Psychiatric Quarterly

, Volume 68, Issue 4, pp 361–375

Assessment and Intervention for the Suicidal Patient with Schizophrenia

  • Jill M. Harkavy-Friedman
  • Elizabeth A. Nelson
Article

Abstract

The risk for suicidal behavior in schizophrenia is high with 10–15% committing suicide and 20–40% making suicide attempts. Due to the chronicity and complexity of schizophrenia and the multi-determined nature of suicidal behavior, the clinician must utilize a biopsychosocial approach to assessment and intervention. Clinical factors such as psychosis, depression and substance abuse increase the risk for suicidal behavior in schizophrenia. Social factors such as social adjustment and social supports also play a critical role. Ongoing assessment and intervention of suicidal behavior, clinical symptomatology, social environment and treatment issues are essential. Prediction and prevention of suicidal behavior are not always possible however. Treatment focused on the reduction of symptomatology and maintenance of an effective social environment may attenuate the risk for suicidal behavior in schizophrenia.

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REFERENCES

  1. 1.
    Black DW, Warrack G, Winokur G. The Iowa record linkage study. Arch Gen Psychiatry 42:71–75, 1985.Google Scholar
  2. 2.
    Johns CE, Stanley M, Stanley B. Suicide in schizophrenia. Annals of The New York Academy of Sciences, 487:294–300, 1986.Google Scholar
  3. 3.
    Miles C. Conditions predisposing to suicide: A review. J Nerv Ment Dis 164:231–246, 1977.Google Scholar
  4. 4.
    Tsuang MT. Suicide in schizophrenics, manics, depressives and surgical controls. Arch Gen Psychiatry 35:153–155, 1978.Google Scholar
  5. 5.
    Winokur G, Tsuang M. The Iowa 500: Suicide in mania, depression and schizophrenia. Am J Psychiatry 132:650–651, 1975.Google Scholar
  6. 6.
    Landmark J, Cernovsky Z, Mersky H. Correlates of suicide attempts and ideation in schizophrenia. Br J Psychiatry 151:18–20, 1987.Google Scholar
  7. 7.
    Niskanen P, Lonnqvist J, Achte K, et al. Suicide in Helsinki psychiatric hospitals in 1964–1972. Psychiatr Fennica 275–280, 1974.Google Scholar
  8. 8.
    Planansky K, Johnston R. The occurrence and characteristics of suicidal preoccupation and acts in schizophrenia. Acta Psychiat Scand 47:473–483, 1971.Google Scholar
  9. 9.
    Roy A, Mazonson A, Pickar D. Attempted suicide in schizophrenia. Br J Psychiatry 144:303–306, 1984.Google Scholar
  10. 10.
    Wyatt RJ, Henter I, Lear MC, Taylor E. An economic evaluation of schizophrenia-1991. Soc Psychiatry Psychiatr Epidemiol 30:196–205, 1995.Google Scholar
  11. 11.
    Banen DM. Suicide by psychotics. J Nerv Ment Dis 120:349–357, 1954.Google Scholar
  12. 12.
    Cohen SCV, Farberow LNL, Shneidman ES. Tranquilizers and suicide in schizophrenic patients. Arch Gen Psychiatry 11:312–321, 1964.Google Scholar
  13. 13.
    Levy S, Southcombe RH. Suicide in a state hospital for the mentally ill. J Nerv Ment Dis 117: 504–514, 1953.Google Scholar
  14. 14.
    Virkkunen M. Suicide in schizophrenia and paranoid psychoses. Acta Psychiatr Scand (Suppl) 250:1–305, 1974.Google Scholar
  15. 15.
    Yarden P. Observations on suicide in chronic schizophrenia. Comp Psychiat 15:325–333, 1974.Google Scholar
  16. 16.
    Lindelius R, Kay DWK. Some changes in the pattern of mortality in schizophrenia in Sweden. Acta Psychiatr Scand 49:315–323, 1973.Google Scholar
  17. 17.
    Roy A. Suicide in chronic schizophrenia. Br J Psychiatry 141:171–177, 1982.Google Scholar
  18. 18.
    Warnes H. Suicide in schizophrenics. Dis Nerv Sys (Suppl) 29:35–40, 1968.Google Scholar
  19. 19.
    Wilkinson DG. The suicide rate in schizophrenia. Br J of Psychiatry 140:138–141, 1982.Google Scholar
  20. 20.
    Bleuler M. The schizophrenic disorders: Long-term patient and family studies (trans. SM Clemens). New Haven, CT: Yale University Press, 1978.Google Scholar
  21. 21.
    Ciompi L. Late suicide in former mental patients. Psych Clin 9:59–63, 1976.Google Scholar
  22. 22.
    Tsuang MT, Woolson RF. Excess mortality in schizophrenia and affective disorders: Do suicides and accidental deaths solely account for this excess? Acta Psychiat Scand 35: 1181–1185, 1978.Google Scholar
  23. 23.
    Mandel MR, Severe JB, Schooler NR, et al. Development and prediction of postpsychotic depression in neuroleptic treated schizophrenics. Arch Gen Psychiatry 39:197–203, 1982.Google Scholar
  24. 24.
    Siris SG, Harmon GK, Endicott J. Postpsychotic depressive symptoms in hospitalized schizophrenic patients. Arch Gen Psychiatry 38:1122–1123, 1981.Google Scholar
  25. 25.
    Caldwell BC, Gottesman, II. Schizophrenics kill themselves too: A review of the risk factors for suicide. Schiz Bull 16:571–589, 1990.Google Scholar
  26. 26.
    Copas JB, Freeman-Browne DL, Robin AA. Danger periods for suicide inpatients under treatment. Psychol Med 1:400–404, 1971.Google Scholar
  27. 27.
    Planasky K, Johnston R. Clinical setting and motivation in suicide attempts. Acta Psychiat Scand 49:680–690, 1973.Google Scholar
  28. 28.
    Sletten I, Brown M, Evenson R, et al. Suicide in mental hospital patients. Dis Nerv Sys 33:328–334, 1972.Google Scholar
  29. 29.
    Breier A, Astrachan BM. Characterization of schizophrenics who commit suicide. Am J Psychiatry 141:206–209, 1984.Google Scholar
  30. 30.
    Bromet EJ, Schwartz JE, Fennig S, Geller L, Jandorf L, Kovasznay B, Lavelle J, Miller A, Pato C, Ram R, Rich C. The epidemiology of psychosis: The Suffolk County Mental Health Project. Schiz Bull 18:243–255, 1992.Google Scholar
  31. 31.
    Inamdar S, Lewis D, Siomopolous G, et al. Violent and suicidal behavior in psychotic adolescents. Am J Psychiatry 139:932–935, 1982.Google Scholar
  32. 32.
    Wilkinson G, Bacon NA. A clinical and epidemiological survey of parasuicide and suicide in Edinburgh schizophrenics. Psychol Med 14:899–912, 1984.Google Scholar
  33. 33.
    Weissman M. The epidemiology of suicide attempts, 1960–1971. Arch Gen Psychiatry 30:737–746, 1974.Google Scholar
  34. 34.
    Shaffer JW, Perlin CW, Schmidt CW, et al. The prediction of suicide in schizophrenia. J Nerv Ment Dis 159:349–355, 1974.Google Scholar
  35. 35.
    Wilson GC. Suicide in psychiatric patients who have received hospital treatment. Am J Psychiatry 125:752–757, 1968.Google Scholar
  36. 36.
    Roy, A. Family history of suicide. Arch Gen Psychiatry 40:971–974, 1983.Google Scholar
  37. 37.
    Tsuang MT. Risk of suicide in relatives of schizophrenics, manics, depressives and controls. J Clin Psychiatry 44:396–400, 1983.Google Scholar
  38. 38.
    Drake RE, Gates C, Cotton, PG, Whitaker A, et al. Suicide among schizophrenics: Who is at risk?. J Nerv Ment Dis 172:613–618, 1984.Google Scholar
  39. 39.
    Goh SE, Salmons PH, Whittington RM. Hospital suicides: Are there preventable factors? Br J Psych 154:247–249, 1989.Google Scholar
  40. 40.
    Modestin J. Three different types of clinical suicide. European Archives of Psychiatry and Neurological Sciences 236:148–153, 1986.Google Scholar
  41. 41.
    Wolfersdorf M, Vogel R, Keller F, Hole G: The increase of suicides in psychiatric hospitals in southwestern Germany according to diagnostic subgroups. Crisis 12:34–47, 1991.Google Scholar
  42. 42.
    Drake RE, Bartels SJ, Torrey WC. Suicide in schizophrenia: Clinical approaches, in Depression in schizophrenics. Edited by Williams R and Dalby JT, New York: Plenum Press, 1989.Google Scholar
  43. 43.
    DeAlarcon R, Carney MW. Severe depressive mood changes following slow-release intramuscular fluphenazine injection. Br J Psychiatry 3:564–567, 1969.Google Scholar
  44. 44.
    Drake RE, Ehrlich J. Suicide attempts in association with akathisia. Am J Psychiatry 142:499–501, 1985.Google Scholar
  45. 45.
    Hogan TP, Awad AG. Pharmacotherapy and suicide risk in schizophrenia. Canadian Journal of Psychiatry 142:499–501, 1983.Google Scholar
  46. 46.
    Schultz JR. Homicide and suicide associated with akathisia and haloperidol. Am J Psychiatry 6:3–7, 1985.Google Scholar
  47. 47.
    Shear K., Frances A., Weider P. Suicide associated with akathisia and depot fluphenazine treatment. J Clin Psychopharm 3:235–236, 1986.Google Scholar
  48. 48.
    Guze SB, Robbins E. Suicide and primary affective disorders. Br J Psychiatr 117:437–438, 1970.Google Scholar
  49. 49.
    Fawcett J, Scheftner W., Clark D, Hedeker D, Gibbons R, Coryell W. Clinical predictors of suicide in patients with major affective disorders: A controlled prospective study. Am J Psychiatry 144:35–40, 1987.Google Scholar
  50. 50.
    Jones JS, Stein, DJ, Stanley B, Guido JR, Winchel R, Stanley M. Negative and depressive symptoms in suicidal schizophrenics. Acta Psychiat Scand 89: 81–87, 1994.Google Scholar
  51. 51.
    Pickar D, Roy A, Breier A, Doran A, Wolkowitz O, Colison J, Agren H. Suicide and aggression. Annals of the New York Academy of Sciences, 487:189–196, 1986.Google Scholar
  52. 52.
    Allebeck P., Varla, A., Kristjansson E., Wistedt B. Risk factors for suicide among patients with schizophrenia. Acta Psychiat Scand 76: 414–419, 1987.Google Scholar
  53. 53.
    Dassori AM, Mezzich JE, Keshavan M. Suicidal indicators in schizophrenia. Acta Psychiat Scand 81:409–413, 1990.Google Scholar
  54. 54.
    Drake RE, Gates C, Cotton PG. Suicides among schizophrenics: A comparison of attempters and completed suicides. Br J Psychiatry 149:784–787, 1986.Google Scholar
  55. 55.
    Drake RE, Gates C, Whitaker A, Cotton PG. Suicide among schizophrenics: A review. Comp Psychiatry 26: 990–100, 1985.Google Scholar
  56. 56.
    Lim, LCC, Tsoi, WF. Suicide and schizophrenia in Singapore: A fifteen year follow-up study. Annals of the Academy of Medicine, Singapore 20: 201–203, 1991.Google Scholar
  57. 57.
    Beck AT, Kovacs M, Weissman A. Hopelessness and suicidal behavior: An overview. JAMA 234:1146–1149, 1975.Google Scholar
  58. 58.
    Minkoff K, Bergman E, Beck AT, et al. Hopelessness and depression, and attempted suicide. Am J Psychiatry 130:455–459, 1973.Google Scholar
  59. 59.
    Virkkunen M. Attitude toward psychiatric treatment before suicide in schizophrenia and paranoid psychoses. Br J Psychiatry 128: 47–49, 1975.Google Scholar
  60. 60.
    American Psychiatric Association. Diagnostic and Statistical Manual for Mental Disorders, Fourth Edition Washington, D.C.: American Psychiatric Association, 1994.Google Scholar
  61. 61.
    Oquendo M, Malone K, Ellis S Mann JJ. Do antidepressants change rates of suicide attempts in depression? Proceedings of the 35th annual meeting of the American College of Neuropsychopharmacology, San Juan, Puerto Rico, 1996.Google Scholar
  62. 62.
    Ghosh TB, Victor BS. Suicide, in The American Psychiatric Press Textbook of Psychiatry (2nd ed). Edited by R. E. Hales, S. C. Yudofsky, & J. A. Talbott, Washington, DC, American Psychiatric Press, 1994. p. 1251–1271.Google Scholar
  63. 63.
    Murphy GE, Wetzel RD. The lifetime risk of suicide in alcoholism. Arch Gen Psychiatry 47:383–392, 1990.Google Scholar
  64. 64.
    Roy, A. Psychiatric emergencies, in Comprehensive Textbook of Psychiatry (Vol. 2, 6th ed). Edited by Kaplan HI, Sadock BJ, Baltimore, MD, Williams & Wilkins, 1995, p1739–1752.Google Scholar
  65. 65.
    Soyka M, Albus M, Kathmann N, Finelli A, Hofstetter S, Holzbach R., Immler B, Sand P. Prevalence of alcohol and drug abuse in schizophrenic inpatients. European Archives of Psychiatry and Clinical Neuroscience 242:362–372, 1993.Google Scholar
  66. 66.
    Moscicki EK. Epidemiology of suicidal behavior. Suic Life-threat Beh 25:22–35, 1995.Google Scholar
  67. 67.
    Modestin J, Zarro I, Waldvogel D. A study of suicide in schizophrenic inpatients. Br J Psychiatry 160:398–401, 1992.Google Scholar
  68. 68.
    Farberow NL, Shneidman ES, Neuringer C. Case history and hospitalization factors in suicides of neuropsychiatric hospital patients. J Nerv Ment Dis 142:32–44, 1966.Google Scholar
  69. 69.
    Brown GL, Goodwin FK. Cerebrospinal fluid correlates of suicide attempts and aggression. Annals of the New York Academy of Sciences, 487:174–188, 1986Google Scholar
  70. 70.
    Cooper SJ, Kelly CB, King DJ. 5-hydroxy indoleacetic acid in cerebrospinal fluid and predication of suicidal behavior in schizophrenia. Lancet 340:940–941, 1992.Google Scholar
  71. 71.
    Lemus, C., Lieberman J, Johns CA, Pollack S, Bookstein P, Cooper T. CSF 5-hydroxy indoleacetic acid levels and suicide attempts in schizophrenia. Biol Psychiatry 27:923–926, 1990.Google Scholar
  72. 72.
    Garrison CZ, McKeown RE, Valois RF, Vincent ML. Aggression, substance use, and suicidal behavior in high school students. Am J Public Health 83: 179–184, 1993.Google Scholar
  73. 73.
    Grosz DE, Lipschitz DS, Eldar S, Finkelstein G, Blackwood N, Gerbino-Rosen G, Faedda G, Plutchik R. Correlates of violence risk in hospitalized adolescents. Comp Psych 35: 296–300, 1994.Google Scholar
  74. 74.
    Nielsen DA, Goldman D, Virkkunen M, Tokola R, Rawlings R, Linnoila M. Suicidality and 5-hydroxy indoleacetic acid concentration associated with a tryptophan hydroxylase polymorphism. Arch Gen Psychiatry 51: 34–38, 1994.Google Scholar
  75. 75.
    Virkkunen, M., DeJong, J., Bartko, J., Linnoila, M. Psychobiological concomitants of history of suicide attempts among violent offenders and impulsive fire-setters. Arch Gen Psychiatry 46: 604–606, 1989.Google Scholar
  76. 76.
    Bellack, AS. A comprehensive model for treatment of schizophrenia, in A clinical guide for the treatment of schizophrenia. Edited by Bellack AS, New York, NY, Plenum Press, 1989.Google Scholar
  77. 77.
    Linn, MW. Partial hospitalization, in A Clinical Guide for the Treatment of Schizophrenia. Edited by Bellack AS, New York, NY, Plenum Press, 1989.Google Scholar
  78. 78.
    Mosher LR. Community residential treatment: Alternative to hospitalization, in A Clinical Guide for the Treatment of Schizophrenia. Edited by Bellack AS, New York, NY, Plenum Press, 1989.Google Scholar
  79. 79.
    McGlashan TH, Dingman CW. Psychotherapy, in A Clinical Guide for the Treatment of Schizophrenia. Edited by Bellack AS, New York, NY: Plenum Press, 1989.Google Scholar
  80. 80.
    Weisman GK. Crisis intervention, in A Clinical Guide for the Treatment of Schizophrenia. Edited by Bellack AS, New York, NY, Plenum Press, 1989.Google Scholar
  81. 81.
    Cotton PG, Drake RE, Gates C. Critical treatment issues in suicide among schizophrenics. Hosp Comm Psychiatry 36: 534–536, 1985.Google Scholar

Copyright information

© Human Sciences Press, Inc. 1997

Authors and Affiliations

  • Jill M. Harkavy-Friedman
    • 1
  • Elizabeth A. Nelson
    • 2
  1. 1.Columbia University and New York State Psychiatric InstituteUSA
  2. 2.New York State Psychiatric InstituteUSA

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