Psychiatric Annals

CME Article 

Suicide in Schizophrenia Spectrum Disorders

Abigail L. Donovan, MD; Julia Browne, PhD; Oliver Freudenreich, MD, FACLP; Cori Cather, PhD

Abstract

Persons with schizophrenia are at a high risk for suicide, particularly early in the course of illness, but risk of suicide remains elevated throughout the life course. The diathesis for this risk includes demographic, environmental, and psychological factors, which are further influenced by stressors, such as the onset and exacerbation of illness and social influences. Comprehensive treatment for schizophrenia requires knowledge of these risk factors, ongoing assessment of suicide risk over time, and treatment planning to mitigate risk. Treatment interventions include both psychosocial and pharmacologic/somatic treatments. [Psychiatr Ann. 2020;50(4):146–151.]

Abstract

Persons with schizophrenia are at a high risk for suicide, particularly early in the course of illness, but risk of suicide remains elevated throughout the life course. The diathesis for this risk includes demographic, environmental, and psychological factors, which are further influenced by stressors, such as the onset and exacerbation of illness and social influences. Comprehensive treatment for schizophrenia requires knowledge of these risk factors, ongoing assessment of suicide risk over time, and treatment planning to mitigate risk. Treatment interventions include both psychosocial and pharmacologic/somatic treatments. [Psychiatr Ann. 2020;50(4):146–151.]

In 1911, Bleuler reported that “suicidal drive” was “the most serious of schizophrenic symptoms.”1 Today, suicide remains a significant cause of premature death in schizophrenia.2 Risk assessment and management of suicidality are critical components of treatment. Risk for suicide can be conceptualized through a stress-diathesis model, in which stressors include the onset or worsening of psychiatric illness and the diatheses include demographic, psychological, environmental, and individual clinical factors,3 which can be tempered by mitigating factors. This article will summarize risk and mitigating factors as well as recommendations for assessment and treatment of suicidal persons with schizophrenia.

Suicide Risk Among People with Schizophrenia

Suicidal ideation and suicide attempts are highly prevalent in persons with schizophrenia, who are at a 12-fold increased risk of dying by suicide compared to the general population.2 The lifetime risk of suicide in schizophrenia is approximately 5%.4 Between 40% and 50% of people with schizophrenia have reported suicidal ideation in their lives5 and up to 28% have attempted suicide.6

People in the early phases of schizophrenia are at especially high suicide risk, suggesting that illness onset is a particularly vulnerable period. Risk is exceptionally high prior to entering treatment, when between 6.3% and 28.2% of persons with schizophrenia attempt suicide.6–8 Furthermore, prolonged duration of untreated psychosis (DUP) is associated with increased suicide risk8–10 for multiple reasons. Prolonged DUP signifies that people are exposed to psychotic symptoms over long periods of time, often with increasing severity, which is both traumatic and functionally impairing.8 Long DUP may also be associated with more severe illness.8 Finally, during prolonged DUP, people can experience social toxicity and distress, as they fall off their developmental trajectory, struggle to complete school, engage in work, achieve independence from family, and develop a functional adult identity, all while observing unaffected peers achieve these goals. The mismatch between self/societal/developmental expectations and reality creates profound suffering, increasing risk further.

Even after accessing treatment, suicide risk remains high early in illness, approximately 1.6 to 3 times higher than in later illness.4,11 The time immediately after the first hospitalization is especially high risk12 and 22% of those who die by suicide early in illness do so within the first 2 months of treatment contact.7 Similar to other psychiatric illnesses, the period after any hospital discharge is high risk and up to 32.5% of all suicides in schizophrenia occur within 6 months of a hospitalization.13 Suicide risk remains elevated for the first 5 years of illness,14 but even during later stages of chronic illness, suicide risk is significant.

Several factors contribute to the high suicide risk in early illness. During this time, persons with insight may struggle with the realization that they have a chronic illness impacting the future they had envisioned. Persons with schizophrenia may erroneously associate the diagnosis with certain joblessness, homelessness, and severe functional impairment. Several studies have demonstrated that early insight, awareness of illness and negative beliefs about outcomes in schizophrenia are associated with greater suicide risk.12,15 During early illness, treatment has not reached peak efficacy, psychotic and affective symptoms may remain prominent, and significant substance use may continue, all increasing suicide risk. The time immediately after hospital discharge may be similarly high-risk for several reasons: the exacerbated symptoms that triggered hospitalization may not have resolved, lingering symptoms may cause hopelessness that improvement will never happen or that the person has been failed by the system meant to help them, discharge signals the acute loss of intensive support and the abrupt return to the stressors that triggered admission, and discharge is associated with medication nonadherence, all increasing risk.16

Risk Factors

Multiple demographic risk factors are associated with increased suicide risk in schizophrenia. Commonly cited risk factors include young age,12,14 European descent,12,17 and never being married.12 Most studies cite male sex as a risk factor for suicide attempts7,12,17 and completed suicide.14,18 One of the strongest and most consistent predictors of suicide across multiple studies is a history of prior suicide attempts.7,9,12,17 The risk engendered by prior attempts is likely further increased by more serious, more frequent, or more recent attempts.19 Yet, a prior suicide attempt is poorly predictive of a future completed attempt in the general population; 59% of completed suicides occur on the first attempt, and 2.3% of first attempt survivors subsequently complete suicide.20 Additional risk factors include a history of sexual abuse and a family history of severe psychiatric illness9 or completed suicide.18

Premorbid and cognitive function have inconsistent associations with suicide risk. Some research has demonstrated that people with impaired premorbid function have increased risk,5,7,10 possibly because they may have fewer coping skills, limited social supports, or more severe illness. Conversely, other research has demonstrated that high-premorbid function,21 higher levels of education,18 and high IQ13,21 are associated with increased suicide risk. This group may have a deeper understanding of the impact of schizophrenia on their lives, including the change between premorbid potential and current ability. Additionally, they may have better ability to plan and execute a lethal suicide attempt. Thus, both ends of the functioning spectrum may have increased risk.

Psychotic symptoms may also influence suicide risk. Evidence has generally supported that active hallucinations and delusions are suicide risk factors;6,12,18 however, some research has not supported this association.17 During the first episode, elevated positive and negative symptoms appear to predict suicidal behavior.9 Research has not supported an association specifically between command auditory hallucinations and suicide risk,5,17 although many clinicians believe these phenomena hold clinical significance, and some people experiencing psychosis have reported that command hallucinations played a role in their suicide attempt.22 Some research has also described an increased risk of suicide with paranoid delusions and suspiciousness,23 whereas other research has not confirmed this association.6,17

Depression and hopelessness are consistent and substantial suicide risk factors in schizophrenia.5,18 Further, depressive symptoms are often highest after an initial psychotic episode, with several factors associated with increased depression including greater insight, loss, shame, ongoing positive symptoms, and longer DUP.9

Schizophrenia is frequently comorbid with substance use disorders, and substance use is a significant suicide risk factor. Alcohol use, cannabis use, and general substance use have all been consistently found to increase suicide risk.7–9,17 Substance use may increase risk through effects on disinhibition, impulsivity, worsening psychotic and/or affective symptoms, medication nonadherence and impaired socio-occupational role functioning.12

Environmental and social factors also influence suicide risk. Acute social stressors, including losses (financial, relationship), are associated with increased suicide risk.12,17 Additionally, living alone or not living with family and low social support are risk factors.5,17 A lack of social support leaves people vulnerable to feelings of isolation and social disconnection, limiting ability to cope with distress.

Antipsychotic medication is the foundation of treatment for decreasing and preventing the reemergence of positive psychotic symptoms. However, medications can also contribute to suicidality, either due to increasing intolerable mental states or by failing to reduce them. Medication nonadherence, a common long-term management problem in schizophrenia, increases suicide risk.17 Poor efficacy despite taking medications that fail to reduce Shneidman's “psychache” (which may be unrelated to psychosis) is an important consideration, particularly if the patient is demoralized over lack of treatment response emerges. Antipsychotic medication can cause an iatrogenic contribution to suicidality through side effects, particularly akathisia. Akathisia is a distressing side effect, experienced as inner restlessness, sometimes quite severe, which has been associated with suicidality in first-episode psychosis (FEP).24

Suicide may be understood experientially as the desperate need to escape “psychache” or the experience of intolerable affect.16 Psychotic symptoms, depression, hopelessness, medication side effects or lack of effect, demoralization, desperation, aloneness, and other factors can all contribute to this unbearable emotional state. In turn, cognition can become rigid and concrete, limiting the ability to problem solve, leading to the unfortunate conclusion that suicide is the only means of relief or escape.16

Mitigating Factors

Factors that mitigate suicide risk in schizophrenia have also been identified. Higher levels of social support have consistently been found to mitigate suicide risk; positive interpersonal connections provide reasons for living, add meaning to life, and may increase self-esteem.5 Similarly, children in the home and a sense of responsibility to family have also been associated with decreased suicide risk.5,17,19 Positive coping strategies, effective problem-solving skills, a sense of purpose, and general life satisfaction are also mitigating factors.5,19,25 Illness-related mitigating factors include positive therapeutic alliances with providers19 and antipsychotic medication adherence.18

Religion has been identified as an important mitigating factor in general19 and specifically in a subset of persons with schizophrenia.26 Religious persons may believe that suicide is morally wrong, that suicide prevents entry into Heaven, and/or that the body is sacred. Religion may increase meaning in life, promote hope, and buffer stress through positive coping techniques like prayer. Further, religious communities provide social support.26 Conversely, religion may increase suicide risk through fostering a desire to be with God or to experience peace in the afterlife, or if there is a loss of faith or estrangement from one's religious community.26

Assessment of Suicidality

Given the substantial suicide risk, regular assessment of suicidality is critical. Providers should also assess for changes in symptomatology as well as emergence of specific risk factors. Assessment of modifiable risk factors, including substance use, medication adherence, side effects, access to firearms, and comorbid depression, is particularly important, given that these factors can be actively addressed. Assessments should be conducted with increased frequency during high-risk periods, including after an initial psychotic episode, during hospital admission, after discharge, and particularly after a suicide attempt. Collateral information from family and supports provides an invaluable perspective on risk. In addition to monitoring for changes in symptoms and risk factors, providers may also find it valuable to use specific assessment measures. The Columbia-Suicide Severity Rating Scale is considered the gold standard for suicide assessment and examines severity of ideation, behavior, and lethality. This measure has excellent validity and is sensitive to change over time, thereby supporting its utility in clinical practice.27

Treatment Considerations

Key recommendations for reducing suicide risk in schizophrenia include reducing DUP, optimizing treatment of schizophrenia and associated symptoms (eg, depression) with evidence-based treatment, and providing ongoing monitoring of suicidality and risk factors.17 Reducing DUP is an important systems-level intervention requiring public education, outreach, and establishment of clinical teams for rapid assessment.9,10 Early detection programs to decrease DUP have demonstrated significant reduction in suicide plans and attempts.10 Evidence-based psychosocial treatments such as cognitive-behavioral therapy (CBT), supported employment, family psychoeducation and therapy, integrated dual-disorder treatment, and social skills training lead to better overall management of schizophrenia, which may reduce suicide risk indirectly by targeting modifiable risk factors, including medication adherence, psychotic, negative, and depressive symptoms, social functioning, and coping skills. Coordinated specialty care programs for FEP, which often include these treatments, have been found to reduce suicide risk.28

Commonly used psychosocial approaches to reducing suicidal behavior include psychodynamic therapy, CBT, and dialectical-behavior therapy (DBT). Psychodynamic psychotherapies for suicidality focus on the individual's affective experience, attending to conscious and unconscious beliefs, with the goals of instilling hope, modifying relational scripts, and facilitating the emergence of innate capacities.29 DBT promotes the development of both present-centeredness and the skills to regulate emotion and improve relationships. CBT-oriented suicide prevention interventions include developing a coping plan for suicidal impulses, identification and modification of thoughts that trigger suicidal impulses, problem-solving to increase cognitive flexibility so that suicide is not the only apparent solution, and increased salience of reasons for living including developing a “Hope Kit” (a personally meaningful collection of objects).30

Little research exists on the specific efficacy of psychosocial treatments for suicidality in schizophrenia; one small trial of CBT in persons with psychosis and suicidal thinking demonstrated decreased hopelessness, but no effects on suicidal behavior.31 Among people who are suicidal without schizophrenia, CBT is the most studied form of psychotherapy. A meta-analysis demonstrated that CBT is associated with sustained reductions in self-harm at both 6-month (12 studies, N = 1,317) and 1-year follow-up (10 studies, N = 2,232), as well as improved depression, hopelessness, suicidal ideation, and problem-solving skills.32 Moreover, CBT reduces repeat suicide attempts at 1 year by 50% among people who attempted suicide in the past 6 months.33 Although there are fewer randomized controlled trials, psychodynamic therapy and DBT have also shown promise in reducing suicidal behavior. A meta-analysis of psychoanalytic and psychodynamic therapies demonstrated reductions in suicide attempts (3 studies, N = 276), reduced self-harm at 6-month (2 studies, N = 125), but not 12-month follow-up (3 studies, N = 278), decreased hospital admissions at 12-month follow-up, and potentially better psychosocial functioning.34 DBT is associated with a decrease in frequency of self-harm, but not with likelihood of repeating self-harm (3 studies).32

Given the value of psychosocial treatments and the importance of treatment engagement, forming and maintaining a strong therapeutic alliance is critical. A strong alliance is thought to comprise agreement on goals of therapy, agreement on tasks of therapy (what will be done in therapy that aligns with the client's goals), and the presence of a supportive bond.35 Recent research on alliance in the treatment of schizophrenia and FEP has illustrated that it is not only possible to establish a strong therapeutic relationship but also that this relationship is predictive of better treatment adherence and improved functioning36 as well as improved psychotic symptoms.37 Providers should employ a nonjudgmental, curious stance when working with clients, particularly those with more severe symptoms. Specific inquiries around the thoughts and affects underlying suicidality can deepen the therapeutic engagement. Therapists should also openly discuss and track client goals, linking the tools and strategies used in therapy to those goals, to foster a strong alliance.

In addition, medications are important in reducing suicide risk, in both the short-term (during acute psychosis) and the long-term (during chronic management). In one recent study, effective treatment with antipsychotics (ie, clozapine or long-acting injectable antipsychotics) was best in reducing treatment failures including suicide attempts.38 In acute psychosis, suicides may occur because of disorganization that medication could prevent. Adding antidepressants during acute psychosis is usually unnecessary, even if depressive symptoms are present, as depressive symptoms often recede in parallel with psychotic symptoms after antipsychotic treatment initiation.39 Residual symptoms and comorbid disorders can then be specifically targeted. For example, in persons with chronic schizophrenia with residual depression, one trial demonstrated that suicidal ideation improved when citalopram was added.40

However, the only US Food and Drug Administration-approved medication to manage suicidality in persons with schizophrenia spectrum disorders (schizoaffective disorder) is clozapine.41 Clozapine is more effective in reducing suicidality than olanzapine.42 The mood stabilizer lithium is a well-established anti-suicidal agent in bipolar disorder and can be considered adjunctively in schizophrenia to manage suicidality; however, lithium is not effective for the core symptoms of schizophrenia. If rapid relief of the suicidal drive is required, electroconvulsive therapy should be strongly considered.21 Although ketamine, another rapid-acting treatment, is increasingly used for treatment-resistant depression and suicidality in some populations, its use in psychotic disorders is contraindicated because ketamine can trigger or worsen psychotic symptoms.

Conclusion

A core component of schizophrenia is the high risk for suicide, particularly early in the illness, but remaining prominent throughout life. Developing strong therapeutic relationships and conducting regular assessments, particularly during high risk periods, is crucial. Key modifiable risk factors include psychotic symptoms, depressive symptoms, substance use, and a lack of a sense of meaning, purpose, and connection to others. A thorough understanding of a person's risk is critical to inform a comprehensive treatment plan with the goal of decreasing suicide risk. Treatment interventions may include both psychosocial and pharmacologic/somatic treatments, with close monitoring during high-risk periods.

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Authors

Abigail L. Donovan, MD, is the Director, First Episode and Early Psychosis Program; the Associate Director, Acute Psychiatry Service; and an Assistant Professor of Psychiatry. Julia Browne, PhD, is a Clinical and Research Fellow, Center of Excellence for Psychosocial and Systemic Research. Oliver Freudenreich, MD, FACLP, is the Co-Director, Schizophrenia Clinical and Research Program; and an Associate Professor of Psychiatry. Cori Cather, PhD, is the Director, Psychological Services for the Massachusetts General Hospital Schizophrenia Clinical and Research Program; and an Associate Professor of Psychiatry. All authors are affiliated with Massachusetts General Hospital, Harvard Medical School.

Address correspondence to Abigail L. Donovan, MD, Massachusetts General Hospital, 55 Fruit Street, Boston, MA 02114; email: aldonovan@partners.org.

Disclosure: Oliver Freudenreich discloses royalties from Wolters-Kluwer and UpToDate; consultation for Alkermes, Neurocrine, Janssen, Novartis, and Roche; contracted research for Avanir, Janssen, Otsuka, and Saladax; and continuing medical education talks and medical editing for Medscape, Elsevier, Neurocrine, and Global Medical Education. Cori Cather discloses consultation for Charles River Analytics, Department of Mental Health, Maine Medical Health Center, and the New England Research Institute. The remaining authors have no relevant financial relationships to disclose.

10.3928/00485713-20200309-01

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