CLINICAL HANDBOOK OF SCHIZOPHRENIA

11. Course and Outcome 111to a smaller degree, depressive symptoms predict a greater frequency of psychotic relapses.All types of comorbidity with severe misuse of or dependence on psychoactivesubstances predict a poor social course, poor cognitive functioning, and more severe psychoticsymptoms.RISK OF SUICIDE IN THE COURSE OF SCHIZOPHRENIAPatients with schizophrenia compared with the general population show elevated rates ofunnatural causes of death, of which suicide is the most frequent. In recent studies the portionof suicides in total deaths (proportional mortality) of people with schizophrenia isestimated at about 30%. Exact estimates are hampered by transnational variability of therates and by the fact that suicides are frequently masked (e.g., as car accidents). Althoughseveral reviews have reported that about 10% of people with schizophrenia commit suicide,single studies show a high degree of variance in the rates.In a sophisticated meta-analysis of 29 studies published between 1966 and 2000,and based on a total of 22,600 patients with schizophrenia, Palmer, Pankratz, andBostwick (2005) calculated a weighted lifetime incidence of 4.9% (95% confidence interval[CI]: 4.3–5.6%). Schizophrenia itself does not seem to be the only risk factor forsuicide over the course of the disorder. Heilä and colleagues (1999) analyzed by means ofpsychological autopsy all suicides committed in a year in Finland. In 46% of people withschizophrenia, stressful life events had occurred in the 3 months preceding the suicide.Most of these events were beyond the influence of the persons in question, such as deathor severe illness of a family member.Risk for suicide in people with schizophrenia markedly decreases with age as opposedto that for most general populations, which increase with age. Severe depressivesymptoms and comorbid alcohol and drug abuse are main risk factors both in peoplewith schizophrenia and in the general population, whereas severe negative symptomstend to be a protective factor, reducing the risk.Apart from these mostly observable risk factors is consideration of individual psychologicalrisk factors and coping abilities, which can only be assessed in a personal interview.For example, suicidal ideation has been found to be a better predictor of future suicidalbehavior than depressed mood (Young et al., 1998).In a small number of studies suicide rates are increased, particularly in the first yearsfollowing illness onset. The somewhat lower rates reported by those studies for subsequentperiods are probably accounted for by selective suicide mortality, resulting in a declineof high-risk cases. But the risk remains increased throughout the lifetime. Accordingto a majority of studies, unlike in the general population, the risk does not differ essentiallybetween males and females with schizophrenia.KEY POINTS• The main domains of schizophrenia spectrum disorders—symptom dimensions, frequencyof relapses, cognitive impairment, and social disability—on average show a stable course,without a trend for either the better or the worse.• The course of schizophrenia shows a high degree of interindividual variability, with about20% of individuals with a first psychotic episode staying free of symptoms for 10 years.• The traditional subtypes of schizophrenia are not stable over time (e.g., paranoid, undifferentiated).