Letters to the Editor
Re: Schizophrenia, Suicide, and Blood Count During Treatment With Clozapine
Dear Editor:
We read with great interest the recent article about clozapine treatment and blood counts (1), which has led us to reconsider another beneficial aspect of periodic blood-cell counts for patients with schizophrenia. More specifically, we refer to the importance of the patient–doctor relationship in reducing suicidality among these patients.
An in-depth analysis of follow-up studies has estimated that 10% to 13% of individuals with schizophrenia die by suicide, making it the first cause of death for this group (2). Most authors suggest that the following characteristics indicate individuals with schizophrenia who are more likely to commit suicide: young age, male sex, white ethnicity, good premorbid function, never-married status, postpsychotic depression, and a history of substance abuse and suicide attempts. Hopelessness, awareness of illness, and hospitalization are also very important risk factors. In recent years, atypical antipsychotic drugs have changed the therapeutic approach to schizophrenia. These new drugs—as is the case with clozapine—can also affect the suicide rate among these individuals (3). One of the most important risk factors for suicide among patients with schizophrenia is the social isolation they experience. Together with hopelessness, it induces several feelings that may lead to suicide. It should not be underestimated that meeting with medical staff may play a central role in reducing this social isolation (4). The fact that these patients have to follow a specific pattern of tests (as is the case with periodic blood counts), which leads to interaction with people who may provide warmth and empathy, may alleviate their ever-increasing sense of worthlessness and inadequacy. Most schizophrenia patients experience social isolation, even within their families, and are eager to establish even a tiny interpersonal contact (5). Further, these meetings represent a unique opportunity to check compliance, depressive symptoms, and suicidality. General practitioners and medical staff should always consider the importance of their role when interacting with these people (6). Providing a safe environment to these patients should be paramount, not only among mental health professionals but also among all who interact with them. Such effort no doubt contributes to preventing suicide among schizophrenia patients.
References
1. Oyewumi LK, Cernovsky ZZ, DJ Freeman, Streiner DL. Relation of blood counts during clozapine treatment to serum concentrations of clozapine and nor-clozapine. Can J Psychiatry 2002;47:257–61.
2. Caldwell CB, Gottesman II. Schizophrenics kill themselves too: a review of risk factors for suicide; Schizophr Bull 1990;16:571–89.
3. Meltzer HY. Suicide in schizophrenia: risk factors and clozapine treatment. J Clin Psychiatry 1998;59 (Suppl 3):15–20.
4. Meltzer HY, Okayli G. Reduction of suicidality during clozapine treatment of neuroleptic-resistant schizophrenia: impact on risk-benefit assessment. Am J Psychiatry 1995;152:183–90.
5. Phelan JC, Bromet EJ, Link BG. Psychiatric illness and family stigma. Schizophr Bull 1998;24:115–26.
6. Pompili M, Mancinelli I, Tatarelli R. GPs’ role in the prevention of suicide in schizophrenia. Fam Pract 2002;19:221.
Maurizio Pompili, MD
Iginia Mancinelli, MD
Roberto Tatarelli, MD
Rome, Italy
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