Suicidality in schizophrenia: A review of the evidence for risk factors and treatment options

Abstract

Suicide is a major contributor to the morbidity and mortality of schizophrenia, accounting for approximately 10% of deaths in these patients. The known risk factors for suicide in schizophrenia include prior suicide attempts, substance abuse, male sex, onset during first decade of illness, social isolation, depression, and feelings of hopelessness. There is significant evidence suggesting that clozapine reduces the suicide rate in patients with schizophrenia and schizoaffective disorder. Possible factors that lead to a decrease in suicidality with clozapine include the following: a direct antidepressant action, improved cognitive function and insight, diminished negative symptoms, reduced substance abuse, and improved compliance. These effects may converge or lessen feelings of hopelessness and more of its converse optimism. The International Suicide Prevention Trial (InterSePT) is a large prospective, 2-year randomized trial of the comparative effects of clozapine and olanzapine involving 980 patients at high risk for suicide in 11 countries in 56 sites. The study included complete freedom to augment these treatments if needed, blinded ratings, a blinded Suicide Monitoring Board, and equivalent clinical contact. The results support the superiority of clozapine over olanzapine to reduce the risk of suicidality and suggest its use should be considered for all patients with schizophrenia with high risk for suicide.

Future‐directed thinking in first‐episode psychosis

“…They are male gender, living alone, increased severity of depressive symptoms, higher impulsivity and aggression, having a history of previous suicide attempts, substance misuse, and increased hopelessness (Balhara & Verma, 2012;Caldwell & Gottesman, 1990;Drake & Cotton, 1986;Hawton, Sutton, Haw, Sinclair, & Deeks, 2005;Meltzer, 2002;Reid, 1998). By contrast, some factors that increase risk for suicide in the general population confer risk in the opposite direction to that expected in individuals with psychosis.…”

Substance abuse and schizophrenia: Pharmacotherapeutic intervention

“…Many clinicians consider treatment with an atypical antipsychotic primary, when feasible and acceptable to the patient (Krystal, D'Souza, Madonick, & Petrakis, 1999;Mueser, Noordsy, Drake, & Fox, 2003;Ziedonis et al, 2005), and they have a lower threshold for recommending a trial of clozapine than in patients without a substance use disorder (Ziedonis et al, 2005). Although the potential side effects of weight gain and metabolic abnormalities that can occur in patients treated with atypical antipsychotics need to be considered, the risks associated with uncontrolled substance abuse, including suicide (Meltzer, 2002), violence and aggression (Soyka, 2000;Swanson et al, 2006), and blood-borne infections (Cournos & McKinnon, 1997;Rosenberg, Trumbetta et al, 2001) should also be taken into account. Importantly, clozapine treatment has been shown to be associated with decreased suicidality (Meltzer et al, 2003) and decreased aggression (Chengappa et al, 2002;Krakowski, Czobor, Citrome, Bark, & Cooper, 2006;Volavka, Zito, Vitrai, & Czobar, 1993) among people with schizophrenia.…”

Diretrizes da Federação Mundial das Sociedades de Psiquiatria Biológica para o tratamento biológico da esquizofrenia. Parte 1: tratamento agudo

“…Considera-se que fatores genéticos e neurobiológicos distintos influenciam no comportamento suicida, talvez de forma independente dos fatores genéticos associados à esquizofrenia (Meltzer, 2002). O suicídio é a principal causa de morte prematura entre pacientes com esquizofrenia (Meltzer, 2002).…”

“…Considera-se que fatores genéticos e neurobiológicos distintos influenciam no comportamento suicida, talvez de forma independente dos fatores genéticos associados à esquizofrenia (Meltzer, 2002). O suicídio é a principal causa de morte prematura entre pacientes com esquizofrenia (Meltzer, 2002). Idéias ou ameaças suicidas devem ser julgadas no contexto da história clínica, conforme relatada pelo paciente, pelos parentes e pelo terapeuta atual, se essas informações estiverem disponí-veis (APA, 1997).…”