CNS Drugs

, Volume 25, Issue 2, pp 129–143 | Cite as

Managing Suicide Risk in Patients with Schizophrenia

Review Article

Abstract

The management of suicide risk in patients with schizophrenia poses many challenges for clinicians. Compared with the general population, these patients have an 8.5-fold greater risk of suicide. This article reviews the literature dealing with the treatment of at-risk patients with schizophrenia. An integrated psychosocial and pharmacological approach to managing this population of patients is recommended. Although there is at least modest evidence suggesting that antipsychotic medications protect against suicidal risk, the evidence appears to be most favourable for second-generation anti-psychotics, particularly clozapine, which is the only medication approved by the US FDA for preventing suicide in patients with schizophrenia. In addition, treating depressive symptoms in patients with schizophrenia is an important component of suicide risk reduction. While selective serotonin receptor inhibitors (SSRIs) ameliorate depressive symptoms in patients with schizophrenia, they also appear to attenuate suicidal thoughts. Further research is needed to more effectively personalize the treatment of suicidal thoughts and behaviours and the prevention of suicide in patients with schizophrenia.

References

  1. 1.
    Allebeck P, Wistedt B. Mortality in schizophrenia: a ten-year follow-up based on the Stockholm County inpatient register. Arch Gen Psychiatry 1986; 43: 650–3PubMedGoogle Scholar
  2. 2.
    Montross L, Zisook S, Kasckow JW. Suicide among patients with schizophrenia: a consideration of risk and protective factors. Ann Clin Psychiatry 2005; 17: 173–82PubMedGoogle Scholar
  3. 3.
    Inskip HM, Harris EC, Barraclough B. Lifetime risk of suicide for affective disorder, alcoholism and schizophrenia. Br J Psychiatry 1998; 172: 35–7PubMedGoogle Scholar
  4. 4.
    Harris EC, Barraclough B. Suicide as an outcome for mental disorders: a meta-analysis. Br J Psychiatry 1997; 170: 205–28PubMedGoogle Scholar
  5. 5.
    Nasrallah HA, Smeltzer DJ. Contemporary diagnosis and management of the patient with schizophrenia. Newton (PA): Handbooks in Health Care, 2002Google Scholar
  6. 6.
    Breier A, Schreiber JL, Dyer J, et al. National Institute of Mental Health longitudinal study of chronic schizophrenia: prognosis and predictors of outcome. Arch Gen Psychiatry 1991; 48: 239–46PubMedGoogle Scholar
  7. 7.
    Roy A. Depression, attempted suicide, and suicide in patients with chronic schizophrenia. Psychiatr Clin North Am 1986; 9: 193–206PubMedGoogle Scholar
  8. 8.
    Drake RE, Gates C, Whitaker A, et al. Suicide among schizophrenics: a review. Compr Psychiatry 1985; 26: 90–100PubMedGoogle Scholar
  9. 9.
    Miles CP. Conditions predisposing to suicide: a review. J Nerv Ment Dis 1977; 164: 231–46PubMedGoogle Scholar
  10. 10.
    Meltzer HY. Suicide and schizophrenia: clozapine and the InterSePT study. J Clin Psychiatry 1999; 60: 47–50Google Scholar
  11. 11.
    Palmer BA, Pankratz VS, Bostwick JM. The lifetime risk of suicide in schizophrenia: a reexamination. Arch Gen Psychiatry 2005; 62: 247–53PubMedGoogle Scholar
  12. 12.
    Heila H, Isometsa ET, Henriksson MM, et al. Suicide and schizophrenia: a nationwide psychological autopsy study on age- and sex-specific clinical characteristics of 92 suicide victims with schizophrenia. Am J Psychiatry 1997; 154: 1235–42PubMedGoogle Scholar
  13. 13.
    Kreyenbuhl JA, Kelly DL, Conley RR. Circumstances of suicide among individuals with schizophrenia. Schizophr Res 2002; 58: 253–61PubMedGoogle Scholar
  14. 14.
    Allebeck P, Varla A, Kristjansson E, et al. Risk factors for suicide among patients with schizophrenia. Acta Psychiatr Scand 1987; 76: 414–9PubMedGoogle Scholar
  15. 15.
    Caldwell CB, Gottesman II. Schizophrenia: a high risk factor for suicide: clues to risk reduction. Suicide Life Threat Behav 1992; 22: 479–93PubMedGoogle Scholar
  16. 16.
    Roy A. Suicide in schizophrenia. Int Rev Psychiatry 1992; 4: 205–9Google Scholar
  17. 17.
    Modestin J, Zarro I, Waldvogel D. A study of suicide in schizophrenic in-patients. Br J Psychiatry 1992; 160: 398–401PubMedGoogle Scholar
  18. 18.
    Cannon M, Buckley P, Larkin C. Suicide in schizophrenia. Irish J Psychol Med 1991; 8: 19–21Google Scholar
  19. 19.
    Cheng KK, Leung CM, Lo W, et al. Risk factors of suicide among schizophrenics. Acta Psychiatr Scand 1990; 81: 220–4PubMedGoogle Scholar
  20. 20.
    Tandon R, Jibson MD. Suicidal behavior in schizophrenia: diagnosis, neurobiology, and treatment implications. Curr Opin Psychiatry 2003; 16: 193–7Google Scholar
  21. 21.
    Cotton PG, Drake RE, Gates C. Critical treatment issues in suicide among schizophrenics. Hosp Community Psychiatry 1985; 36: 534–6PubMedGoogle Scholar
  22. 22.
    Pinikahana J, Happell B, Keks NA. Suicide and schizophrenia: a review of literature for the decade (1990–1999) and implications for mental health nursing. Issues Ment Health Nurs 2003; 24: 27–43PubMedGoogle Scholar
  23. 23.
    De Hert M, McKenzie K, Peuskens J. Risk factors for suicide in young people suffering from schizophrenia: a long-term follow-up study. Schizophr Res 2001; 47: 127–34PubMedGoogle Scholar
  24. 24.
    Siris SG. Suicide and schizophrenia. J Psychopharmacol 2001; 15: 127–35PubMedGoogle Scholar
  25. 25.
    Raymont V. Suicide in schizophrenia: how can research influence training and clinical practice? Psychiatr Bull 2001; 25: 46–50Google Scholar
  26. 26.
    Roy A. Suicide in chronic schizophrenia. Br J Psychiatry 1982; 141: 171–7PubMedGoogle Scholar
  27. 27.
    Gut-Fayand A, Dervaux A, Olie JP, et al. Substance abuse and suicidality in schizophrenia: a common risk factor linked to impulsivity. Psychiatry Res 2001; 102: 65–72PubMedGoogle Scholar
  28. 28.
    Rossau CD, Mortensen PB. Risk factors for suicide in patients with schizophrenia: nested case-control study. Br J Psychiatry 1997; 171: 355–9PubMedGoogle Scholar
  29. 29.
    McGlashan TH, Carpenter WT. Postpsychotic depression in schizophrenia. Arch Gen Psychiatry 1976; 3: 231–9Google Scholar
  30. 30.
    Siris SG, Addington D, Azorin JM, et al. Depression in schizophrenia: recognition and management in the USA. Schizophr Res 2001; 47: 185–97PubMedGoogle Scholar
  31. 31.
    Pompili M, Mancinelli I, Tatarelli R. Suicide and schizophrenia. Psychiatr Serv 2003; 54: 747–8PubMedGoogle Scholar
  32. 32.
    Henriksson MM, Marttunen MJ, Isometsa ET, et al. Mental disorders in elderly suicide. Int Psychogeriatr 1995; 7: 275–86PubMedGoogle Scholar
  33. 33.
    Conwell Y, Duberstein PR, Cox C, et al. Relationships of age and axis I diagnoses in victims of completed suicide: a psychological autopsy study. Am J Psychiatry 1996; 153: 1001–8PubMedGoogle Scholar
  34. 34.
    Altamura AC, Bassetti R, Bignotti S, et al. Clinical variables related to suicide attempts in schizophrenic patients: a retrospective study. Schizophr Res 2003; 60: 47–55PubMedGoogle Scholar
  35. 35.
    Breier A, Astrachan BM. Characterization of schizophrenic patients who commit suicide. Am J Psychiatry 1984; 141: 206–9PubMedGoogle Scholar
  36. 36.
    Cohen LJ, Test MA, Brown RL. Suicide and schizophrenia: data from a prospective community treatment study. Am J Psychiatry 1990; 147: 602–7PubMedGoogle Scholar
  37. 37.
    Andia AM, Zisook S, Heaton RK, et al. Gender differences in schizophrenia. J Nerv Ment Dis 1995; 183: 522–8PubMedGoogle Scholar
  38. 38.
    Copas JB, Robin A. Suicide in psychiatric in-patients. Br J Psychiatry 1982; 141: 503–11PubMedGoogle Scholar
  39. 39.
    Black D, Winokur G, Warrach G. Suicide in schizophrenia: the Iowa Linkage Study. J Clin Psychiatry 1985; 46: 14–7PubMedGoogle Scholar
  40. 40.
    Caldwell CB, Gottesman II. Schizophrenics kill themselves too: a review of risk factors for suicide. Schizophr Bull 1990; 16: 571–89PubMedGoogle Scholar
  41. 41.
    Evenson RC, Wood JB, Nuttall EA, et al. Suicide rates among public mental health patients. Acta Psychiatr Scand 1982; 66: 254–64PubMedGoogle Scholar
  42. 42.
    Waern M, Runeson BS, Allebeck P, et al. Mental disorder in elderly suicides: a case-control study. Am J Psychiatry 2002; 159: 450–5PubMedGoogle Scholar
  43. 43.
    Mamo D. Caring for the suicidal patient: an evidence-based approach. Can J Psychiatry 2007; 52 Suppl. 1: 59S–70SPubMedGoogle Scholar
  44. 44.
    Nordentoft M. Prevention of suicide and attempted suicide in Denmark: epidemiological studies of suicide and intervention studies in selected risk groups. Dan Med Bull 2007; 54: 306–69PubMedGoogle Scholar
  45. 45.
    Nordentoft M, Jeppesen P, Abel M, et al. OPUS study: suicidal behaviour, suicidal ideation and hopelessness among patients with first-episode psychosis: one-year follow-up of a randomised controlled trial. Br J Psychiatry 2002; 43 Suppl. : s98–106Google Scholar
  46. 46.
    Pompili M, Mancinelli I, Girardi P, et al. Nursing schizophrenic patients who are at risk of suicide. J Psychiatr Ment Health Nurs 2003; 10: 622–4PubMedGoogle Scholar
  47. 47.
    Farberow N, Shneidman E, Neuringer C. Case history and hospitalization factors in suicides of neuropsychiatric hospital patients. J Nerv Ment Dis 1966; 142: 32–44PubMedGoogle Scholar
  48. 48.
    Morgan HG, Priest P. Assessment of suicide risk in psychiatric in-patients. Br J Psychiatry 1984; 145: 467–9PubMedGoogle Scholar
  49. 49.
    Morgan HG, Priest P. Suicide and other unexpected deaths among psychiatric in-patients: the Bristol confidential inquiry. Br J Psychiatry 1991; 158: 368–74PubMedGoogle Scholar
  50. 50.
    Crammer JL. The special characteristics of suicide in hospital in-patients. Br J Psychiatry 1984; 145: 460–3PubMedGoogle Scholar
  51. 51.
    Goh SE, Salmons PH, Whittington RM. Hospital suicides: are there preventable factors? Profile of psychiatric hospital suicide. Br J Psychiatry 1989; 154: 247–9PubMedGoogle Scholar
  52. 52.
    Saarinen PI, Lehtonen J, Lonnqvist J. Suicide risk in schizophrenia: an analysis of 17 consecutive suicides. Schizophr Bull 1999; 25: 533–42PubMedGoogle Scholar
  53. 53.
    De Leo D, Spathonis K. Do psychosocial and pharmacological interventions reduce suicide in schizophrenia and schizophrenia spectrum disorders? Arch Suicide Res 2003; 7: 353–74Google Scholar
  54. 54.
    Lauriello J, Lenroot R, Bustillo JR. Maximizing the synergy between pharmacotherapy and psychosocial therapies for schizophrenia. Psychiatr Clin North Am 2003; 26: 191–211PubMedGoogle Scholar
  55. 55.
    Lehman AF, Lieberman JA, Dixon LB, et al. Practice guideline for the treatment of patients with schizophrenia, second edition. Am J Psychiatry 2004; 161(2 Suppl. ): 1–56PubMedGoogle Scholar
  56. 56.
    Lenroot R, Bustillo JR, Lauriello J, et al. Integrated treatment of schizophrenia. Psychiatr Serv 2003; 54: 1499–507PubMedGoogle Scholar
  57. 57.
    Grawe RW, Falloon IR, Widen JH, et al. Two years of continued early treatment for recent-onset schizophrenia: a randomised controlled study. Acta Psychiatr Scand 2006; 114: 328–36PubMedGoogle Scholar
  58. 58.
    Turkington D, Kingdon D, Turner T. Effectiveness of a brief cognitive-behavioural therapy intervention in the treatment of schizophrenia. Br J Psychiatry 2002; 180: 523–7PubMedGoogle Scholar
  59. 59.
    Tarrier N, Haddock G, Lewis S, et al. Suicide behaviour over 18 months in recent onset schizophrenic patients: the effects of CBT. Schizophr Res 2006; 83: 15–27PubMedGoogle Scholar
  60. 60.
    Bateman K, Hansen L, Turkington D, et al. Cognitive behavioral therapy reduces suicidal ideation in schizophrenia: results from a randomized controlled trial. Suicide Life Threat Behav 2007; 37: 284–90PubMedGoogle Scholar
  61. 61.
    Ponizovsky AM, Grinshpoon A, Levav I, et al. Life satisfaction and suicidal attempts among persons with schizophrenia. Compr Psychiatry 2003; 44: 442–7PubMedGoogle Scholar
  62. 62.
    Nyman AK, Jonsson H. Patterns of self-destructive behaviour in schizophrenia. Acta Psychiatr Scand 1986; 73: 252–62PubMedGoogle Scholar
  63. 63.
    Drake RE, Bartels SJ, Torrey WC. Suicide in schizophrenia: clinical approaches. In: Williams R, Dalby JT, editors. Depression in schizophrenia. New York: Plenum Press, 1989: 153–69Google Scholar
  64. 64.
    Beck AT, Steer RA, Kovacs M, et al. Hopelessness and eventual suicide: a 10-year prospective study of patients hospitalized with suicidal ideation. Am J Psychiatry 1985; 142: 559–63PubMedGoogle Scholar
  65. 65.
    Mueser KT, Berenbaum H. Psychodynamic treatment of schizophrenia: is there a future? Psychol Med 1990; 20: 253–62PubMedGoogle Scholar
  66. 66.
    Harkavy-Friedman JM, Nelson EA. Assessment and intervention for the suicidal patient with schizophrenia. Psychiatr Q 1997; 68: 361–75PubMedGoogle Scholar
  67. 67.
    Drake RE, Cotton PG. Depression, hopelessness and suicide in chronic schizophrenia. Br J Psychiatry 1986; 148: 554–9PubMedGoogle Scholar
  68. 68.
    Restifo K, Harkavy-Friedman JM, Shrout PE. Suicidal behavior in schizophrenia: a test of the demoralization hypothesis. J Nerv Ment Dis 2009; 197: 147–53PubMedGoogle Scholar
  69. 69.
    Haghighat R. A discourse for hope: on defenses against suicide in people with schizophrenia. New York: Nova Science Publishers, 2007: 189–213Google Scholar
  70. 70.
    Lee PW, Lieh-Mak F, Wong MC, et al. The 15-year outcome of Chinese patients with schizophrenia in Hong Kong. Can J Psychiatry 1998; 43: 706–13PubMedGoogle Scholar
  71. 71.
    Appleby L, Shaw J, Amos T, et al. Suicide within 12 months of contact with mental health services: national clinical survey. Br Med J 1999; 318: 1235–9Google Scholar
  72. 72.
    Schooler NR. Relapse prevention and recovery in the treatment of schizophrenia. J Clin Psychiatry 2006; 67 Suppl. 5: 19–23PubMedGoogle Scholar
  73. 73.
    Hawton K, Sutton L, Haw C, et al. Schizophrenia and suicide: systematic review of risk factors. Br J Psychiatry 2005; 187: 9–20PubMedGoogle Scholar
  74. 74.
    Ward A, Ishak K, Proskorovsky I, et al. Compliance with refilling prescriptions for atypical antipsychotic agents and its association with the risks for hospitalization, suicide, and death in patients with schizophrenia in Quebec and Saskatchewan: a retrospective database study. Clin Ther 2006; 28: 1912–21PubMedGoogle Scholar
  75. 75.
    Bustillo J, Lauriello J, Horan W, et al. The psychosocial treatment of schizophrenia: an update. Am J Psychiatry 2001; 158: 163–75PubMedGoogle Scholar
  76. 76.
    Cipriani A, Pretty H, Hawton K, et al. Lithium in the prevention of suicidal behaviour and all-cause mortality in patients with mood disorders: a systematic review of randomized trials. Am J Psychiatry 2005; 162: 1805–19PubMedGoogle Scholar
  77. 77.
    Leucht S, Kissling W, McGrath J. Lithium for schizophrenia. Cochrane Database Syst Rev 2007; (3): CD003834Google Scholar
  78. 78.
    Winokur G, Tsuang M. The Iowa 500: suicide in mania, depression, and schizophrenia. Am J Psychiatry 1975 Jun; 132: 650–1PubMedGoogle Scholar
  79. 79.
    Axelsson R, Lagerkvist-Briggs M. Factors predicting suicide in psychotic patients. Eur Arch Psychiatry Clin Neurosci 1992; 241: 259–66PubMedGoogle Scholar
  80. 80.
    Meltzer HY. Treatment of suicidality in schizophrenia. Ann N Y Acad Sci 2001; 932: 44–58; discussion 58-60PubMedGoogle Scholar
  81. 81.
    Ernst CL, Goldberg JF. Antisuicide properties of psychotropic drugs: a critical review. Harv Rev Psychiatry 2004; 12: 14–41PubMedGoogle Scholar
  82. 82.
    Cohen S, Leonard CV, Farberow NL, et al. Tranquilizers and suicide in the schizophrenic patient. Arch Gen Psychiatry 1964; 11: 312–21PubMedGoogle Scholar
  83. 83.
    Warnes H. Suicide in schizophrenics. Dis Nerv Syst 1968; 29 Suppl. : 35–40PubMedGoogle Scholar
  84. 84.
    Taiminen TJ, Kujari H. Antipsychotic medication and suicide risk among schizophrenic and paranoid inpatients: a controlled retrospective study. Acta Psychiatr Scand 1994; 90: 247–51PubMedGoogle Scholar
  85. 85.
    Taiminen TJ. Effect of psychopharmacotherapy on suicide risk in psychiatric inpatients. Acta Psychiatr Scand 1993; 87: 45–7PubMedGoogle Scholar
  86. 86.
    Palmer DD, Henter ID, Wyatt RJ. Do antipsychotic medications decrease the risk of suicide in patients with schizophrenia? J Clin Psychiatry 1999; 60 Suppl. 2: 100–3; discussion 111-6PubMedGoogle Scholar
  87. 87.
    Van Putten T, May RP. Akinetic depression in schizophrenia. Arch Gen Psychiatry 1978; 35: 1101–7PubMedGoogle Scholar
  88. 88.
    Cem Atbaşoglu E, Schultz SK, Andreasen NC. The relationship of akathisia with suicidality and depersonalization among patients with schizophrenia. J Neuropsychiatry Clin Neurosci 2001; 13: 336–41PubMedGoogle Scholar
  89. 89.
    Wilkinson G, Bacon NA. A clinical and epidemiological survey of parasuicide and suicide in Edinburgh schizophrenics. Psychol Med 1984; 14: 899–912PubMedGoogle Scholar
  90. 90.
    Johnson DA, Pasterski G, Ludlow JM, et al. The discontinuance of maintenance neuroleptic therapy in chronic schizophrenic patients: drug and social consequences. Acta Psychiatr Scand 1983; 67: 339–52PubMedGoogle Scholar
  91. 91.
    Heila H, Isometsa ET, Henriksson MM, et al. Suicide victims with schizophrenia in different treatment phases and adequacy of antipsychotic medication. J Clin Psychiatry 1999; 60: 200–8PubMedGoogle Scholar
  92. 92.
    Tran PV, Hamilton SH, Kuntz AJ, et al. Double-blind comparison of olanzapine versus risperidone in the treatment of schizophrenia and other psychotic disorders. J Clin Psychopharmacol 1997; 17: 407–18PubMedGoogle Scholar
  93. 93.
    Müller-Siecheneder F, Müller MJ, Hillert A, et al. Risperidone versus haloperidol and amitriptyline in the treatment of patients with a combined psychotic and depressive syndrome. J Clin Psychopharmacol 1998; 18: 111–20PubMedGoogle Scholar
  94. 94.
    Beasley Jr CM, Hamilton SH, Crawford AM, et al. Olanzapine versus haloperidol: acute phase results of the international double-blind olanzapine trial. Eur Neuro-psychopharmacol 1997; 7: 125–37Google Scholar
  95. 95.
    Meltzer HY, Alphs L, Green AI, et al. Clozapine treatment for suicidality in schizophrenia: International Suicide Prevention Trial (InterSePT). Arch Gen Psychiatry 2003 Jan; 60(1): 82–91PubMedGoogle Scholar
  96. 96.
    Meltzer HY, Baldessarini RJ. Reducing the risk for suicide in schizophrenia and affective disorders. J Clin Psychiatry 2003; 64: 1122–9PubMedGoogle Scholar
  97. 97.
    Barak Y, Mirecki I, Knobler HY, et al. Suicidality and second generation antipsychotics in schizophrenia patients: a case-controlled retrospective study during a 5-year period. Psychopharmacology (Berl) 2004; 175: 215–9Google Scholar
  98. 98.
    Khan A, Khan SR, Leventhal RM, et al. Symptom reduction and suicide risk among patients treated with placebo in antipsychotic clinical trials: an analysis of the Food and Drug Administration database. Am J Psychiatry 2001; 158: 1449–54PubMedGoogle Scholar
  99. 99.
    Storosum JG, van Zwieten BJ, Wohlfarth T, et al. Suicide risk in placebo vs active treatment in placebo-controlled trials for schizophrenia. Arch Gen Psychiatry 2003; 60: 365–8PubMedGoogle Scholar
  100. 100.
    Meltzer HY, Okayli G. Reduction of suicidality during clozapine treatment of neuroleptic-resistant schizophrenia: impact on risk-benefit assessment. Am J Psychiatry 1995; 152: 183–90PubMedGoogle Scholar
  101. 101.
    Spivak B, Roitman S, Vered Y, et al. Diminished suicidal and aggressive behavior, high plasma norepinephrine levels, and serum triglyceride levels in chronic neuroleptic-resistant schizophrenic patients maintained on clozapine. Clin Neuropharmacol 1998; 21: 245–50PubMedGoogle Scholar
  102. 102.
    Walker AM, Lanza LL, Arellano F, et al. Mortality in current and former users of clozapine. Epidemiology 1997; 8: 671–7PubMedGoogle Scholar
  103. 103.
    Reid WH, Mason M, Hogan T. Suicide prevention effects associated with clozapine therapy in schizophrenia and schizoaffective disorder. Psychiatr Serv 1998; 49: 1029–33PubMedGoogle Scholar
  104. 104.
    Sernyak M, Desai R, Stolar M, et al. Impact of clozapine on completed suicide. Am J Psychiatry 2001; 158: 931–7PubMedGoogle Scholar
  105. 105.
    Potkin SG, Alphs L, Hsu C, et al. Predicting suicidal risk in schizophrenic and schizoaffective patients in a prospective two-year trial. Biol Psychiatry 2003; 54: 444–52PubMedGoogle Scholar
  106. 106.
    Modestin J, Dal Pian D, Agarwalla P. Clozapine diminishes suicidal behavior: a retrospective evaluation of clinical records. J Clin Psychiatry 2005; 66: 534–8PubMedGoogle Scholar
  107. 107.
    Hennen J, Baldessarini RJ. Suicidal risk during treatment with clozapine: a meta-analysis. Schizophr Res 2005; 73: 139–45PubMedGoogle Scholar
  108. 108.
    Tiihonen T, Lönnqvist J, Wahlbeck K, et al. 11-year follow-up of mortality in patients with schizophrenia: a population-based cohort study (FIN11 study). Lancet 2009; 374: 620–7PubMedGoogle Scholar
  109. 109.
    De Hert M, Correll C, Cohen D. Do antipsychotic medications reduce or increase mortality in schizophrenia? A critical appraisal of the FIN-11 study. Schizophr Res 2010; 117: 68–74PubMedGoogle Scholar
  110. 110.
    American Psychiatric Association practice guidelines for the assessment and treatment of patients with suicidal behaviors. Am J Psychiatry 2003; 160 Suppl. 11: 1-60Google Scholar
  111. 111.
    Kerwin R. Preventing suicide [letter]. Br J Psychiatry 2003 Apr; 182: 366PubMedGoogle Scholar
  112. 112.
    Miller AL, Hall CS, Buchanan RW, et al. The Texas medication algorithm project antipsychotic algorithm for schizophrenia: 2003 update. J Clin Psychiatry 2004; 65: 500–8PubMedGoogle Scholar
  113. 113.
    Meltzer H. Suicide in schizophrenia: clozapine, the adoption of evidence-based medicine [commentary]. J Clin Psychiatry 2005; 66: 4Google Scholar
  114. 114.
    Meltzer HY. Treatment-resistant schizophrenia: the role of clozapine. Curr Med Res Opin 1997; 14: 1–20PubMedGoogle Scholar
  115. 115.
    Meltzer HY, Conley RR, De Leo D, et al. Intervention strategies for suicidality [audiograph]. J Clin Psychiatry 2003; 6: 1–16Google Scholar
  116. 116.
    Roy A, Pompili M. Management of schizophrenia with suicide risk. Psychiatr Clin N Am 2009; 32: 863–83Google Scholar
  117. 117.
    Kasckow J, Fellows I, Golshan S, et al. Treatment of subsyndromal depressive symptoms in middle-age and older patients with schizophrenia: effect of age on response. Am J Geriatr Psychiatry 2010; 18: 853–7PubMedGoogle Scholar
  118. 118.
    Kasckow JW, Zisook S. Co-occurring depressive symptoms in the older patient with schizophrenia. Drugs Aging 2008; 25: 631–47PubMedGoogle Scholar
  119. 119.
    Furtado VA, Srihari V, Kumar A. Atypical antipsychotics for people with both schizophrenia and depression. Schizophr Bull 2009; 35: 297–8PubMedGoogle Scholar
  120. 120.
    Treatment of schizophrenia 1999: the expert consensus guideline series. J Clin Psychiatry 1999; 60 Suppl. 11: 3-80Google Scholar
  121. 121.
    Kane J, Leucht S, Carpenter D. The expert consensus guideline series: optimizing pharmacologic treatment of psychotic disorders. Introduction: methods, commentary, and summary. J Clin Psychiatry 2003; 64 Suppl. 12: 5–19PubMedGoogle Scholar
  122. 122.
    Siris SG, Morgan V, Fagerstrom R, et al. Adjunctive imipramine in the treatment of postpsychotic depression: a controlled trial. Arch Gen Psychiatry 1987; 44: 533–9PubMedGoogle Scholar
  123. 123.
    Siris SG, Bermanzohn PC, Mason SE, et al. Maintenance imipramine therapy for secondary depression in schizophrenia: a controlled trial. Arch Gen Psychiatry 1994; 51: 109–15PubMedGoogle Scholar
  124. 124.
    Silver H, Nassar A. Fluvoxamine improves negative symptoms in treated chronic schizophrenia: an add-on double-blind, placebo-controlled study. Biol Psychiatry 1992 Apr 1; 31(7): 698–704PubMedGoogle Scholar
  125. 125.
    Addington D, Addington J, Patten S, et al. Double-blind, placebo-controlled comparison of the efficacy of sertraline as treatment for a major depressive episode in patients with remitted schizophrenia. Clin Psychopharmacol 2002; 22: 20–5Google Scholar
  126. 126.
    Buchanan RW, Kirkpatrick B, Bryant N, et al. Fluoxetine augmentation of clozapine treatment in patients with schizophrenia. Am J Psychiatry 1996; 153: 1625–7PubMedGoogle Scholar
  127. 127.
    Goff DC, Midha KK, Sarid-Segal O, et al. A placebo-controlled trial of fluoxetine added to neuroleptic in patients with schizophrenia. Psychopharmacology 1995; 117: 417–23PubMedGoogle Scholar
  128. 128.
    Spina E, De Domenico P, Ruello C, et al. Adjunctive fluoxetine in the treatment of negative symptoms in chronic schizophrenia patients. Int Clin Psychopharmacol 1994; 9: 281–5PubMedGoogle Scholar
  129. 129.
    Salokangas RK, Saarijarvi S, Taiminen T, et al. Citalopram as an adjuvant in chronic schizophrenia: a double-blind placebo-controlled study. Acta Psychiatr Scand 1996; 94: 175–80PubMedGoogle Scholar
  130. 130.
    Vartiainen H, Tiihonen J, Putkonen A, et al. Citalopram, a selective serotonin reuptake inhibitor, in the treatment of aggression in schizophrenia. Acta Psychiatr Scand 1995; 91: 348–51PubMedGoogle Scholar
  131. 131.
    Zisook S, Kasckow JW, Lanouette NM, et al. Augmentation with citalopram for suicidal ideation in middle-aged and older outpatients with schizophrenia and schizoaffective disorder who have subthreshold depressive symptoms: a randomized controlled trial. J Clin Psychiatry 2010; 71: 915–22PubMedGoogle Scholar
  132. 132.
    Zisook S, Kasckow JW, Golshan S, et al. Citalopram augmentation for sub-syndromal symptoms of depression in middle-aged and older outpatients with schizophrenia and schizoaffective disorder: a randomized controlled trial. J Clin Psychiatry 2009; 70: 562–71PubMedGoogle Scholar

Copyright information

© Adis Data Information BV 2011

Authors and Affiliations

  1. 1.MIRECC and Behavioral Health ServiceVA Pittsburgh Health Care SystemPittsburghUSA
  2. 2.Western Psychiatric Institute and ClinicsUniversity of Pittsburgh Medical CenterPittsburghUSA
  3. 3.VA San Diego Health Care SystemSan DiegoUSA
  4. 4.Department of PsychiatryUniversity of CaliforniaSan DiegoUSA

Personalised recommendations