CLINICAL HANDBOOK OF SCHIZOPHRENIA

496 VI. SPECIAL POPULATIONS AND PROBLEMSAlcoholism may be common among middle-aged men with schizophrenia who dieby suicide (Heilä et al., 1997). Although Hawton and colleagues (2005) did not find aclear risk for suicide among individuals with schizophrenia and alcoholism, they reportedelevated risk associated with drug abuse. Behavioral impulsivity, increased agitation, andmotor restlessness have been implicated in elevated risk for suicide in schizophrenia;however, no clear association was found linking violence with elevated risk for suicide inthis population (Hawton et al., 2005). Thus, clinicians should attend to mood symptoms,possible substance abuse, and impulsivity and agitation in individuals with schizophrenia,because these factors can increase risk for suicide.Psychosocial FactorsStressful life events, transitions, and impaired general and social functioning may all increaserisk for suicide. Negative life events are prevalent in individuals with schizophreniawho die by suicide but may be even more common among those without schizophreniawho die by suicide, possibly due to the more restricted lifestyles of individuals withschizophrenia, affording them fewer social and occupational contacts. Negative lifeevents are generally more common among outpatients than among inpatients who die bysuicide, and among those with a greater abundance of social contacts. Problems with financesand imprisonment are more common among those with schizophrenia andcomorbid alcoholism who die by suicide. Losses, disappointments, frustrations, livingalone, and social isolation increase risk for suicide in schizophrenia (Hawton et al.,2005). Clinicians are advised to monitor the reactions of individuals with schizophreniato negative life events, stressors, and losses, which can increase risk for suicide. No cleareffect of marital status on suicide risk is apparent in people with schizophrenia, unlike thegeneral population, which may be due partly to the fact that individuals with schizophreniaare more likely to be unmarried (Harkavy-Friedman & Nelson, 1997). A study ofsuicide in men in Montréal, Canada, indicated that most men with schizophrenia diedduring the winter/fall seasons, possibly reflecting effects of seasonal biological changesand/or restriction of social activity, which suggests the potential value of enhancing communityoutreach to at-risk populations, especially during high-risk periods.Resiliency FactorsThere is a paucity of research on resiliency factors that protect against suicide among individualswith schizophrenia. Research generally suggests that degree of religious commitmentand/or religious activities help to decrease suicide risk; this issue is complicatedamong individuals with delusions of good versus evil, or with suicidal command hallucinations.Clinical research findings indicated less suicide ideation in patients with greaterlife satisfaction, perceived social support, future orientation, and perceived meaning andpurpose in life (Heisel & Flett, 2004). Research exploring risk and resiliency to suicide inschizophrenia is needed.RISK FACTORS FOR SUICIDAL BEHAVIOR IN SCHIZOPHRENIAAND/OR SCHIZOAFFECTIVE DISORDERResearch supports elevated suicide risk among all patients with psychotic symptoms(Busch, Fawcett, & Jacobs, 2003; Radomsky, Haas, Mann, & Sweeney, 1999); however,there is evidence of differing risk factors in patients with schizophrenia compared to