CLINICAL HANDBOOK OF SCHIZOPHRENIA

500 VI. SPECIAL POPULATIONS AND PROBLEMSsoporifics (60.2 vs. 69.4%, p = .05) than those treated with olanzapine. Overall, therewere no significant between-group differences in number of adverse events or reasons forstudy discontinuation, except for “unsatisfactory therapeutic effect for lowering suiciderisk,” which favored the clozapine over the olanzapine group (0 vs. 1.2%; p = .03). Therewas a higher frequency of deaths by suicide in the clozapine (n = 5, 1.0%) compared withthe olanzapine group (n = 3, 0.6%); however, this difference did not reach statistical significance(p = .73). This trial suggests benefit to clozapine treatment for at-risk patientswith schizophrenia; replication studies are warranted.Heilä and colleagues (1999) reported inadequate active-phase treatment or nonadherencein 57% of individuals with schizophrenia who died by suicide, with low ratesof antidepressants prescribed (13%) and no use of electroconvulsive therapy (ECT). Cliniciansare advised to consider appropriate antidepressant and anxiolytic medications forindividuals with comorbid mood and/or anxiety disorders given the high prevalence ofmood disorders among suicidal individuals with schizophrenia and research implicatingserotonergic dysfunction in elevated risk for suicide (Radomsky et al., 1999). Cliniciansmust carefully consider patient medical history prior to prescription of any medication, aswell as response to past medications and potential medication interaction effects, side effects,withdrawal effects, toxicity of overdose, and potential for abuse and nonadherence.Poor adherence to treatment has been associated with elevated suicide risk amongindividuals with schizophrenia (De Hert et al., 2001; Hawton et al., 2005); Heilä and colleagues(1997) found that a majority of those who died by suicide during an active phaseof illness were being inadequately treated or were nonadherent to treatment. One studyreported a fourfold increased risk for suicidal behavior among nonadherent individualswith schizophrenia. Partial medication adherence or nonadherence may increase the likelihoodof relapse or resurgence of psychotic symptoms, necessitating involuntary hospitalizationand hospitalizations of longer duration, and contribute to suicide risk (Leucht& Heres, 2006). Patients are nonadherent for a variety of reasons, including fear of takingmedication, familiarity with certain auditory hallucinations (i.e., “supportive” voices),amotivation, cognitive impairment, comorbid substance abuse, and presence of nonsupportiveor overly emotional and/or demanding caregivers. Given that physicians tend tooverestimate patients’ medication adherence, they are encouraged to ask patients explicitlyabout their adherence to treatment; to provide clear instructions to patients on whenand how to take their medications, and reminders to refill prescriptions; and to be clearand supportive in educating patients on the importance and value of taking medications,unpleasant side effects notwithstanding. Psychosocial interventions, including psychoeducationfor the patient and/or his or her family and social support providers, and provisionof literature and resources, peer-support, family-to-family support, compliance therapy,and shared patient–physician decision making may increase treatment adherence (Leucht& Heres, 2006). One psychoeducational trial did not show a reduction in relapse ratesfor individuals with schizophrenia, and demonstrated a paradoxical increase in suicideideation in the treatment arm (Cunningham Owens et al., 2001). Notably, insight has notbeen found to be a risk factor for suicide in schizophrenia (Hawton et al., 2005).Psychotherapy and Other Psychosocial InterventionsSuicidal individuals are typically excluded from clinical trials, severely limiting availableevidence for psychotherapeutic and psychosocial interventions with those at-risk for suicide.There is a growing body of evidence that specific psychotherapies help to reduce riskfor suicide, including cognitive approaches, such as problem-solving therapy, cognitivetherapy, and dialectical behavior therapy, and more interpersonal approaches, such aspsychodynamic and interpersonal psychotherapy. Clinical psychotherapy trials have not