CLINICAL HANDBOOK OF SCHIZOPHRENIA

47. Suicide 499assessment tools can compromise therapeutic rapport and/or yield incorrect findings.Some individuals at excess risk for suicide do not admit to suicidal thoughts and planswhen asked directly. Busch and colleagues (2003) explored the characteristics of 76 patientswho died by suicide while in the hospital or immediately after discharge, over halfof whom had evidence of psychosis. Of the 50 patients for whom information on suicideideation was present in the hospital chart, 78% were reported to have denied suicidalthoughts and intent in their final communication before suicide. Clinical experience inworking with individuals with schizophrenia is especially warranted when using assessmentscales given the potential impact of cognitive and psychotic symptoms on responsecharacteristics.TREATMENTEarly Intervention ProgramsThe high rate of suicide among individuals with schizophrenia early in the course of thedisorder supports the importance of mental health promotion, prevention, and early interventionprograms. Melle and colleagues (2006) compared patients with “nonorganic”and “nonaffective psychosis” who sought treatment in hospital catchment areas, with orwithout early detection of psychosis programs, and reported higher rates of suicidalideation, plans, and attempts in communities without such programs. Results from theOPUS Study demonstrated effectiveness for an integrated treatment regimen, includingassertive community treatment, antipsychotic medication, family treatment, and socialskills training, in reducing hopelessness among individuals with first-episode psychosis.Research is needed to investigate the efficacy of early intervention programs in reducingrisk for suicidal ideation and behavior. Clinicians should exercise caution and sensitivitywhen communicating to patients the diagnosis of schizophrenia and associated prognosisto minimize the likelihood of hopelessness and despair.MedicationResearch findings support so-called “antisuicidal” properties of certain medications, suchas lithium for patients with bipolar affective disorder, antidepressants for patients withmajor depressive disorder, and antipsychotics for patients with schizophrenia andschizoaffective disorder. Evidence of efficacy in reducing suicide risk among patients withschizophrenia and schizoaffective disorder derives primarily from the InterSePT trial, oneof the largest randomized controlled treatment studies to date on prevention of suicidalbehavior (Meltzer et al., 2003). Investigators compared 980 patients, recruited from 67medical centers worldwide, who were treated with clozapine (n = 490) or olanzapine (n =490), on 2-year outcomes of suicide attempts or hospitalizations to prevent suicideattempts and worsening of suicide ideation. Study patients were 18–65 years of age, diagnosedwith schizophrenia or schizoaffective disorder, and had a history of suicideattempts, or hospitalizations to prevent a suicide attempt, in the previous 3-year period,and/or moderate-to-severe current suicide ideation and depressive symptoms, and/orcommand hallucinations for self-harm within the previous week. Findings indicated thatpatients receiving clozapine treatment had significantly fewer “significant suicide attempts”(6.9 vs. 11.2%, p = .03), hospitalizations to prevent suicide attempts (16.7 vs. 21.8%,p = .05), and fewer episodes of “much worsening” suicide ideation (24.5 vs. 32.9%, p =.005) than patients treated with olanzapine. Patients receiving clozapine were additionallyless frequently prescribed antidepressants (49.1 vs. 55.1%, p = .01) and anxiolytics/