A ‘Substantial Risk’ 

Stephen R. Marder, MD, director of the VISN 22 Mental Illness Research Education and Clinical Center in the VA Greater Los Angeles Healthcare System, and professor and director of the Section on Psychosis at the Semel Institute at UCLA, also notes schizophrenia’s strong association with an increase in the risk of suicide. “In the past there have been estimates that as many as 10% people with schizophrenia will commit suicide; recently the profession has come to believe it is less, but that it is still very high,” he says. Marder adds that it has also been estimated that as many as 50% of people with schizophrenia will attempt suicide at one time or another.

Co-morbidities further elevate the risk of suicide, he points out, “in particular, depression, which is common in schizophrenia, and substance abuse.” Further, certain symptoms, such as command hallucinations “absolutely do elevate risk,” he adds.

Accordingly, says Marder, clinicians should ask questions not just about whether or not an individual has hallucinations but about the nature of those hallucinations. “Of course, a person early in the illness who feels hopeless about their future and feels impending losses would be among those who appear to be at great risk,” her adds.

In fact, overall risk of suicide is higher early in the progression of the illness -- sometimes when the individual is having their first episode or developing the first evidence of schizophrenia, he notes, adding, “Interestingly, the people who have the best prognosis and signs that they will do well – those are the ones at greater risk.” 

Aggressive Interventions

Marder notes there is evidence that general adherence to antipsychotic medication can be effective, and clozapine has been shown to be especially valuable when it comes to suicide risk. “There was a large international study comparing it with diazepam and the researchers found clozapine reduced suicidal ideation,” he says. Clozapine can cause some uncomfortable side-effects such as restlessness, he cautions.

Aggressive psychosocial interventions are recommended for schizophrenia patients, along with pharmacotherapy.  “If you look at cognitive behavior therapy it seems to be effective for psychosis; there is also some evidence it reduces suicidal ideation,” Marder observes. “There is evidence that patients who engaged in programs like supported employment, which is widely available for veterans, can also help.”

The same recommendations would apply if a patient has attempted suicide, and the clinician is seeking to prevent a repeat attempt. “Once an attempt has been made, that individual is in a particularly high-risk group,” says Marder. “Anyone who has made a serious suicide attempt should be monitored more carefully, particularly for the risk factors I suggested earlier.”

While Marder says he is not aware of VA programs specific to preventing suicide in veterans who have schizophrenia, he notes that VA has several programs, including a national hotline, which can be useful. “A lot of interventions are relevant whether a patient has schizophrenia, PTSD, or bipolar illness,” he observes, “So the widespread programs in VA that reduce suicide pertain to schizophrenia along with other illnesses.”

References

1. Denneson L et al. Suicide Risk Assessment and Content of VA Health Care Contacts Before Suicide Completion. Psychiatr Serv.2010; 61: 1192-1197.

2. Ilgen M, Bohnert ASB, Ignacio RV, McCarthy JF, et al. Psychiatric Diagnoses and Risk of Suicide in Veterans. Arch Gen Psychiatry. 2010;67(11):1152-1158.

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