Suicide Prevention in Schizophrenia, Obstacles and Awareness

According to researchers, approximately 10% of people with schizophrenia die by suicide, which is the largest contributor to reduced life expectancy among those who have this psychotic disorder. Researchers indicate that comprehensive treatment is the only reliable protective factor for suicide in schizophrenia. However, there remain many obstacles that stand in the way of suicide prevention, such as inadequate detection of schizophrenia and comorbidities. In a review recently published in Medicina, researchers discuss the importance of recognizing suicide risk factors in schizophrenia so that treatments may be enhanced and the suicide rate decreased.

Demographic and psychosocial risk factors of suicide in schizophrenia include being a man, being unemployed, being unmarried and living alone, and being intelligent and well-educated, according to the article. Poor work functioning, having high personal hopes and expectations, and having access to lethal accessories such as firearms are also demographic and psychosocial risk factors of suicide in schizophrenia.

Researchers say suicidal behavior in schizophrenia is usually more common in patients who are aged under 45 years, though this association may be more related to the onset of illness than to age. Patients with schizophrenia tend to have a significantly higher risk for suicide during the first 10 years of their disorder, with 44% dying by suicide within this time period. This elevated risk that occurs early on in schizophrenia has been attributed to delays in receipt of psychiatric treatment.

In the context of symptomatology and course of illness, risk factors for suicide in schizophrenia include earlier age of onset, recurrent relapses, being in an earlier stage of illness, having awareness of symptoms, such as delusions and anhedonia, and nonadherence to treatment. Researchers say that patients with the paranoid subtype of schizophrenia are 8 times more likely to die by suicide compared with those having the deficit subtype. Patients who suffer delusions tend to exhibit more suicidal behavior than those who do not, as do those who fail to adhere to treatment with antipsychotic drugs.

The researchers pointed out that investigators of a previous study indicated that patients who did not take antipsychotic drugs after their first schizophrenia episodes were at 12-fold higher risk for all-cause mortality and at 37-fold higher risk for death by suicide. Despite the efficacy of antipsychotics for schizophrenia, some observers suggest that certain side effects of these medications may contribute to suicide. For instance, health conditions induced by antipsychotics such as akathisia and akinesia may increase the risk of committing suicide in schizophrenia.

According to research, comorbid disorders such as depression, a history of suicidal behavior, substance abuse, and medical and/or neurological disorders are also found to increase the risk for suicide in schizophrenia. Feelings of hopelessness, demoralization, and panic are other comorbid symptoms associated with a higher suicide risk for this population.

Researchers suggest that clinicians receive additional education and training to identify patients with schizophrenia at high risk for suicide, and say that suicide in this group may be effectively prevented with careful management of psychotic symptoms, comorbid depression, and comorbid substance use disorders. Antipsychotic medications that have been shown promising at reducing the suicide risk for schizophrenia include clozapine, olanzapine, quetiapine, and risperidone; therefore, future efforts in suicide prevention should focus on increasing compliance with these medications. Researchers say that the number of suicide attempts may be 4-fold higher in patients with schizophrenia who stop olanzapine or risperidone therapy.

In 2002, the US Food and Drug Administration approved the use of clozapine to reduce the risk for recurrent suicidal behavior in individuals with schizophrenia because results from several studies revealed that clozapine was effective at reducing symptoms of depression. Researchers say clinicians should consider starting clozapine in patients with schizophrenia as early as possible to reduce the risk for suicide. Current guidelines suggest that patients be started on clozapine after 2 antipsychotic drugs have been attempted, though newer evidence suggests starting clozapine after 1 failed antipsychotic drug trial.

Long-acting injections of antipsychotic drugs are commonly and frequently used to treat schizophrenia and other psychotic disorders; however, the effects of these drugs on suicide risk have produced inconsistent results. For instance, researchers of 1 study showed that monthly injections of fluphenazine decanoate were effective at reducing self-harm behavior in patients with a history of multiple suicide attempts, while researchers of another study indicated that this same therapy caused 2 men to develop severe akathisia and die by suicide.

Patients with schizophrenia who have comorbid depression may be at lower risk for suicide if they also use antidepressant medications. Some investigators suggest an association between the use of antidepressants and a decreased suicide risk for schizophrenia. Those with comorbid substance use disorders may benefit from combining antipsychotics with medications such as naltrexone and acamprosate that reduce drug and alcohol use.

In addition to using medications to reduce suicide in schizophrenia, researchers suggest that clinicians use nonpharmacological approaches, including family therapy and psychosocial interventions such as cognitive-behavioral therapy and supported education. Family interventions have been found to increase adherence to pharmacological therapy, and may be effective at reducing psychological distress in those related to patients with schizophrenia.

Researchers say that all mental and nonmental health providers should receive adequate education on how to prevent suicide in patients with schizophrenia. Researchers encourage health providers to understand and learn the risk factors for suicide in schizophrenia and how to identify patients at great risk, which may allow health providers to deliver the best therapies possible to effectively manage schizophrenia, along with comorbid depression and/or substance use disorders.

Reference

Sher L, Kahn RS. Suicide in schizophrenia: an educational overview. Medicina. 2019;55(7):361.