Schizophrenia,mental capacity,and rational suicide

A diagnosis of schizophrenia is often taken to denote a state of global irrationality within the psychiatric paradigm, wherein psychotic phenomena are seen to equate with a lack of mental capacity. However, the little research that has been undertaken on mental capacity in psychiatric patients shows that people with schizophrenia are more likely to experience isolated, rather than constitutive, irrationality and are therefore not necessarily globally incapacitated. Rational suicide has not been accepted as a valid choice for people with schizophrenia due in part to a belief that characteristic irrationality prevents autonomous decision-making. Since people with schizophrenia are often seen to lack insight into the nature of their disorder, both psychiatric and ethical perspectives generally presume that suicidal acts result directly from mental illness itself and not from second-order desires. In this article, I challenge notions of global irrationality conferred by a diagnosis of schizophrenia and argue that, where delusional beliefs are unifocal, schizophrenia does not necessarily lead to a state of mental incapacity. I then attempt to show that people with schizophrenia can sometimes be rational with regard to suicide, where this decision stems from a realistic appraisal of psychological suffering.     

Characteristics of suicide attempters and nonattempters with schizophrenia in a rural community

In this study, demographic and clinical characteristics of individuals with schizophrenia in a Chinese rural community who had attempted suicide at some time in their lives and those who had not made a suicide attempt were compared. Among individuals with schizophrenia, subjects with (n = 38) and without (n = 472) a lifetime history of suicide attempt were assessed with the Present State Examination. The results indicate that attempters had a significantly younger age, higher level of education, higher rate of lifetime depressed mood and hopelessness, and a larger number of positive symptoms than patients without suicide attempts. The logistic regression models also indicated that hopelessness, the number of positive symptoms and age were the most important predictors. Early interventions focusing on reducing hopelessness and controlling positive symptoms may help reduce the risk of suicide attempts among patients with schizophrenia.     

Inpatient suicide in a Chinese psychiatric hospital

Little is known about the risk factors for suicide among psychiatric inpatients in China. In this study we identified the risk factors of suicide among psychiatric inpatients at Guangzhou Psychiatric Hospital. All psychiatric inpatients who died by suicide during the 1956-2005 period were included in this study. Using a case-control design, 64 inpatients with schizophrenia who died by suicide were compared with a matched 64 controls. The results indicate that the rate of suicide was 133.1/100,000 admissions (95%CI 103.4-162.9). There were no significant differences in the method, location, or time of suicide between male and female inpatients. The number of hospitalizations was significantly larger in the suicide group than that in the control group. In logistic regression analyses, guilty thought, depressive mood, and suicidal ideation and suicide attempt 1 month before hospital admission were identified as independent predictors of suicide among inpatients with schizophrenia. The findings of risk factors for schizophrenic inpatient suicide should be taken into account when developing interventions to prevent suicide among these patients.     

Schizophrenia--a high-risk factor for suicide: clues to risk reduction.

Suicide is the chief cause of premature death among schizophrenic persons. The lifetime incidence of suicide for patients with schizophrenia is 10% to 13% compared to a general population estimate of about 1%, and is quite close to that observed among those with major affective disorder. The magnitude of increased risk for suicide among schizophrenics peaks before middle age and declines thereafter, although schizophrenic persons tend to be at increased risk throughout the life span. Among psychiatric patients, schizophrenics are overrepresented among suicides, and often schizophrenics constitute the majority of inpatient suicides. It is important in evaluating suicide risk among schizophrenic persons to assess depression and suicidal ideation especially during index admission and during acute phases of the illness. It is noteworthy that schizophrenic persons often commit suicide as the overall level of psychopathology decreases during a nonpsychotic phase. Research has yielded salient risk factors for suicide in schizophrenic persons and "types" of especially vulnerable patients, even though statistical prediction of individual suicides has not proven effective.     

Suicide attempts and family history of suicide in three psychiatric populations

The influence of a family history of suicide on suicide attempt rate and characteristics in depression, schizophrenia, and opioid dependence was examined. One hundred sixty inpatients with unipolar depression, 160 inpatients with schizophrenia, and 160 opioid-dependent patients were interviewed. Overall, a family history of suicide was associated with a higher risk for suicide attempt, with high-lethality method, with repeated attempts, and with number of attempts, while the interaction between family history and diagnostic group was not significant. Thus, a positive family history of suicide was a risk factor for several suicide attempt characteristics independent of psychiatric diagnosis.     

Reported childhood trauma and suicide attempts in schizophrenic patients

Childhood traumas are associated with suicidal behavior but this aspect has not been examined in relation to schizophrenia. In this study, 50 chronic schizophrenic patients who had attempted suicide were compared with 50 chronic schizophrenic patients who had never attempted suicide for their scores on the 34-item Childhood Trauma Questionnaire (CTQ). It was found that schizophrenics who had attempted suicide reported significantly higher CTQ scores for emotional abuse, physical abuse, sexual abuse, emotional neglect, and physical neglect than schizophrenics who had never attempted suicide. Therefore, childhood trauma may be a risk factor predisposing schizophrenic patients to attempt suicide.     

Suicide ideation: its relation to depression, suicide and suicide attempt

A random sample of 3,935 adults from a general population were interviewed and asked to report how often they had thoughts of suicide as well as their opinion on the frequency of suicide ideation in others. Depression was found to be related to the respondent's reports of his/her own suicidal thoughts and to reports of frequent suicide ideation in others. A total of 5.4 percent of the respondents reported some degree of suicide ideation in the previous month and 9.1 percent reported that others think about suicide once a month or more. When the demographic characteristics of those who report suicide ideation in themselves or others were compared to those of suicide attempters and committers, some consistencies were found, suggesting that such questions may be useful in identifying those "at risk." Nevertheless, sufficient discrepancies were found which suggest that there may be a number of factors which increase or decrease the likelihood that someone with thoughts of suicide will attempt or commit suicide. Follow-up studies are necessary to uncover such factors and the degrees to which they influence the occurrence of suicide.     

Suicide mortality of suicide attempt patients discharged from emergency room, nonsuicidal psychiatric patients discharged from emergency room, admitted suicide attempt patients, and admitted nonsuicidal psychiatric patients

The suicide mortality rate and risk factors for suicide completion of patients who presented to an emergency room (ER) for suicide attempt and were discharged without psychiatric admission, patients who presented to an ER for psychiatric problems other than suicide attempt and were discharged without psychiatric admission, psychiatric inpatients admitted for suicide attempt, and psychiatric inpatients admitted for other reasons were examined. The records of 3,897 patients who were treated at a general hospital in Seoul, Korea, from July 2003 to December 2006 were reviewed. Forty-three of the 3,897 subjects died by suicide during the 2.5-year observation period. Compared to the general Korean population, the suicide mortality rate was 82-fold higher for suicide attempt patients, admitted; 54-fold higher for suicide attempt patients, discharged; 21-fold higher for nonsuicidal patients, admitted; and 11-fold higher for nonsuicidal patients, discharged. In all four groups, diagnosis of a depressive disorder and suicide attempt at presentation were each significant independent risk factors for suicide completion. These results highlight the need for suicide prevention strategies for depressed patients who present to the ER or are admitted to a psychiatric ward after a suicide attempt.     

Suicide schema in schizophrenia: the effect of emotional reactivity, negative symptoms and schema elaboration

Suicide risk is thought to increase with a greater potential for activation of suicide-related schemas. Suicide schemas are less likely to be activated with reductions of emotional range associated with certain negative symptoms of schizophrenia. The study tested whether suicide risk would increase in patients with recent onset schizophrenia with increased potential for suicide schema activation as indicated by lower levels of specific negative symptoms that reflected emotional reactivity, namely emotional withdrawal and blunted affect. A logistic regression analysis of baseline data of 278 recent onset schizophrenic patients with a measure of suicide behaviour as the dependent variable and negative symptoms, delusions, hallucinations, depression, gender, episode, ethnicity, education, age, duration of untreated psychosis and substance use as independent variables was carried out. Emotional withdrawal, but not blunted affect was significant and negatively associated, and depression positively associated with suicide behaviour. There was evidence to indicate that restricted emotions are associated with reduced suicide risk as predicted.     

Panic disorder and suicide attempt in the National Comorbidity Survey

Clinical and some epidemiological data conflict concerning the likelihood of suicide attempt in individuals with panic disorder (PD). The purpose of this study was to illuminate the panic disorder-suicide attempt association in the National Comorbidity Survey (NCS; R. C. Kessler et al., 1994). Specifically, suicide attempt histories of those 5,872 respondents answering "yes" or "no" to the suicide attempt question were regressed against lifetime diagnostic histories. Lifetime PD history, in the presence of other disorders, was unrelated to elevated risk of suicide attempt and did not account for additional variance. PD respondents who had made a suicide attempt were characterized by Comorbidity. Epidemiological respondents with lifetime histories of PD alone are not at heightened risk for self-reported suicide attempt.     

Selected risk factors in adolescent suicide attempts.

This study examined stress, depression, attempted suicide, and knowledge of common signs of potential suicide in Alabama adolescents. A modified version of the National Adolescent Student Health Survey (NASHS) was administered to 3,803 eighth- and tenth-grade public school students during the fall of 1988. The incidence of stress, depression, and attempted suicide was analyzed by gender, ethnicity, locale (urban vs. rural), and participation in sexual intercourse and use of alcohol. Chi-square tests were used to determine if there were significant differences between groups. Findings indicated that females were at greater risk than were males. Both males and females who engaged in sexual intercourse and alcohol consumption were at greater risk than were abstainers. When analyzed by ethnicity, white adolescents who engaged in these behaviors were at significantly greater risk than were those who abstained; differences were not as pronounced for black youth. Comparisons on the knowledge scale indicated that females scored better than males, whites scored better than blacks, and urban students scored better than rural students. The data suggest that many adolescents are having difficulty coping with stress and depression, and that those who are engaging in various types of risk-taking behavior are at greater risk for depression and suicide.     

Psychache and suicide: a preliminary investigation

Shneidman's Psychological Pain Assessment Scale (PPAS; 1999) was administered to 88 psychiatric patients. Both current and worst-ever psychache were significantly higher in those patients judged by a psychiatrist, on the basis of a structured clinical interview, to be at risk of suicide. However, current and worstever psychache were not associated with having attempted suicide in the past. Thus, for the present sample of psychiatric patients, the PPAS appears to be more sensitive to current suicidality than to past suicidality. Further, there are validity issues with the PPAS, with the need for multi-item measures and probably a multifactor measure.     

The association between bankruptcy and hospital-presenting attempted suicide: a record linkage study

The associations between admissions to an emergency department following attempted suicide and personal bankruptcy in the preceding and subsequent 2 years were evaluated. Records from a level 1 trauma center (June 1993-December 2002) in Seattle, WA, were linked with case files from the local U.S. District Bankruptcy Court (June 1991 onward). Univariable and multivariable logistic regression models were used to examine the risk of bankruptcy in (i) the 2 years after and (ii) the 2 years before a suicide attempt using a violent method, compared to patients admitted for any other reason. After adjusting for several confounders, patients who had attempted suicide were more likely than other patients to experience bankruptcy in the following 2 years (OR = 2.10, 95% CIs: 1.29, 3.42). A somewhat weaker association was seen with bankruptcy in the preceding 2 years (OR = 1.68, 95% CIs 1.06; 2.67). Attempted suicide is therefore associated with bankruptcy in the preceding and following 2 years. Changes to legislation, improved mental health counselling for those in financial difficulty, and provision of financial advice to those admitted to hospital following a suicide attempt may reduce future cases of serious self-harm and completed suicide.     

Suicide intervention trainees' knowledge of myths about suicide

The responses of 70 trainees in suicide intervention to 10 Suicide Opinion Questionnaire items were evaluated for accuracy of their knowledge about suicide myths. Participants were Canadian adults (62 women, 8 men, M (age) = 35 yr.) representing a wide variety of occupations and educational backgrounds. Analysis indicated knowledge for most items was high but less accurate for items concerning the most common method of suicide and suicide risk across the lifespan. Those trained in suicide intervention were more knowledgeable on four items than those awaiting training; they more frequently knew that most suicides are not triggered by an argument with a spouse, people who are depressed are more likely to commit suicide, a person whose parent has committed suicide is at greater risk for suicide, and that shooting is the most common method of suicide in Canada.     

Reactive aggression and suicide: Theory and evidence

Aggression confers risk for suicide. However, “aggression” is a heterogeneous construct, and it is likely that subgroups of individuals with particular types of aggression are at higher risk. We postulate that a subtype of aggression, reactive aggression, underlies the link with suicide with implications for suicide risk-recognition and prevention. The theoretical rationale and empirical evidence for the role of reactive aggression in suicide is presented from the perspectives of neurobiology, psychopathology, and overt violent behavior. It is hypothesized that partner–relationship disruptions amplify risk for suicide in the near term among reactive aggressive individuals, particularly those with psychiatric disorders, and preliminary evidence in support of this hypothesis is reviewed. We also discuss being jailed as a potential precipitant of suicide in reactive aggressive individuals. Recommendations are made to advance the study of reactive aggression and suicide, including methodological innovations and a greater focus on research of women and older adults.     

The newsworthiness of suicide

There is a paucity of studies examining which suicides are considered news-worthy. By combining data on media reports of individuals' suicides with routinely collected suicide data, it was found that 1% of Australian suicides were reported over a 1-year period. There was evidence of over-reporting of suicides by older people and females, and those involving dramatic methods. Reported suicides fell into three groups: suicides reported in a broader context; suicides by celebrities; and suicides involving unusual circumstances/methods. The data suggest a need for media professionals and suicide experts to work together to balance newsworthiness against the risk of copycat behavior.     

Psychologist suicide: Incidence, impact, and suggestions for prevention, intervention, and postvention

Psychologist practitioners are not immune to some mental health problems, including suicidality, for which they provide services. In the aftermath of two recent psychologist suicides, the American Psychological Association's Advisory Committee on Colleague Assistance (ACCA) initiated the formation of a conjoint ad hoc committee consisting of members from ACCA, the American Psychological Association (APA) Practice Directorate, and the Section on Clinical Emergencies and Crises (Section VII of APA's Division 12) to investigate the incidence of psychologist suicide and its impact on colleagues, students or interns, patients or clients, and the profession. The committee reviewed the extant empirical literature on suicide rates for psychologists, evaluated unpublished data on psychologist suicide provided by the National Institute of Occupational Safety and Health (NIOSH), interviewed colleague survivors, reviewed published case reports of the impact of therapist suicides, and linked their findings to the literature on professional distress, impairment, and self-care. The committee concluded that there is evidence suggestive of an elevated risk of suicide for psychologists in past decades. It further concluded that there is a need for further research to confirm if there is a heightened risk of suicide for psychologists in the present day, and to determine factors that might contribute to such risk. Accounts from colleague-survivors suggest that the impact of a psychologist's suicide can affect many people including family, colleagues, students, and patients or clients. This article offers suggestions for possible preventive approaches, for intervention with potentially at-risk colleagues, and for postvention efforts in the wake of a colleague suicide.     

Estimation of suicide risk by the use of clinical models

This report details some preliminary experience in the use of clinical models to develop scales for the estimation of suicide risk. A cohort was drawn for each of two models: Stable with Forced Change (N = 333) and Alienated (N = 566). A set of postulated discriminators regarding suicide was examined with negative results. Available data revealed 12 items for the Stable with Forced Change model and 20 items for the Alienated model that discriminated between the suicides and the nonsuicides at a .05 level of confidence. That only 4 items were common to both supports the idea that the models represent different populations in regard to vulnerability to suicide and thus require independent lethality scales.     

Suicidal behavior among inpatients with schizophrenia and mood disorders in Chengdu, China

This study evaluated the characteristics of suicidal behavior (suicide attempt or suicidal ideation) among 230 consecutively admitted inpatients with schizophrenia and mood disorders in a university hospital in China. The rate of lifetime suicidal behavior was found to be significantly higher in patients with mood disorders (62.4%) than in patients with schizophrenia (38.6%). The rate of suicidal behavior was significantly higher in patients with major depressive disorder (86.8%) than those with bipolar disorders (42.6%). Patients with schizophrenia attempted suicide for the first time earlier in life than the patients with mood disorders. Mood disorder patients, especially those with major depressive disorder, had more and more serious suicide attempts than the patients with schizophrenia.     

Patterns of suicide among hospitalized mentally disordered offenders

The case records of 29 mentally disordered offenders who committed suicide in a state hospital were reviewed. Information was collected on demographic and clinical characteristics; time, method and location of the suicides; and the presence of suicide indicators. Comparisons were made between the characteristics of the suicide patients and those of the current hospital population. Major findings were: 80 percent of the suicides were committed by psychotic patients and 66 percent were by patients with diagnoses which included paranoia; 48 percent of the suicide patients had been charged with or convicted of murder or attempted murder; most suicides occurred in individual patient rooms; nearly 50 percent of the patients had a history of suicide attempts; and other common indicators of suicide risk were often masked by psychotic symptomatology. Several recommendations for identifying and managing potentially suicidal patients in this population are presented.