Suicide Behavior and Its Predictors in Patients with Schizophrenia in Ethiopia

Validation of the Amharic version of Cognitive Assessment Interview (CAI-A) in people with schizophrenia in Ethiopia

Introducing an interview-based cognitive assessment tool for people with Schizophrenia in Ethiopia

Cognitive difficulties significantly burdened people with schizophrenia (PWS). However, cognitive assessment is often unavailable in low- and middle-income counties (LMICs) due to a lack of validated and culturally adapted cognitive assessment tools. In this study, we developed and evaluated a culturally sensitive cognitive battery for PWS in Ethiopia. This study was conducted in three phases. First, we selected appropriate tests through an instrument selection procedure and created a new battery. Then, we rigorously adapted the tests using culturally competent procedures, including cognitive interviewing and expert meetings. Finally, we tested the new battery in 208 PWS and 208 controls. We evaluated its psychometric properties using advanced statistical techniques, including Item Response Theory (IRT). The Ethiopian Cognitive Assessment battery for Schizophrenia (ECAS) was developed from three different batteries. Participants reported tests were easy to complete, and the raters found them easy to administer. All tests had good inter-rater reliability, and the composite score had very high test-retest reliability (ICC = 0.91). One-factor structure better represented the data with excellent internal consistency (α = .81). ECAS significantly differentiated PWS from controls with 77% sensitivity and 62% specificity at a Z-score ≤0.12 cut-off value. IRT analysis suggested that the battery functions best among moderately impaired participants (difficulty between -0.06 and 0.66). ECAS is a practical, tolerable, reliable, and valid assessment of cognition. ECAS can supplement current assessment tools in LAMICs for PWS and can be used to measure cognitive intervention outcomes.

Hallucinations are a common symptoms found in individuals with schizophrenia. These hallucination cause people with schizophrenia (PWS) to experience difficulty in controlling themselves. This has an impact on suicidal behavior, harming other people, and destroying the surrounding environment. Therefore, a cognitive behavioral intervention based on self-management is needed as a non-pharmacological therapy to help PWS control hallucinations. This study aims to identify the effect of cognitive behavioral interventions based on self-management in people with schizophrenia. This study uses a quasy-experimental two groups pretest-posttest design. The sample consists 78 inpatient respondents with schizophrenia, divided into two groups, 39 in the intervention group and 39 in control group. Technique sample in this study using purposive sampling. Research data collection uses a questionnaire instrument for the ability to control hallucinations. The data explained used statistics, such as descriptive, dependent, and independent t-tests. The research results show that there are changes in the ability to control hallucinations in the intervention group and control group before and after self-management-based cognitive behavioral intervention (p-value=0.001). There was a difference in the ability to control hallucinations between the intervention group with the control group after cognitive behavioral intervention based on self-management (p-value= 0.013). The cognitive behavioral intervention based on self-management can be used as an effective cessation intervention to improve the ability of PWS to control hallucinations so that they can optimize their function in carrying out daily activities.

This study examined the association between family history of completed suicide and suicidal behavior and other clinical variables in subjects with bipolar disorder. 374 outpatients aged from 19 to 88 years (mean +/- SD age = 41.9 +/- 4.1 years) (54.3% female) meeting DSM-IV criteria for bipolar disorder type I or II or schizoaffective disorder, bipolar subtype, were included in the study. Forty-eight subjects with a family history of completed suicide were compared to 326 subjects without a family history of completed suicide regarding several clinical and demographic variables. The study was conducted from 2001 to 2004. There were no statistically significant demographic differences between bipolar disorder subjects with and without a family history of suicide. Bipolar disorder subjects with a family history of suicide showed higher rates of cluster C personality disorders than subjects without a family history of suicide (14.9% vs. 2.5%, OR = 6.72, 95% CI = 2.31 to 19.51, p < .001). Subjects with a family history of suicide also demonstrated a significantly greater lifetime prevalence of suicide attempts (52.2% vs. 25.5%, OR = 3.19, 95% CI = 1.7 to 6.0, p < .001). Results remained significant after controlling for all possible interactions. Family history of completed suicide is a significant risk factor associated with suicidal attempts in patients with bipolar disorder. These findings underscore the importance of identifying patients with a family history of suicide in order to provide prompt treatment and careful follow-up.

Introduction: Cognitive impairment (CI) is a core feature of schizophrenia (SCZ). Comorbidities such as substances/smoking, metabolic syndrome, and medications contribute to CI. There are racial disparities in CI in the general US population. No study has evaluated CI racial disparities among people with schizophrenia (PWSCZ). The aims of this study were to describe the clinical/psychosocial correlates and racial disparities in CI. Methods: Cognitive performance in PWSCZ over 55 years old was measured using MATRICS Consensus Cognitive Battery (N=66). We calculated age- and gender-corrected scores for global cognitive performance, which represent number of standard deviations away from the mean of the MCCB normative sample. Clinical and sociodemographic data were collected. A counterfactual approach was used to explore mediation of CI through education. Results: Our “all-comer” convenience sample represented 57.6% white, 25.8% black, and 16.6% other non-white groups. There was a black/non-black disparity in cognitive score (-2.33 v.s. -1.68, t=2.843, p<.01). This difference remained significant in a regression model adjusted for age, substance use, smoking, education, antipsychotic medication, and positive/negative symptoms (-.6611, [95%CI:-1.12,-.20], overall F8, 57=3.690, p=.0016). In the mediation analysis, education accounted for 19% of the disparity in CI. In the counterfactual scenario in which education was distributed equally, education accounted for 48% of the disparity. Conclusion: There are significant racial disparities in cognitive performance among older PWSCZ, and educational attainment may account for a sizable portion of the disparity.

Differences between female suicidal patients with family history of suicide attempt and family history of completed suicide

Long-term mortality and the risk factors for premature death among patients with schizophrenia living in rural communities are unknown. To explore the 10-year mortality and its risk factors among patients with schizophrenia. We used data from a 10-year prospective follow-up study (1994-2004) of mortality among people with schizophrenia, and death registration data for Xinjin County, Chengdu, China. The mortality rate was 2228 per 100,000 person-years during follow-up. Both all-cause mortality and suicide rates were significantly greater in male than in female patients. Age at illness onset (>45 years), duration of illness (> or =10 years), age greater than 50 years, physical illness, in ability to work, male gender, and never having received treatment were identified as independent predictors of increased mortality. Higher mortality rates in male patients may contribute to the higher prevalence of schizophrenia in women compared with men in China. The findings of risk factors for mortality should be taken into account when developing interventions to improve outcomes among people with schizophrenia.

Predicting Hospitalization Versus Discharge of Suicidal Patients Presenting to a Psychiatric Emergency Service

At the American Association of Suicidology’s (AAS) 46th Annual Conference in Austin, Texas (http://www.suicidology.org/web/guest/education-and-training/annualconference), participants were challenged to address why there has not been more progress in reducing the rates of completed suicides (Berman, 2013). A draft of recommendations from the National Action Alliance for Suicide Prevention’s Research Prioritization Task Force was presented at the meeting and subsequently published in this journal (National Action Alliance for Suicide Prevention [NAASP], 2013a, 2013b). The purpose of this commentary is to address this challenge by emphasizing the importance of employing a disease etiology strategy that integrates molecular data with clinical data, environmental data, and health outcomes in a dynamic, iterative fashion. The recommendations of the Research Prioritization Task Force tackle important public health program issues and are embedded within seven key questions, summarized as: 1. Why do people become suicidal? 2. How do we better detect/predict risk? 3. What interventions prevent suicidal behavior? 4. What are the effective services for treating suicidal persons and preventing suicidal behavior? 5. How do we reduce stigma? 6. What are the suicide prevention interventions outside of health-care settings? 7. Which existing and new infrastructure needs are required to further reduce suicidal behavior? (NAASP, 2013b; Silverman et al., 2013)

Background: Community-based rehabilitation (CBR) is a promising intervention to address the complex needs of people with schizophrenia in low-income countries, in particular the high levels of disability, problems accessing treatment and stigma experienced by this group. There have been few randomised controlled trials of communitybased psychosocial interventions for schizophrenia using non-specialist workers, and none which have utilised a community mobilisation approach or that are set in low-income countries. This thesis presents the intervention development, piloting and evaluation plans of a CBR intervention for people with schizophrenia in Ethiopia. Methods: A theory of change approach was used. Intervention development work, including a situational analysis, qualitative interviews and participatory workshops, was conducted to design the CBR intervention. The intervention was manualised and ten non-specialists were trained to deliver CBR. Ten people with schizophrenia and their caregivers received CBR in a 12 month pilot study. Qualitative, process and quantitative data were collected. The protocol for a cluster randomised trial to evaluate CBR, refined on the basis of the pilot findings, was produced. Results: CBR delivered by non-specialists is an acceptable approach for people with schizophrenia in rural Ethiopia. This CBR intervention is likely to be feasible but this requires evaluation on a larger scale. CBR may improve functioning in people with schizophrenia through maximising family and community support, supporting income-generating activities, facilitating access to medication, and increasing hope. However, contextual factors, including poverty and inaccessible anti-psychotic medication, may be beyond the capacity of CBR to overcome. Conclusion: A community-based intervention such as CBR should be provided for people with schizophrenia in low-income countries, alongside accessible anti-psychotic medication. There are indications that CBR can impact on functioning but a randomised controlled trial remains essential. The trial analysis will help to determine the ‘active ingredients’ of CBR that should be prioritised in scaling up.

BackgroundSuicide is a prominent cause of death among inmates worldwide, accounting for over 30% of all deaths. Several factors, including prison-related, psychiatric disorders, stressful life events, and substance use-related factors are believed to be associated with an increased risk of suicidal behavior in a correctional facility. The present study aimed to determine the prevalence and associated factors of Suicidal Behavior among prisoners at Dessie town correctional institution, Ethiopia.MethodsFrom February 16 to March 5, 2020, a cross-sectional survey was conducted among 288 inmates at the Dessie Town Correctional Center. A systematic random sampling technique was used to select study participants during the study period. Data was collected through face-to-face interview methods using Suicidal Behavior Revised (SBQ-R). The collected data were coded, entered into Epi-data data version 3.1, and analyzed by SPSS Version 26. Binary logistic regression was carried out to identify independent predictors of suicidal behavior at a 95% confidence level. Variables at a p-value < 0.05 with 95% CI were declared statistically significant.ResultsThe prevalence of Suicidal behavior among prisoners was found to be 25.3% [(95% CI: 20.5, 30.6)]. This study showed that being female [AOR = 5.14;95% CI (1.62,16.29)], depression [AOR = 4.97;95%CI (2.53,9.77)], anxiety [AOR = 3.14; 95%CI (1.59,6.22)], experienced stressful life events [AOR = 5.11; 95%CI (2.24, 11.65)], and ever substance use [AOR = 2.83; 95%CI (1.41, 5.59)] were variables significantly associated with suicidal behavior among prisoners in Dessie town correctional institution.Conclusion and recommendationsIn this study, suicidal behavior was highly prevalent among prisoners compared to the general population. Being female, depression, anxiety, stress full life events, and substance use were variables that are independent predictors of suicidal behavior. This study recommends that the institution needs to deliver an appropriate psychiatric facility to diagnose and treat prisoners with suicidal behavior. Also, special attention should be given to early screening and treatment of prisoners through prison health services, which is the most critical prevention strategy of suicide in prisoners.

Background: According to the World Health Organization, substance dependence is persistent or sporadic drug use inconsistent with or unrelated to acceptable medical practice. Substance dependence is showing a rising trend all over the world, and these disorders are rapidly recognized throughout in India. It is considered as a major cause of preventable ill health, social harm, and premature death throughout the population. As compared to the general population, those with substance use disorders are 5.3% more likely to die from suicide. There are several distal or predisposing risk factors associated with suicidal behavior such as personality traits, childhood trauma, and family history of suicide. Therefore, the present study is to compare and examine the distal factors of suicidal ideation (SI) and suicidal attempt (SA) with patients without SI and SA (WS) in patients with substance dependence. Materials and Methods: This was a cross-sectional observational study conducted at the inpatient departments of Central Institute of Psychiatry, Ranchi. Purposive sampling of sixty patients was done to further divide them into Group 1 (SI), Group 2 (SA), and Group 3 (WS). The sample was purposively collected to include sixty patients with substance dependence. They were screened by using the Addiction Severity Index scale, and Beck Scale for Suicidal Ideation (BSSI), Suicide Intent Scale, Childhood Trauma Questionnaire (CTQ), and the NEO five-factor inventory-3 (NEO-FFI-3) were administered to assess SI, SA, childhood trauma and personality traits, respectively. Results: The present study reveals that all the personality domains except conscientiousness on NEO-FFI 3 may have importance in differentiating the substance-dependent patients with SI/SA from WS patients. Only physical and emotional abuse on CTQ may be a significant distal factor for suicidal thoughts and behavior, whereas physical abuse may have more significance for SAs in substance dependence patients. Family history of suicide was not significant in patients with SI/SA. Conclusions: These findings may assist in formulation of therapeutic strategies for suicidal patients of substance dependence.

Pathological personality traits have repeatedly been identified as important risk factors for suicidal ideation and behaviors. Moreover, impulsive-aggressive traits, have shown a consistent association with suicidal behaviors across the lifespan. Adolescence represents a critical period for the emergence of different personality traits, mood disorders, and suicidal behaviors, but the relationship between these variables remain poorly understood. These variables were examined in a cross-sectional case-control design involving three groups: 30 adolescents with a depressive disorder and past suicide attempt (Mean Age = 16.2, Females = 26), 38 adolescents with a depressive disorder but without past suicide attempt (Mean age = 16.0, Females = 29), and 34 healthy adolescent controls (Mean age = 15.2, Females = 22). Suicidal ideations were indexed using Suicidal Behavior Questionnaire (SBQ-R), psychiatric disorder assessed using a semi-structured questionnaire (K-SADS-PL), depressive symptoms with the Beck Depressive Inventory (BDI), symptoms characteristics of personality disorders with the Scheduled Clinical Interview for the DSM-IV (SCID-II) screening questionnaire, and impulsivity with the Barratt Impulsivesness Scale (BIS). Findings showed that impulsivity (F = 11.0, p < 0.0001) and antisocial symptoms characteristics of personality disorders (p < 0.001, d = 0.70) displayed the most robust association with adolescent suicide attempts. Borderline symptoms characteristics of personality disorders did not discriminate attempters from non-attempters but presented high correlations with suicidal ideation and depression severity. In an item-wise analysis, suicide attempt status was uniquely correlated with symptoms characteristics of an antisocial personality disorder. Suicide attempt status also correlated with non-suicidal self-injury and a chronic feeling of emptiness. The caveats of this cross-sectional study include the stability of symptoms characteristics of personality disorders in adolescence and the limited sample size. In sum, suicidal behaviors were characteristically correlated with increased impulsivity and antisocial symptoms characteristics of personality disorders, but other symptoms characteristics of personality disorders were relevant to adolescent depression and suicidal ideation. Understanding the emergence of symptoms characteristics of personality disorders and suicidal behaviors in a developmental context can ultimately inform not only the neurobiological origin of suicidal behaviors, but also provide new avenues for early detection and intervention.

Psychopathology, especially depression, is the most important risk factor for suicidal behaviour [ 1, 2] with between 25% and 40% of depressed patients attempting suicide [ 3] and about 3.4% completing suicide eventually [ 4]. Given recent figures suggesting that the lifetime prevalence of a major depressive episode among the US population is 32.6–35.1 million [ 5], it is no surprise that suicide ranks among the top ten causes of death in many other countries [ 6]. Understanding the aetiology of a significant public health issue such as suicide is important but difficult because of its complex and multifactorial origins. Although most suicidal behaviour occurs within the context of a mood disorder, most depressed individuals never attempt suicide. Furthermore, no linear relationship between the severity of the depressive episode and the likelihood of suicide has been forthcoming [ 7], highlighting the importance of other factors in addition to psychiatric illness. These factors include substance abuse or alcoholism, a head injury, a dysfunctional family or childhood abuse [ 8], high rates of gun ownership [ 9], smoking [ 10], socioeconomic adversity [ 11], and personality factors [ 12]. Genetic factors may also be very important [ 13, 14]. Marusic and Farmer [ 15] argue that the variation in the suicide rate across European countries (7–43 per 100,000 inhabitants per year) cannot be explained by sociocultural factors alone and is probably due to shared genetic vulnerability. A case in point is the high suicide rate in Hungary and Finland, two populations with a common genetic origin but with divergent cultural and political trajectories [ 15]. Colours of Depression At the family level, the risk of suicide is higher in individuals with a family history of suicide [ 16, 17], and the suicide rate of adolescents is highly correlated with the suicide rate among their relatives [ 18]. Even studies that have controlled for levels of psychopathology have shown that relatives of suicide completers and attempters are at an increased risk for suicidal behaviour [ 19, 20]. Twin studies indicate that this familial clustering of suicidal behaviour has a partly genetic basis with heritability estimates of 17%–55% for suicidal behaviour [ 21, 22] and 20% for suicide [ 23] reported. The only adoption study we are aware of suggested that as far as suicidal behaviour is concerned, adoptees resemble their biological parents more than the adoptive family [ 24]. These data have catalysed the search for genes that predispose to suicidal behaviour, with more than 100 studies now published [ 25]. Post-mortem studies of people who committed suicide have led to the general consensus that a disturbance of the serotonergic system is associated with suicidal behaviour. Therefore, it is no surprise that most of the genes implicated in suicidal behaviour—the serotonin transporter (SERT), tryptophan hydroxylase (TPH), monoamine oxidase A (MAO-A), and the serotonin receptors, 5-HTR1A, 5-HTR2A, and 5-HTR1B—modulate central serotonergic function (see Table 1). As is the case with most complex traits, however, success tends to plateau at a point where good candidate genes are identified but conclusive causal inferences remain elusive because of replication failures. Table 1 Association Analyses of Genes Predisposing to Suicide or Suicidal Behaviour The unequivocal identification of genes related to psychiatric disorder is retarded by a complex interplay of latent environmental influences or gene–environment interactions; genetically and phenotypically heterogeneous samples; the possible effects of numerous loci of small effect size; and the difficulty of adequately correcting for multiple testing. Faced with these frustrations, the use of endophenotypes as an aid to molecular genetic investigations has become almost de rigueur. In the case of suicide, a number of researchers have advocated the use of personality traits as endophenotypes [ 12, 26].