CLINICAL HANDBOOK OF SCHIZOPHRENIA

Clinical Course and Symptoms of Schizophrenia47. Suicide 495Suicide risk factors specific to schizophrenia include diagnostic subtype, time since onsetof illness, presence of positive and negative symptoms, and recency of mental health hospitalization.Paranoid and undifferentiated subtypes may be the most common diagnosticsubtypes associated with suicide in schizophrenia. As many as 60% of individuals withschizophrenia who die by suicide do so within the initial 6–10 years of being diagnosed;however, suicide risk remains high throughout the course of the disorder, even decades afterthe onset of illness (Harkavy-Friedman & Nelson, 1997; Heilä et al., 1997). Suiciderisk may be especially high after acute psychotic exacerbations, especially for women.Conflicting evidence has been reported regarding suicide risk associated with bothpositive and negative symptoms of schizophrenia, due in part to limited available data(Hawton et al., 2005). Researchers in Finland reported that 78% of individuals withschizophrenia who died by suicide had active psychotic symptoms at the time of death;approximately 10% experienced suicidal command hallucinations (Heilä et al., 1997).Individuals with schizophrenia who were actively ill more frequently expressed suicideideation or engaged in suicidal behavior in the 3 months prior to suicide than didnonpsychotic individuals (56 vs. 41%). Other positive symptoms associated with elevatedsuicide risk include paranoid ideation, suspiciousness, delusions of thought control, flightof ideas, and loose associations. Fear of mental disintegration may further increase riskfor suicide, as may loss of interest.As with the general adult population, risk for suicide in schizophrenia increases withrecent hospital admission, whether voluntary or involuntary, necessitating vigilance tosuicide risk during discharge planning and follow-up in the community. Risk is especiallyhigh within 6 months of discharge from hospital. Heilä and colleagues (1997) reportedthat approximately 33% of individuals with schizophrenia who died by suicide did sowithin 3 months of hospital discharge, more than 25% were mental health inpatients atthe time of death, more than 50% were outpatients at the time, and only 3% had neverbeen hospitalized. Those who died by suicide had an overall mean of eight lifetime mentalhealth hospitalizations (standard deviation [SD] = 8, range: 0–49); women had a highernumber of mean admissions than men (11.5 vs. 6.6). Individuals with schizophrenia whodie by suicide are more likely to be recipients of mental health care; those without schizophreniawho die by suicide are more likely to receive treatment in general medical practices.Presentation to a health care provider is quite common prior to suicide; in the Finnishstudy, over 50% of individuals with schizophrenia who died by suicide saw a healthcare provider within 4 days of death, and over 95% did so in the prior 3 months, necessitatingclinician vigilance to patient distress and other mental health symptoms.Depression, Substance Misuse, and Other Mental Health SymptomsThere are high rates of comorbidity of depression and substance misuse in individualswith schizophrenia. Those who harm themselves often do so in the context of extreme depression,despair, hopelessness, and feelings of worthlessness. A review of psychologicalautopsy studies of suicide in schizophrenia reported that depression, but not physical illness,increases risk for suicide (Hawton et al., 2005). Heilä and colleagues (1997) reportedthat 64% of individuals with schizophrenia experienced depressive symptoms atthe time of suicide; depression was quite common among middle-aged women withschizophrenia who died by suicide. Clinicians often did not detect these symptoms. It iscritical that clinicians attend to mood symptoms and hopelessness in people with schizophreniaand not focus exclusively on treating diagnosis-specific symptoms.