Schizophrenia and suicide: systematic review of risk factors.
Jul 5, 2005 - 10:22:38 PM

The most comprehensive review of the international evidence to date on suicide in schizophrenia has found that the key risk factors are: depression, previous suicide attempts, drug misuse, agitation or restlessness, fear of mental disintegration, poor compliance with treatment and recent loss.

Suicide risk is greatly increased in schizophrenia, and detection of those at risk is clinically important. Published in the July issue of the British Journal of Psychiatry, this study systematically reviewed the world literature on patients with schizophrenia or related conditions in which suicide was reported.

28 eligible studies were identified. It was found that suicide risk in patients with schizophrenia was related less to the core psychotic symptoms of the disorder, such as hallucinations and delusions, and more to affective symptoms, agitation or restlessness, and to awareness that the illness was affecting mental functioning.

Previous suicidal behaviour was a strong risk factor. Drug misuse and loss also appeared to increase risk. Compliance with treatment was important in reducing risk.

Positive psychotic symptoms were not associated with increased risk. Indeed, hallucinations were actually associated with decreased risk, as were delusions. It is likely that the negative symptoms of schizophrenia are also associated with decreased risk of suicide.

Although this meta-analysis has shown that some of the risk factors for suicide in schizophrenia are similar to those for suicide in the general population, it has highlighted certain risk factors that are clearly specific to schizophrenia and its consequences.

The risk for suicide in men compared with women with schizophrenia of 1.57 is somewhat less than the ratio observed in the general populations of most countries. In contrast to the risk in the general population, being single or divorced was not associated with greater risk.

The living circumstances of patients appeared to be important, in that those living alone, or not living with their families, were at increased risk, a finding that might reflect the severity of the disorder.

Life events in the form of recent losses appear to be associated with suicide risk in patients, as is the case for suicide risk in general.

The most robust findings were of risk of suicide being strongly associated with affective disorders, such as depression; specific affective symptoms (agitation, sense of worthlessness and hopelessness); a history of suicidal thinking; threats of suicide; and (especially) non-fatal suicidal acts.

Further support for the importance of depression as a risk factor came from the positive association of risk with a family history of affective disorders. A family history of suicide was also a risk factor in the largest study that examined this area.

The meta-analysis provides some support for the idea that a higher level of education is associated with suicide risk, and this may also be the case with higher IQ. Fear of mental disintegration was also associated with increased risk.

Surprisingly, given the significance of alcohol misuse as a major risk factor for suicide in the general population, it does not appear to be a risk factor in schizophrenia. On the other hand, drug misuse or dependence was strongly associated with risk. Drug misuse is twice as common among people with schizophrenia as in the general population.

Suicide risk is considerably increased in patients who adhere poorly to treatment. Prevention of suicide is likely to result from active treatment of affective symptoms; improving compliance with treatment; use of medication that may have special anti-suicidal effects; and maintaining special vigilance in patients with risk factors, especially after significant loss events.

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