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The increased risk of suicide among schizophrenia patients is well documented (1,2), and schizophrenia is recognized as a disease that reduces the life expectancy of those afflicted by approximately 10 years (3). To date, suicide research in schizophrenia has primarily focused on attempted or completed suicide; it has been estimated that 30% of patients with schizophrenia attempt suicide, and 10% are successful (2–4). These 2 groups of patients have been excessively studied with regard to frequency of occurrence, psychopathological state, and sociodemographic characteristics. Data on suicidal thoughts in schizophrenia patients are scarce. However, it is worth noting that suicidal ideation and planning are important steps in a process of suicide characterized by a stepwise hierarchy of actions with an underlying gradient of severity: ideation precedes planning, which may result in an attempt that perhaps leads to death (5). It should therefore be clinically valuable to consider the risk factors associated with suicidal ideation. This study investigates the prevalence of recent suicidal thoughts and attempts in a population of inpatients with acute schizophrenia and seeks to reveal the clinical parameters associated with suicidal ideation. Material and MethodsPatients The patients were given a diagnosis according to DSM-IV criteria (6) by 2 independent psychiatrists with similar levels of education and experience. These diagnoses were reviewed on the day of discharge; all information collected during the inpatient period was taken into account. The patients’ mean age was 30.3 years (SD 8.9). They had a mean of 12.3 years (SD 2.5) of education and a mean duration of illness of 7.2 years (SD 7.5). We excluded from the study patients with any other diagnosis on Axis I of DSM-IV, with current alcohol or drug abuse, with serious physical (especially neurological) illness, or with mental retardation. At the time of assessment, the patients were receiving the following medications: antipsychotic drugs (76%), antiparkinsonian agents (56%), anxiolytics (51%), antidepressants (14%), and mood stabilizers (2%). Of the patients taking antipsychotic drugs, 63% used conventional antipsychotics, 19% used an atypical antipsychotic as monotherapy, and 18% used atypical antipsychotics concurrently with conventional antipsychotics. It should be noted that all patients taking antidepressants belonged to the depressed-suicidal group. Measures The CDSS is considered a specific, reliable, and valid measure of depression in schizophrenia. It comprises 9 items selected from the Hamilton Depression Rating Scale (HDRS) and the Present State Examination (PSE) and assesses symptoms of depression at any stage of the disease. Each item has a 4-choice response format (0 to 3). The total possible score is between 0 and 27. Three psychiatrist-raters trained in the use of the instruments evaluated patients within a period of a few hours. The first rater assessed depressive symptomatology, using the CDSS, and akathisia, using the BARS. The second independent rater assessed positive symptoms, negative symptoms, and general psychopathology, using the PANSS, and extrapyramidal symptoms, using the RSESE. The third rater assessed abnormal involuntary movements, using the AIMS. A standardized data schedule that included social, clinical, and pharmacologic parameters was completed for each patient. Reported suicidal thoughts and attempts were derived from the CDSS item 8 (“suicidality”). The ratings were as follows: 0 = absent; 1 = frequent thoughts of being better off dead or occasional thoughts of suicide; 2 = deliberately considered suicide with a plan, but made no attempt; 3 = suicide attempt apparently designed to end in death. Statistical Methods Because clinical symptoms potentially associated with suicidal thoughts are interrelated, we performed stepwise multiple regression analyses to assess their independent effect on suicidal ideation. We included all PANSS and CDSS items in the regression analysis. Statistical significance was set at P < 0.05. Values are expressed as mean (SD). Data were analyzed with the Statistical Package for Social Sciences (SPSS) (14). ResultsOf the patients, 20.4% reported any suicidal thought during the last 15 days; 11.8% reported frequent thoughts of being better off dead or occasional thoughts of suicide; and 6.4% reported deliberate suicide with a plan but made no attempt. Two subjects (2.2%) had attempted suicide during the last 15 days. All subjects reported both the more intense and the less intense suicidal feelings. Table 1 compares schizophrenia patients with suicidal thoughts with those without suicidal thoughts in terms of the severity of psychopathological parameters and motor side effects. In all parameters, there were no significant differences between the 2 matched groups of patients, with 1 exception: patients with suicidal thoughts scored higher than control subjects on the CDSS (10.52 vs 3.52, P < 0.0001).
There were no statistically significant differences between Group A and Group B patients in many social and clinical parameters, that is, in marital status (single, 84% vs 95%), education (years of schooling, 12.1 vs 13.2), employment status (unemployed, 79% vs 74%), duration of illness (years, 4.8 vs 6.6) duration of hospitalizations (years, 0.40 vs 0.45), number of hospitalizations (2.55 vs 2.73), use of neuroleptics (58% vs 68%), history of electroconvulsive therapy (16% vs 15%), and mean daily dosage of neuroleptics (chlorpromazine equivalents in mg, 747.0 vs 770.3). Stepwise multiple regression analyses revealed that the following scores predicted the patients’ suicidality: on the PANSS, the items “depression” (β = 0.408, P < 0.01), “guilt feelings” (β = 0.402, P < 0.008), and “motor retardation” (β = 0.369, P = 0.01); and on the CDSS, the items “pathological guilt” (β = 0.603, P < 0.001) and “self-depreciation” (β = 0.513, P < 0.01). DiscussionTo our knowledge, this is the first report on the prevalence and characteristics of inpatients with acute schizophrenia and suicidal thoughts that uses the CDSS, a specific instrument for assessing aspects of depression in schizophrenia. Until now several scales, such as the HDRS, have been used to estimate the depressive symptomatology of schizophrenia patients. However, all these scales have been standardized only for patients suffering from depression (15–18). Limitations of this study include the relatively small sample of patients and the basing of suicidal ideation rating on the CDSS “suicidality” item, which was included in the calculation of the total depression score. However, the validity of the results is supported by the multivariate statistical methods used, as well as by the established reliability of the rating of depressive symptoms in schizophrenia patients. According to our findings, suicidal thoughts are frequent among inpatients with acute schizophrenia. Recent suicidal ideation was reported by 20.4% of the entire group of patients, and 2.2% reported a suicide attempt in the 15 days before hospital admission. Other authors have also reported high rates of suicidal thoughts among schizophrenia patients. Amador and others (19) pointed out that 22% of schizophrenia patients reported “yes” to the question of suicidal thoughts and behaviour in the past, while Dassori and others (20) reported that 32% of the schizophrenia patients in their sample exhibited death wishes with or without suicidal plans or attempts. Fenton and others (21) reported that 40% of the schizophrenia patients studied expressed suicidal ideation at some time during a 19-year follow-up, and Grave mentioned that, among patients with psychotic disorders, 30% were reported to have suicidal thoughts, threats, and (or) attempts before or during their index hospitalization (22). Risk factors for suicide in schizophrenia include several social and clinical parameters, such as young age, male sex, single and (or) unemployed status, having a high level of premorbid functioning, and having depression, severe psychopathology, previous suicide attempts, and multiple relapses (1,2,23–28). There is, however, no information on risk factors for schizophrenia patients with suicidal thoughts. Moreover, there are few data regarding the relation between the presence of suicidal ideation and future suicidal behaviour. According to Funahashi and others, the presence of suicidal ideation was revealed as a predictor of suicide in their clinical investigation of 80 suicides by schizophrenia sufferers (29). Conversely, Young and others reported that low levels of suicidal ideation may predict future suicidal behaviour better than depressed mood (30). Suicide has been described as a process of different stages, starting with thoughts of death and suicide and ending in self-inflicted death. Most efforts to prevent suicide have been directed to those who have already made an attempt. However, primary prevention should involve people with suicidal thoughts. According to our study results, there is a close relation between suicidal ideation and the presence of depression, guilt feelings, pathological guilt, self-depreciation, and motor retardation. Although most suicide ideators tend not to go through subsequent steps in the suicidal process, prevention of suicidal behaviours in schizophrenia patients should probably focus on reducing depressive and guilt feelings and on helping the individual to enhance self-esteem. Our study focused on describing the clinical characteristics of inpatients with acute schizophrenia and suicidal ideation. The degree to which these characteristics represent risk factors relevant to future suicide behaviours remains unknown. A long-term follow-up study could provide an answer to this crucial question. References1. Westenmeyer JF, Harrow M, Marengo JT. Risk for suicide in schizophrenia and other psychotic and non-psychotic disorders. J Nerv Ment Dis 1991;179:259–66. 2. Caldwell GB, Gottesman JJ. Schizophrenia—a high risk factor for suicide: clues to risk reduction. Suicide Life Threat Behav 1992;22:479–93. 3. Allebek P. Schizophrenia: a life-shortening disease. Schizophr Bull 1989;13:81–8. 4. Kontaxakis VP, Christodoulou GN, Havaki-Kontaxaki BJ, Skoumbourdis T. Attempted suicide among schizophrenic outpatients in Athens. In: Ferrari and others, editors. Suicidal behavior and risk factors. Bologna: Monduzzi Editore; 1990. p 627–31. 5. Hawley CJ, James DV, Birkett PL, Baldwin DS, De Ruiter MJ, Priest RG. Suicidal ideation as a presenting complaint. Br J Psychiatry 1991;159:232–8. 6. American Psychiatric Association. Diagnostic and statistical manual of mental disorders. 4th ed. Washington (DC): APA; 1994. 7. Addington D, Addington J, Maticka Tyndale E. Assessing depression in schizophrenia: the Calgary Depression Scale. Br J Psychiatry 1993(Suppl 22):39–44. 8. Kontaxakis VP, Havaki-Kontaxaki BJ, Margariti MM, Stamouli SS, Kollias CT, Angelopoulos EK, and others. The Greek version of the Calgary Depression Scale for schizophrenia. Psychiatry Res 2000;94:163–71. 9. Kay SR. Positive and negative syndromes in schizophrenia: assessment and research. New York: Brunner-Mazel Publishers; 1991. 10. Lykouras L, Botsis A, Oulis P. Positive and Negative Syndrome Scale. Translation–validity–reliability. Athens: Tsiveriotis Editions; 1997. 11. Simpson GM, Angus JWS. A rating scale for extrapyramidal side effects. Acta Psychiatr Scand 1970 (Suppl 212):11–9. 12. Barnes TRE. A rating scale for drug-induced akathisia. Br J Psychiatry 1989;154:672–6. 13. Guy W. ECDEU assessment manual of psychopharmacology–revised. Washington (DC): DHEW; 1976. 14. Norusis MJ. SPSS/PC and advanced statistics 4.0. Chicago (IL): SPSS Inc; 1990. 15. Snaith P. What do depression rating scales measure? Br J Psychiatry 1993;163:293–8. 16. Nakaya M, Komahashi T, Ohmori K, Suwa H. The composition of the depressive syndrome in acute schizophrenia. Schizophr Res 1998;34:151–7. 17. Kontaxakis VP, Havaki-Kontaxaki BJ, Stamouli SS, Margariti MM, Kollias CT, Christodoulou GN. Comparison of four scales measuring depression in schizophrenic patients. Eur Psychiatry 2000;15:274–7. 18. Kontaxakis VP, Havaki-Kontaxaki BJ, Stamouli SS, Margariti MM, Kollias CT, Christodoulou GN. Depression measures and motor-side-effects in patients with acute schizophrenia. Schizophr Res 2002;56:197–8. 19. Amador XF, Friedman JH, Kasapis C, Yale SA, Flaum M, Gorman JM. Suicidal behavior in schizophrenia and its relationship to awareness of illness. Am J Psychiatry 1996;153:1185–8. 20. Dassori AM, Mezzich JH, Keshavan M. Suicidal indicators in schizophrenia. Acta Psychiatr Scand 1990;81:409–13. 21. Fenton WS, Mc Glashan TH, Victor BJ, Blyler CR. Symptoms, subtype and suicidality in patients with schizophrenia spectrum disorders. Am J Psychiatry 1997;154:1999–2004. 22. Grawe RW, Pedersen PB, Widen JH. Changes in prevalence and comorbidity in a total population of patients with psychotic disorders in Norwegian psychiatric hospitals. Nord J Psychiatry 1997;51:127–32. 23. Havaki-Kontaxaki BJ, Kontaxakis VP, Protopappa VA, Christodoulou GN. Suicides in a large psychiatric hospital: risk factors for schizophrenic patients. Bibl Psychiatr 1994;165:63–71. 24. Drake RE, Gates C, Whitaker A, Cotton PG. Suicide among schizophrenics: a review. Compr Psychiatry 1985;26:90–100. 25. Rossau CD, Mortensen PB. Risk factors for suicide in patients with schizophrenia: Nated case-control study. Br J Psychiatry 1997;171:355–9. 26. Roy A, Schreiber J, Mazonson A, Pickar D. Suicidal behavior in chronic schizophrenic patients: a follow-up study. Can J Psychiatry 1986;31:737–40. 27. De Hert M, Peuskens J. Suicide in schizophrenia. Acta Psychiatr Belg 1998;(Suppl 1):37–45. 28. Haas GL. Suicidal behavior in schizophrenia. In: Marris RW and others, editors. Review of suicidology. New York: Guilford Press; 1997. 29. Funahashi T, Ibuki Y, Domon Y, Nishimura T, Akehashi D, Sugiura H. A clinical study of suicide among schizophrenics. Psychiatr Clin Neurosci 2000:54:173–9. 30. Young AS, Nuechterlein KH, Mintz J, Ventura J, Gitlin VM, Liberman RP. Suicidal ideation and suicide attempts in recent-onset schizophrenia. Schizophr Bull 1998;24:629–34. Author(s)Manuscript received January 2003, revised, and accepted May 2003. 1. Associate Professor of Psychiatry, University of Athens, Eginition Hospital, Athens, Greece. 2. Lecturer in Psychiatry, University of Athens, Eginition Hospital, Athens, Greece. 3. Professor of Psychiatry, University of Athens, Eginition Hospital, Athens, Greece. Address for correspondence: Dr VP Kontaxakis, Department of Psychiatry, University of Athens, Eginition Hospital, 74, Vas. Sophias Avenue, 11528 Athens, Greece e-mail: bkont@eexi.gr, bkont@cc.uoa.gr
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