CLINICAL HANDBOOK OF SCHIZOPHRENIA

47. Suicide 501yet focused on suicide risk reduction in schizophrenia; however, efficacious psychotherapiesthat reduce depression, hopelessness, impulsivity, agitation, and other mental healthsymptoms may help reduce risk for suicide in schizophrenia. Research is critically neededin this area.Additional Clinical Care IssuesClinicians are strongly advised to be ever-cautious for signs and symptoms of mountingclinical distress and suicide warning signs among individuals with schizophrenia giventheir high risk for suicidal behavior and for suicide throughout the course of the disorder.Clinicians should initially collect a thorough medical and mental health history, and assessfor suicide risk factors, including personal and familial history of suicidal behaviorand of suicide, and presence of suicidal command hallucinations. Vigilance is needed forsigns of increasing suicide risk, such as depressed mood, hopelessness, agitated depression,suicidal expressions and communications expressing a longing for death, or vaguereferences regarding not being around much longer. A patient who has been depressedand suddenly appears much brighter or energetic, even in the context of medicationchanges, should be watched very carefully, because that patient may have decided to endhis or her life. Additionally, it is advisable to assess for homicidal ideation and/or plans toharm or kill others. This is especially important in individuals with paranoid schizophrenia,who may be at risk of harming others in what they perceive to be preemptive self-defense.Clinicians should additionally assess for the presence of guilt and shame, and misuse ofsubstances, including nicotine, alcohol, and both illicit and prescribed medication. Assessmentof social supports and social support deficits, negative life events, perceivedburdensomeness, and other sources of stress or emotional pain, is essential for assessingincreased risk for suicide. Other telltale signs of increased suicide risk include gettingone’s affairs in order, as if planning for a lengthy vacation; writing a will or suicide note;giving away prized possessions or pets, stockpiling lethal implements; and withdrawingfrom social networks and/or discontinuing clinical care.When providing pharmacological care to persons judged to be at-risk for suicide, cliniciansare advised to prescribe only small doses of medications that may be potentiallylethal on overdose, and to consider eliciting assistance from family members or other careproviders in administering medications. Increasing the frequency of health care visits and/or psychotherapy sessions may be advisable in the face of mounting distress and risk forsuicide. ECT may have beneficial short-term effects in reducing suicide risk in individualswith mood disorders; however, there is a paucity of evidence from the literature exploringrandomized controlled trials of suicide risk and ECT in individuals with schizophrenia(see McClintock, Ranginwala, & Husain, Chapter 20, this volume, for a discussion ofECT as a treatment for individuals with schizophrenia).Hospitalization may be needed for individuals with schizophrenia at excess risk forsuicide. Hospitalization can be an important safeguard for a person at risk for suicide andshould be considered when an individual is judged to be at risk for harming self and/orothers, when risk for suicide and/or medical complications is high during periods of starting,stopping, augmenting, or switching medications, and/or for medical or psychologicalstabilization. Removal from stressful life circumstances can provide the suicidal individualwith respite, and a structured hospital milieu, close supervision, and access to medicaland psychosocial interventions can all prove therapeutic. Absolute safety is not ensuredwith hospitalization; people have died by suicide while on 24-hour in-hospital suicidewatch (Busch et al., 2003), and suicide risk is high immediately following hospital discharge.Clinicians must weigh the potential benefits and risks of hospitalization to thetherapeutic relationship, while recognizing that patient safety must always take prece-