenia have been identified, the most important of which are previous suicide attempts, depression, hopelessness, substance abuse, and male gender. Insight into having a serious mental illness and less severe cognitive impairment are also associated with increased risk for suicide in schizophrenia, most likely when accompanied by feelings of hopelessness. Typical neuroleptic drugs have not been shown to reduce the risk of suicide. However, several types of evidence suggest that clozapine, an atypical antipsychotic drug, appreciably reduces the suicide attempt and completion rates in schizophrenia and schizoaffective disorder, perhaps by as much as 75-85%. Other atypical antipsychotic drugs may have a similar effect, but direct evidence is lacking. Improvement in positive and negative symptoms, reduced extrapyramidal side effects (EPS), a direct antidepressant action, improved cognitive function, and improved compliance may contribute to reduced suicidality. The International Suicide Prevention Trial (InterSePT) is a large prospective, randomized study intended to compare the effectiveness of clozapine with that of olanzapine in reducing suicide and suicide-related events in schizophrenic and schizoaffective patients. Some information about suicidality in the patient sample is reported here.
Article
The well-known fact of suicides of psychiatric inpatients duringpsychiatric hospital treatment is discussed according to national andinternational suicide data. In our Baden-Wrttemberg (Germany)Psychiatric Inpatient Suicide Study an increase in suicide and suicide ratesfrom 1970 to 1993 can be shown with an mostly impressive increase in the1970s and a plateau formation in the 1980s and constant figures in the1990s. The group of 585 suicides (59% men, 41%women) is composed of: 26% primarily depressives, 53%schizophrenics (ICD-9); where the following features were notablepresuicidal syndrome with depressive mood (68%), insight into illness(63%), feelings of suffering (64%), failure (57%),hopelessness (54%) and helplessness (54%).
Article
Suicide is a major public health problem and the leading cause of premature death in patients with schizophrenia. Information about the patient's personality is helpful for assessing the risk of suicide attempts and suicidal ideation. The sample consisted of 120 outpatients with a diagnosis of schizophrenia, 29 of whom had previously attempted suicide. We used the Temperament and Character Inventory to assess personality differences between patients who had previously attempted and had not previously attempted suicide and between patients who had and did not have current suicidal ideation. Current suicidal ideation was assessed using the four-point severity scale, which is item nine from the Beck Depression Inventory. The character dimension Self-transcendence was shown by logistic regression to be a predictor of lifetime suicide attempts. Low Self-directedness was shown to be a predictor of current suicidal ideation. To prevent suicidal behaviour, it is important to better understand the personality traits associated with suicidal ideation and suicide attempts. Suicide attempts and suicidal ideation in schizophrenia may not represent the same phenomenon ranging on a single continuum. The importance of these results suggests that further study is needed.
Article
Suicidal behavior and suicide is prevalent in schizophrenia, with an estimated lifetime risk of approximately 5%. The risk is particularly high in the early phases of the disorder, and especially during the years around treatment initiation. Suicide attempts before first treatment contact are also prevalent, with the risk of suicide attempt associated with the length of untreated illness. Several risk factors are in common with the general population, and include previous suicide attempts, impulsive personality traits, substance abuse, depression and feelings of hopelessness. Recent research examines how patients' subjective experiences, including their insight into having a severe mental illness and their beliefs about mental illnesses, may influence suicidal behavior. In this article, we will present a review of studies illustrating the complex background of suicide risk in schizophrenia, with a particular emphasis on the role of insight in the early phases of schizophrenia.
Article
Research of suicidal behavior in individuals with schizophrenia has often suggested that clinical characteristics and symptoms likely influence a patient's suicidal risk. However, there is a lack of research describing the link between patients' subjective quality of life (SQOL) and suicidal behavior in non-Western countries. Therefore, the current study attempts to explore how schizophrenia patients' SQOL and their suicidal behavior are related in a Taiwanese sample. In this study, 102 schizophrenia outpatients were investigated using the Taiwanese World Health Organization Quality of Life Schedule-Brief Version (WHO-QOL-BREF-TW), several Beck-Related symptom rating scales, and the Positive and Negative Syndrome Scale (PANSS) for psychopathology. These patients were also evaluated for suicidal risk using the critical items of the Scale for Suicide Ideation (SSI) and lifetime suicide attempts. Statistical analyses, including independent sample t tests, analysis of covariance (ANCOVA) and logistic stepwise regression models were completed. Compared with the non-suicidal group, suicidal patients had significantly lower scores in SQOL domains. The differences in social domain remained significant after adjusting for depressive symptoms. In multiple logistic regression analyses, level of depressive and psychotic symptoms increased and poor social and psychological SQOL were significant contributors to suicidal behavior. Having removed depressive symptoms from the model, only dissatisfaction with social SQOL was associated with heightened suicidal risk. Schizophrenia is associated with a high suicidal risk, of which depressive and psychotic symptoms are the major correlates. Again, the present study confirms and extends previous research showing that dissatisfied SQOL, particularly dissatisfaction with social relationships, should be considered in the assessment of suicidal risk in outpatients with schizophrenia, even when accounting other possible confounding factor such as depression.
Article
This study tested whether feelings of defeat and entrapment mediated the effects of negative appraisals upon suicidal ideation and behavior. A sample of 93 university students who reported some degree of suicidal ideation completed questionnaires of negative appraisals of social-support and problem-solving, defeat, entrapment, hopelessness and suicidality. The results supported a model whereby defeat and entrapment fully mediated the effect of appraisals of social support and problem-solving ability upon suicidality. Furthermore, controlling for hopelessness had no substantive impact upon this model. The findings support socio-cognitive models of suicidal behavior and highlight the key role of defeat and entrapment in suicide. The clinical implications of these findings are discussed.
Article
The current study tests whether perceptions of defeat and entrapment are the psychological mechanisms underlying the link between positive psychotic symptoms and suicidal ideation in schizophrenia. A sample of 78 patients with schizophrenia spectrum disorders completed self-report measures and a clinical interview. Of this sample, 21.8% reported a single past suicide attempt and 50% reported multiple past attempts. It was found that perceptions of defeat and entrapment, conceptualised as a single variable, accounted for a large proportion (31%) of the variance in suicidal ideation and behaviour. Defeat and entrapment also mediated the relationship between positive symptom severity and suicidal ideation. This result held whilst controlling for levels of hopelessness and depression. Secondary analyses suggested that suspiciousness in particular was linked to suicidal ideation. The results support a socio-cognitive model (The Schematic Appraisals Model of Suicide: SAMS) of suicide in psychosis.
Article
To evaluate the factors affecting suicidal ideas in patients with schizophrenia in terms of some socio-demographic and clinical properties. The sample of the study consisted of 120 patients with schizophrenia selected from among patients receiving treatment at Trabzon Atakoy Psychiatry Hospital. All patients were evaluated using a Socio-demographic Data Collection Form, Reasons for Living Inventory (RLI), Calgary Depression Scale for Schizophrenia (CDSS), Positive and Negative Syndromes Scale (PANSS), and Structured Clinical Interview for DSM-IV Axis I Disorders (SCID-I). Of the patients, 31.6% had suicide ideation. Negative symptoms are found to be significantly higher. The group with suicidal ideation had fewer reasons for living than the group without. Evaluations of the history of suicide attempts, depression and hopelessness in patients with schizophrenia are thought to be important in the prevention of suicidal behavior in these patients.
Article
Stigma can be a major stressor for people with schizophrenia and other mental illnesses, leading to emotional stress reactions and cognitive coping responses. Stigma is appraised as a stressor if perceived stigma-related harm exceeds an individual's perceived coping resources. It is unclear, however, how people with mental illness react to stigma stress and how that affects outcomes such as self-esteem, hopelessness and social performance. The cognitive appraisal of stigma stress as well as emotional stress reactions (social anxiety, shame) and cognitive coping responses were assessed by self-report among 85 people with schizophrenia, schizoaffective or affective disorders. In addition to self-directed outcomes (self-esteem, hopelessness), social interaction with majority outgroup members was assessed by a standardized role-play test and a seating distance measure. High stigma stress was associated with increased social anxiety and shame, but not with cognitive coping responses. Social anxiety and shame predicted lower self-esteem and more hopelessness, but not social performance or seating distance. Hopelessness was associated with the coping mechanisms of devaluing work/education and of blaming discrimination for failures. The coping mechanism of ingroup comparisons predicted poorer social performance and increased seating distance. The cognitive appraisal of stigma-related stress, emotional stress reactions and coping responses may add to our understanding of how stigma affects people with mental illness. Trade-offs between different stress reactions can explain why stress reactions predicted largely negative outcomes. Emotional stress reactions and dysfunctional coping could be useful targets for interventions aiming to reduce the negative impact of stigma on people with mental illness.
Article
This study examines the prevalence and correlates of current suicidal ideation and past suicide attempts among patients aged 40 and older with schizophrenia spectrum disorders and concurrent depressive symptoms. Nearly half the sample (n = 132) reported having attempted suicide once or more in their lifetime; those who had attempted, exhibited greater depression and psychopathology. A regression analysis revealed that only past suicide attempts and hopelessness significantly accounted for the presence of current suicidal ideation. Surprisingly, current suicidal ideation did not differ by diagnosis, race/ethnicity, marital status, living situation, age, education, or severity of medical illness. Overall, suicidal ideation and the presence of past suicide attempts were remarkably prevalent, highlighting the need for continued clinical vigilance with this patient population. The impact of hopelessness and general psychopathology, as well as the insignificance of demographic characteristics and medical illness severity warrant further investigation.
Article
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.
Article
Since existing depression scales were designed for assessment of depression in non-psychotic populations, such scales have items which do not distinguish depressed from non-depressed psychotic subjects. The authors describe a new scale, the Calgary Depression Scale, which was designed for the assessment of depression in schizophrenia. The scale was derived from two existing scales by factor analysis and reliability analysis. It has been further tested in two new samples. In the first it has been shown to be reliable, congruent with a self-report scale and valid. In the second sample it has been shown that there is no overlap with negative or extrapyramidal symptoms.
Article
Synopsis This paper explores the hypothesis that depression in chronic schizophrenia is in part a psychological response to an apparently uncontrollable life-event, namely the illness and its long-term disabilities. It is suggested that depression is linked to patients' perception of controllability of their illness and absorption of cultural stereotypes of mental illness. Clinically and operationally diagnosed schizophrenic and manic-depressive patients receiving long-term maintenance treatment were studied. The cross-sectional prevalence of depression in schizophrenics was 29% and 11% for patients with bipolar affective illness. The hypothesis was supported. Multivariate analyses revealed that patients' perception of controllability of their illness powerfully discriminated depressed from non-depressed psychotic patients. Although those patients who accepted their diagnosis reported a lower perceived control over illness and an external locus of control, label acceptance was not associated with lowered depression, self-esteem or unemployment. The cross-sectional nature of the study makes the direction of causality and the role of intrinsic illness variables difficult to ascertain; however, the results set the scene for prospective and intervention studies and the various possibilities are discussed.
Article
Suicidal behavior is prevalent in individuals with schizophrenia. Although a relationship between greater awareness of illness and suicidal behavior has been posited, the question has not been systematically studied. The purpose of this study was to examine the relationship between suicidal behavior and various aspects of insight in 218 patients with schizophrenia. Patients who were participating in the DSM-IV field trial for schizophrenia were assessed with the Scale to Assess Unawareness of Mental Disorder and an instrument that was developed for the field trial study that measured multiple aspects of psychopathology, including suicidal behavior. The prevalence of suicidal thoughts and behavior found in this study was consistent with previous published reports. Schizophrenia patients with recurrent suicidal thoughts and behavior were generally more aware of their negative symptoms and delusions than were nonsuicidal patients. Contrary to expectations, general awareness of having a mental disorder did not predict suicidal behavior. The notion that insight may be associated with greater suicidality was partially supported.
Article
Biological findings such as low 5-HIAA levels in cerebrospinal fluid (CSF) in suicidal patients compared to non-suicidal patients independent of the type of psychiatric disorder indicate a broad basis for suicidality. It is therefore important to ask whether a suicidality syndrome can be delineated on a phenomenological level, and whether it is independent of specific major psychiatric disorders which are otherwise considered to be aetiologically different. This paper reports on a study of 2383 schizophrenic and 1920 depressive unselected patients with and without suicidality. They were assessed during the first 24 h after admission to a psychiatric in-patient facility using a comprehensive psychopathological assessment (AMDP system). Using multiple variance analysis and logistic regression analysis based on single symptoms, for both suicidal and non-suicidal patients it was shown that a suicidality syndrome independent of the underlying illness can be delineated. In schizophrenia as well as in major affective disorders it was found that hopelessness, ruminative thinking, social withdrawal and lack of activity are core symptoms of this suicidal syndrome. The finding of a suicidality syndrome, not associated with a specific major affective disorder, indicates the need to identify this syndrome, which should be seen as an independent dimension and diagnosed separately, and not regarded merely as a secondary symptom of major psychiatric disorders, particularly affective disorders.
Article
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.
Article
Life-events that precede the onset of unipolar depression usually involve an appraisal of loss; recent research has shown that where these events are also appraised as humiliating or involving entrapment and defeat (the absence of a way forward or failure to reaffirm an identity) they are especially potent in triggering depression. Depression in schizophrenia has not been studied from the cognitive or psychosocial perspectives, probably because of its confused nosological status. In a previous study we showed that patients' perceived loss of control and entrapment by psychotic illness (e.g. by recurring relapse) was strongly linked to depression. In this study we follow up the original sample of 49 patients 2.5 years later to examine the hypotheses using more powerful prospective methodology. Two of the sample had died of natural causes and the remaining 47 agreed to be reinterviewed. We used the same measures of patients' appraisal of their illness and symptoms in terms of the extent to which they perceive it as embodying loss, humiliation and entrapment. It was found using multivariate analysis that perceived loss of autonomy and social role, particularly employment, were correlated with depression. The appraisal of entrapment in psychotic illness was found to have high cross-sectional and prospective predictive value independent of illness, symptom and treatment variables and was shown to be influenced by certain aspects of psychiatric treatment, particularly compulsory detention. We propose that episodes of depression in schizophrenia are triggered by psychosis-related events (relapse, compulsory admission, residual voices, loss of job, etc.) that signify the inability to overcome the loss of a cherished personal goal or social role and thereby to affirm an identity. Implications for psychological therapy are discussed.