Suicide Risk In Schizophrenia Research Articles

The Schizophrenia Suicide Risk Scale (SSRS): development and initial validation

Background: Estimations about the lifetime risk of suicide in schizophrenia vary between 4 and 10%. At present, there does not exist a suicide risk scale developed particularly for schizophrenic patients. The aims of the present study were to: (1) develop a clinically useful semi-structured scale for the estimation of short-term suicide risk among schizophrenic patients, and (2) to carry out an initial validation of the scale. Methods: A 25-item Schizophrenia Suicide Risk Scale (SSRS) was constructed on the base of the literature. The SSRS scores of 69 living schizophrenic patients (LS group) were compared with the scores of 69 schizophrenic suicides (SS group) whose data had been collected previously from The Finnish nationwide and representative psychological autopsy study. Internal consistency of the SSRS was evaluated with Cronbach alpha. The most important SSRS items predicting suicide were identified with a logistic regression analysis. Sensitivity, specificity, positive predictive value, and negative predictive value of the SSRS in predicting suicide with various cut-off scores were calculated. Results: In the final logistic regression model, the following SSRS items significantly predicted suicide: suicide plans communicated to someone during the past 3 months; one or more previous suicide attempts; loss of professional skills demanding job; depression observed during an interview; and suicide plans communicated during an interview. With high cut-off scores the specificity of the SSRS became satisfactory, but the sensitivity dropped below 32%. Internal consistency of the anamnestic history of the SSRS was low, which suggests that anamnestic risk factors for suicide in schizophrenia are multifactorial. Internal consistency of the interview-based items was high, and present state risk factors seemed to consist of two separate factors, depression–anxiety and irritability. Conclusions: The SSRS may be clinically useful in identifying schizophrenic patients with a particularly high risk for suicide. However, the SSRS seems not to be a practical screening instrument for suicide risk in schizophrenia, and it is probably impossible to construct a suicide risk scale with both high sensitivity and high specificity in this disorder.

Reducing Suicide Risk in Schizophrenia

The risk of suicide is a major factor in the morbidity and mortality of schizophrenia, accounting for approximately 10% of deaths in patients with this condition. Indicated risk factors include male gender, social isolation, depression, feelings of hopelessness, a history of suicide attempts, deteriorating health and, uniquely to patients with schizophrenia, young age in men and chronic schizophrenia with numerous exacerbations. There is significant evidence suggesting that clozapine, the gold standard treatment for patients with treatment-resistant schizophrenia, reduces the suicide rate. Although the reasons for this are unknown, beneficial effects of clozapine that are thought to contribute to the reduced suicide rate include improved symptom control, reduced extrapyramidal symptoms, direct antidepressant action, improved cognitive function, and improved compliance. These improve self-perceived quality of life and hence lead to greater desire, and capacity, to survive. Reduced suicide attempts and completed suicide may also reflect the effect of weekly contact with mental health providers to obtain blood for white blood cell monitoring or cohort effects (i.e. time-dependent decrease in suicide attempt rates). Data from a number of studies which have investigated the impact of clozapine on suicide rates in patients with schizophrenia demonstrate that the drug reduces the risk of suicide attempts by approximately 75 to 80%. It had a comparable effect in reducing the completed suicide rate in an epidemiological survey of all US patients in the Clozaril® National Registry. A large scale prospective, randomised study comparing clozapine and olanzapine in patients with a recent history of suicidality is in process. The International Suicide Prevention Trial (InterSePT) will compare the effectiveness of clozapine (300 to 900 mg/day) with olanzapine (10 to 20 mg/day) in reducing suicide and suicide-related events in patients with schizophrenia and schizoaffective disor-der. An overview of the study methodology is provided in this review.

Depression, suicide, and suicide prevention in schizophrenia.

Suicide is the single largest cause of premature death among individuals with schizophrenia. Furthermore, epidemiological data indicate that nearly 80% of patients with the diagnosis of schizophrenia will experience a major depressive episode at some time during their lifetime. This report reviews recent findings relative to the risk of suicide in schizophrenia, including data from the Chestnut Lodge longitudinal study of schizophrenia subtypes and symptom domains. Paradoxically, those patients with schizophrenia who are most likely to recover or experience a good outcome are also those at greatest risk for suicide. The reduction of morbidity and mortality in schizophrenia should include depression and suicidality as targets for both psychopharmacological and psychosocial treatment.

Clozapine and Suicides

Back to table of contents Previous article Next article LetterFull AccessClozapine and SuicidesWilliam H. Reid, M.D., M.P.H., Mark Mason, M.S., and Thomas Hogan, M.B.A.William H. ReidSearch for more papers by this author, M.D., M.P.H., Mark MasonSearch for more papers by this author, M.S., and Thomas HoganSearch for more papers by this author, M.B.A.Published Online:1 Jan 1999https://doi.org/10.1176/ps.50.1.116aAboutSectionsView EPUB ToolsAdd to favoritesDownload CitationsTrack Citations ShareShare onFacebookTwitterLinked InEmail In Reply: Sernyak and associates suggest that the difference in medication compliance is a form of bias that accounted for the difference in suicide rates between a subgroup of patients treated with clozapine and a much larger comparison group of patients with schizophrenia. We believe that compliance is instead a causal factor. Compliance and treatment effects are related both to each other and to the particular drug prescribed.This relationship was demonstrated in a recent randomized, controlled trial of clozapine versus haloperidol in which treatment-compliant clozapine patients had statistically significant reductions in symptoms and improvements in quality of life compared with treatment-compliant haloperidol patients. They also had compliance rates that favored clozapine by a ratio of 2 to 1 (1). Clozapine's positive effects are thus probably related to both superior efficacy and superior compliance rates.The presence in the comparison group of two deceased patients who had taken clozapine months or years before their deaths may suggest several things, none of which detract from our suggestion of clozapine's association with suicide prevention. It may suggest that compliance is a variable not equally represented in the two groups, or that responsiveness to clozapine is important to protection against suicide. The overall finding of fewer suicides is notable regardless of the relative importance, if any, of such factors as medication effect, individual response to medication, increased compliance, differential monitoring, and special treatment or management as a result of being on a special medication. The fact that clozapine patients were among the most seriously and intractibly ill patients in our treatment system is important to the clinical interpretation of our findings.In their analysis of our data, Sernyak and associates claim that the two groups are statistically equivalent because the 95 percent confidence intervals around the suicide count yield overlapping ranges of suicide rates. However, application of the Poisson probability formula found in Hays (2), referring to suicide rates in particular, shows that the probability of observing one or fewer suicides in the clozapine group is .04, assuming the same base rate in the comparison group.As we stated in our paper, it is very difficult to extrapolate from a single suicide in six years. We find it hard to envision, in the real world, the large potential for suicide by patients on clozapine—up to 92 suicides per 100,000 patients per year—suggested by Sernyak's calculations. We believe we would have seen evidence of such numbers, in our system or reports from others, if this upper limit were reasonable.Finally, Sernyak and associates mention seeing no evidence of differences in suicide rates in their mortality study comparing episodes of care for patients started on clozapine with episodes for a large group of similar patients. However, they point out that they are not looking at suicide data per se. Despite increased suicide risk in schizophrenia, suicide nevertheless represents a relatively small portion of all causes of mortality among persons with this devastating disorder. Important differential suicide outcomes may not be detectable in a context of a review of mortality from all causes. It is reasonable to consider whether, as they adjust for clinical status in their mortality study, they might eliminate from their analysis the very factors that appear associated with favorable suicide-risk outcomes for clozapine, such as superior efficacy and compliance effects.

Suicide Risk in Schizophrenia

Back to table of contents Previous article Next article Letter to the EditorFull AccessSuicide Risk in SchizophreniaEDUARD VIETA, M.D., EVARISTO NIETO, M.D., and CRISTOBAL GASTO, M.D., EDUARD VIETASearch for more papers by this author, M.D., EVARISTO NIETOSearch for more papers by this author, M.D., and CRISTOBAL GASTOSearch for more papers by this author, M.D., Barcelona, SpainPublished Online:1 Nov 1998https://doi.org/10.1176/ajp.155.11.1626yAboutSectionsPDF/EPUB ToolsAdd to favoritesDownload CitationsTrack Citations ShareShare onFacebookTwitterLinked InEmail To the Editor: We read with great interest the excellent article by Hannele Heilä, M.D., and colleagues (1) on the clinical characteristics of suicide victims with schizophrenia in the general population of Finland. One important finding of this study is that suicide may occur at any point during the course of the illness, since three-fourths of the suicides were committed during an active phase. Previous reports, focusing especially on attempted suicide, had led to the general conclusion that active psychotic features were less important than depression and hopelessness in the assessment of suicide risk in schizophrenic patients (2, 3). When we studied the more severe forms of attempted suicide, however, 81% of the schizophrenic subjects presented positive psychotic symptoms at the time of attempting suicide (4). Our study also stressed the importance of previous attempts and the fact that more than one-quarter of the schizophrenic subjects were receiving psychiatric inpatient care when they attempted suicide, a finding similar to those of Heilä et al. (1). Therefore, we believe that clinicians should keep in mind that not only demoralization or depressive symptoms are important in the assessment of suicide risk in schizophrenia, but positive psychotic symptoms are even more significantly related to the risk of a serious attempt or suicide.

Pharmacotherapy and suicide risk in schizophrenia

Pharmacotherapy and suicide risk in schizophrenia

Pharmacotherapy and suicide risk in schizophrenia.

The authors examined drug prescribing patterns and incidence of side effects in schizophrenic patients who committed suicide as compared with a matched control group. The groups did not differ in type of drug prescribed, though patients in the suicide group received significantly higher doses of fluphenazine enanthate. Extrapyramidal reactions occurred more frequently among the patients in the suicide group in the thirty days preceding suicide, and autonomic side effects less frequently, than in control patients for a corresponding period prior to discharge. The authors conclude that the probability of suicide is not related to the type of drug prescribed.