Medscape

Abstract

Purpose of Review: There has been a recent resurgence of interest in better understanding the nature of suicidal behavior in schizophrenia, and numerous publications in the years 2000-2002 have addressed this topic. All studies are critically reviewed, the current status of the field is summarized, key issues for clinical practice are emphasized, and likely future directions and developments are outlined.
Recent Findings: Several reports published over the past year described studies that attempted to define clinical correlates of suicidal behavior in schizophrenia, clarify its epidemiology, delineate subtypes, and identify predictors of such behavior. A variety of risk factors for suicidal behavior in patients suffering from schizophrenia were identified and these were found to differ across age, gender, treatment setting, and race. Other studies attempted to elucidate the neurobiology of suicidal behavior in schizophrenia and explore the commonalities with the neurobiological underpinnings of suicidal behavior in other conditions. A third set of studies evaluated the impact of treatment on suicidal behavior in schizophrenia, with an emphasis on the role of the newer generation 'atypical' antipsychotics, and, perhaps uniquely, clozapine, in this regard.
Summary: There is clearly a high prevalence of suicidal behavior in individuals suffering from schizophrenia, and studies conducted over the past year add substantially to our knowledge about this problem and provide useful insights about clinical risk factors, the underlying neurobiological basis, and the impact of various treatments on reducing such behavior. Effectively treating positive symptoms and depression, reducing substance abuse, avoiding akathisia, addressing demoralization and instilling hope are important elements in this treatment approach. The newer generation of antipsychotics and developing psychological approaches (particularly cognitive-behavioral therapy) appear to be useful in reducing suicidality in schizophrenia; it is important to monitor the precise impact of these interventions carefully, however. The significant advances in defining the neurobiological basis of suicidality may enable the development of more effective treatments. Over the past year, much has been learned; hopefully this momentum will be maintained over the next few years.

Introduction

It is well known that schizophrenia is a chronic, generally life-long, mental illness that significantly debilitates afflicted individuals and severely compromises their function and quality of life.^[1*] A less-appreciated fact is the twofold increase in age-standardized mortality among patients suffering from schizophrenia, whose lifespan is abbreviated by an average of 15 years in comparison with the general population. The precise etiology of this excess mortality in schizophrenia is not clearly understood. In five studies reported over the past year,^[2-6] causes contributing to this increased mortality in schizophrenia were assessed in different settings, thereby elucidating the factors associated with higher death rates in patients afflicted with schizophrenia. Factors observed to contribute to increased mortality in schizophrenia included both natural (cardiovascular diseases, respiratory diseases, etc.) and unnatural (principally suicide) causes. What is particularly disturbing is the observation that standardized mortality ratios in schizophrenia increased 1.3-1.7-fold over the past two decades.^[4] On a hopeful note, several studies commented on how this excess mortality in schizophrenia could potentially be lessened by effective treatment, close monitoring, and reduction in high-risk behaviors.^[4-7] While this review focuses on recent studies on suicide in schizophrenia, it should be emphasized that suicide is not the only factor that contributes to increased mortality in schizophrenia.