(This is part one of a series on suicide in schizophrenia-Ed.)
The rate of suicide in schizophrenia approximates that in mood disorders and may have increased with deinstitutionalization, warned Herbert Y. Meltzer, M.D., last year's winner of the American Foundation for Suicide Prevention's (AFSP) annual research award.
Meltzer, who is the Bixler professor of psychiatry and pharmacology at Vanderbilt University School of Medicine in Nashville, Tenn., and director of Vanderbilt's Division of Psychopharmacology, gave a special research award lecture on decreasing suicide in patients with schizophrenia at AFSP's Suicide Prevention 2000 Conference in New York City.
Suicide has been linked with schizophrenia for a long time, according to Meltzer. In 1911, Bleuler referred to the suicidal drive as "the most serious of schizophrenic symptoms" (as cited in Meltzer, 1999b).
Meltzer reported that 25% to 50% of people with schizophrenia attempt suicide at least once in their lifetime, and an estimated 3,600 patients with schizophrenia commit suicide each year in the United States alone. What's more, that figure "is probably an under-report because of the stigma associated with suicide," he told attendees.
Before the introduction of conventional antipsychotics and the attendant case management systems, the suicide rate among patients with schizophrenia was reported in the range of 9% to 13% (Meltzer and Okayli, 1995). That rate has persisted, Meltzer said, possibly because of the noncompliance associated with conventional antipsychotics and the often inadequate supervision of patients in the community.
There is "some evidence that deinstitutionalization and lack of effective community support has even increased the rate," Meltzer said.
In a 1993 Danish study, for example, Mortensen and Juel (as cited in Meltzer, 1999b) examined mortality and causes of death in 9,156 first-admitted patients with schizophrenia. Over the past decade, there had been a 50% reduction in the number of psychiatric inpatient beds available in Denmark. The authors evaluated whether this decrease in services had resulted in any changes in mortality or causes of death in patients with schizophrenia. They confirmed that mortality was significantly increased.
"Now [Mortensen and Juel] cited the length of stay decreasing from an average hospitalization of 50 days to 30 days," Meltzer said. "In today's managed-care world, the average person with an acute exacerbation of schizophrenia rarely receives more than five to 10 days in a hospital."
Many risk factors for suicide and schizophrenia have been well-documented, said Meltzer, who directed a clinical research center for the study of schizophrenia and depression funded by the National Institute of Mental Health from 1977 through 1996. He explained that risk factors may include poor premorbid function as well as current work and social function, male gender, shorter duration of illness, current substance abuse including smoking, cognitive impairment, social isolation, being unmarried, having suffered a recent loss or rejection, previous suicide attempts, and significant depressive symptoms and hopelessness (Hawton and Fagg, 1988, and Solomon, 1981, as cited in Meltzer, 1999b; Meltzer, 1998).
Meltzer explained that the patients' attitudes toward their life experience and the feelings of hopelessness that may develop as they note changes in themselves over time "are important reasons why some make suicide attempts."
Schizophrenia has a devastating effect upon patients' work and social function from the onset of psychosis and even before that, in the prodromal period, Meltzer said.
"Return to best premorbid function in people with this illness is extremely rare," he said. "I believe this is one of the major reasons why suicide is such a problem in patients with schizophrenia. A key reason they can't study or work at a level acceptable to themselves or others, even near the beginning of the psychotic period, is because nearly all people with schizophrenia have a severe impairment of cognitive function."
Cognitive impairment has been shown in a number of studies (Meltzer, 1999a) to be the critical factor in community adjustment as well as work and social function for patients with schizophrenia, Meltzer said.
"It is even more important than psychopathology per se, that is, [it is] more important than delusions, hallucinations and negative symptoms with regard to these outcome measures...Inability to function adequately greatly impacts on the decision about living or dying," he added.
To answer the question of whether patients who respond to typical neuroleptics are less likely to be suicidal than neuroleptic-resistant patients, Meltzer cited data from his own study (Meltzer and Okayli, 1995).
"The answer, in our hands at least, was absolutely not," he reported. "It's virtually the same in both groups, again pointing out that the typical neuroleptics have not made that much of a difference."
Patients with greater insight into their illness, Meltzer said, may often have increased suicidality (Meltzer, 1998).
"People with schizophrenia who, despite their cognitive impairment, appreciate how disabled they are and recognize how limited their ability is to cope with challenges and achieve their life goals and who feel hopelessness are the ones most likely to attempt suicide," Meltzer said.
Other factors that contribute to risk for suicide in patients with schizophrenia include: family conflict; lack of acceptance within the family for how the patient is now able to function; poor living conditions; coexisting medical conditions; and an overall poor quality of life. Meltzer added, "The lack of an enduring treatment relationship with clinic staff, because of rapid turnover, is also a negative factor."
The bottom line, he said, is that all these factors suggest the need for the most effective treatments to be applied early in the course of illness to avoid suicide.
"Unfortunately, until recently perhaps, we really haven't had effective pharmacotherapy to reduce suicide in schizophrenia. [Again,] there is no evidence that the typical neuroleptic drugs have diminished the suicide rate compared to the pre-neuroleptic era...Antidepressants and mood stabilizers may be useful in reducing depression, aggression and impulsivity...but their lack of effect on cognition means that even when the mood disturbance is improved, cognitive deficits may suggest life is not worth living and lead to a suicide attempt."
Meltzer said that while the conventional neuroleptics have not proved effective in preventing suicide, recent data suggest that the atypical antipsychotics, particularly clozapine (Clozaril), may reduce the risk of suicide. The second part of this series will discuss the research on the atypical antipsychotics and their relationship to suicide prevention.
Meltzer HY (1999a), Alleviation of functional impairment in treatment-resistant schizophrenia. Symposium 2C. Presented at the 152nd Annual Meeting of the American Psychiatric Association Washington, D.C.; May 15-20.
Meltzer HY (1999b), Suicide and schizophrenia: clozapine and the InterSePT study. J Clin Psychiatry 60(suppl 12):47-50.
Meltzer HY (1998), Suicide in schizophrenia: risk factors and clozapine treatment. J Clin Psychiatry 59(suppl 3):15-20.
Meltzer HY, Okayli G (1995), Reduction of suicidality during clozapine treatment of neuroleptic-resistant schizophrenia: impact on risk-benefit assessment. Am J Psychiatry 152(2):183-190.