Management of Schizophrenia with Suicide Risk

Model of risk factors for suicidal behavior in schizophrenia

The stress diathesis suicide risk factor model is a helpful model for examining suicidal behavior and its management in schizophrenia.¹⁸ In this model suicide risk factors may be either distal or proximal. Distal risk factors create a predisposing diathesis and determine a schizophrenic's response to a stressor. These factors include developmental, personality, biologic, and genetic variables. Distal risk factors affect the threshold for suicide and increase a schizophrenic's risk when he or

Management of suicide risk in schizophrenia through recognition of risk factors

Analysis of risk factors for suicide in general often yields too many false positives, that is, the recognition of individuals as potential suicides when in fact they will never kill themselves. Nevertheless, suicide risk factors have a potential important impact on prevention. The schizophrenic patient at risk of suicide is young and male (except in China where schizophrenia is more prevalent among women, who are more likely to commit suicide than men¹⁹). Schizophrenics who commit suicide are

Importance of a previous suicide attempt

That a schizophrenic patient has previously attempted suicide is an important clinical indicator that he is at increased risk for both further attempts and completed suicide. A high percentage of schizophrenic patients who commit suicide have previously attempted suicide.24, 25, 26, 27, 28 For example, a review of the literature showed that 156 of 289 schizophrenic patient suicides (54%) had made a previous suicide attempt.⁹ Pompili and colleagues²³ recently found that a substantial percentage

Managing suicide risk in schizophrenics with comorbid substance abuse

The literature suggests that nearly 50% of patients with schizophrenia have a co-occurring substance use disorder, most frequently alcohol or cannabis (at a rate about 3 times higher than that of the general population). The increased suicide risk of substance-abusing schizophrenic patients could be the result of a cumulative effect of many factors or events, such as the loss of remaining supportive social contacts through the consumption of psychotropic substances, noncompliance with

Managing the demoralization syndrome in the at-risk schizophrenic

Drake and Cotton²⁹ described a demoralization syndrome in which schizophrenic patients become aware of their illness and its consequences. Patients then may compare their premorbid adjustment with their current state and become hopeless and depressed and, eventually, suicidal. Restifo and colleagues³⁰ recently provided support for aspects of the demoralization model. These investigators tested this model with 164 patients assessing depression, premorbid functioning, insight, and suicidal

Psychometric assessment of suicide risk

The management of suicide risk in schizophrenia might also take advantage of information derived from psychometric instruments. For instance, Taiminen and colleagues³² proposed the research-based 25-item schizophrenia suicide risk scale (SSRS), although the investigators noted the scale was too insensitive or too nonspecific for general use as a screening device. Turner and colleagues³³ proposed a semi-structured interview for suicide in schizophrenia (ISIS) based on chart review, staff

Managing suicide risk with antipsychotic medication

Management of suicide risk through the use of antipsychotic medications is a key factor.³⁶ Typical neuroleptics do not have much evidence for suicide risk reduction.³⁷ The only atypical antipsychotic approved as an antisuicidal agent is clozapine. However, all atypical antipsychotics have some potential impact on suicidality in schizophrenic patients.38, 39 The distinguishing characteristic of atypical antipsychotic drugs is their fewer extrapyramidal symptoms (EPS), lower risk of tardive

Managing suicide risk in the schizophrenic with comorbid depression

Depression is an important potentially modifiable comorbid disorder often associated with suicidal behavior in schizophrenic patients. For example, one review of 270 schizophrenic suicides found that depressive symptoms were noted by their clinicians during the last period of contact before the suicide in approximately 60% of the suicides.⁵¹ Significantly more schizophrenic suicides than schizophrenic controls have their last admission before committing suicide because of suicidal impulses or

Managing suicide risk in schizophrenia through staff education

Managing the schizophrenic patient who is at risk of suicide involves the establishment of supportive relationships. Difficult relationships with the staff and difficult acclimatization to the ward environment have been reported to be risk factors for suicide.36, 64 Staff knowledge of suicidology and their readiness to deal with the anxiety and despair of suicidal schizophrenics are important in the treatment process, and uncertainties may be fatal. Increased attention to interpersonal behavior

Managing the increased suicide risk during and after discharge

Pompili and colleagues¹³ drew attention to the importance of suitable discharge plans. A supportive, supervised living arrangement is ideal. Roy and Draper⁴ also noted that discharge planning was a proximal factor to suicide in several of their long-stay schizophrenics who had to deal with the painful realization that they were losing the hospital and the staff or that their family was not prepared to have them home. Rossau and Mortensen⁵ found the risk for suicide greatest during the first 6

Managing suicide risk with psychotherapy and psychosocial interventions

Psychosocial interventions are commonly believed to play a role in the management of the suicidal schizophrenic patients. However, due to their heterogeneity and diversity from place to place, it has been difficult to establish whether they play a large role in the prevention of suicide.⁷² Schizophrenia patients usually need empathic support,⁷³ therefore nonpharmacologic strategies do have a role. Ponizovsky and colleagues,⁷⁴ in a study of suicidality in schizophrenia, found that

Intervention early in the illness to prevent suicide

Nordentoft and colleagues⁸¹ found that suicidal behavior and suicidal ideation occur frequently among patients with first-episode schizophrenic psychoses. These investigators found that suicidal ideation and reports of suicide attempts during the past year were significantly reduced after treatment, but were still at a high level compared with the general population. Melle and colleagues⁸² confirmed that suicidal behavior is present in the early phases of psychotic disorders and in many cases

Nonadherence with antipsychotics and suicidal behavior

A substantial percentage of schizophrenic patients who exhibit suicidal behavior are nonadherent with antipsychotic medication. The effect of poor compliance with antipsychotics on suicide rates among patients with schizophrenia was noted by an early review as well as by a recent meta-analysis, which concluded that poor compliance with antipsychotics more than triples the suicide risk in these patients.¹⁰ Herings and Erkens⁸⁸ found that an increased suicide attempt rate was observed when

Managing suicide risk in schizophrenics with negative attitudes to treatment

Virkkunen⁹⁵ interviewed relatives and acquaintances of schizophrenic suicides and controls, and found that the schizophrenic suicides were significantly more noncompliant. The patients “had been more adverse to take medicines voluntarily than were the controls during the pre-suicidal months, although the relatives and acquaintances thought that the patient's condition had been relatively good while they had been taking the medicines prescribed.” The patients' psychiatrists similarly reported

Increased number of admissions and suicide in schizophrenia

In 3 studies, schizophrenic patients who had exhibited suicidal behavior had had significantly more psychiatric admissions than schizophrenic controls who had never exhibited suicidal behavior.8, 28, 97

Hu and colleagues²⁴ similarly reported that schizophrenic suicides had had significantly more psychiatric admissions than controls (P<.01), as did Cheng and colleagues²⁵ when comparing 74 schizophrenic suicides with 74 schizophrenic controls. Rossau and Mortensen,⁵ in a nested case-control study

Possible future directions in the management of suicide risk in schizophrenia

At the start of this article, when considering the stress diathesis model for suicidal behavior in schizophrenia, risk factors were divided up into distal and proximal. Biologic and genetic factors are distal risk factors for suicidal behavior. Some of the recent data about biology and genetics that may in the future have relevance to the management of suicide risk in schizophrenia is also discussed here.

Summary and caveat about managing suicide risk schizophrenics by admission

This article discusses the frequency of suicidal behavior in schizophrenia, offers a model for understanding it, and deals with various aspects of the management of the at-risk schizophrenic patient. However, it is noteworthy that many suicide-risk schizophrenic patients are seen in the clinic or in the emergency room, with a recent marked increase of suicide risk. These patients may present with marked suicidal ideas, or with command hallucinations telling them to harm themselves, or with a