Hostname: page-component-78c5997874-j824f Total loading time: 0 Render date: 2024-11-16T23:21:49.578Z Has data issue: false hasContentIssue false
  • English
  • Français

A biopsychosocial evaluation of the risk for suicide in schizophrenia

Published online by Cambridge University Press:  24 May 2017

Nuwan C. Hettige ,
Ali Bani-Fatemi ,
Isaac Sakinofsky  and
Vincenzo De Luca
Nuwan C. Hettige
Affiliation:
Group for Suicide Studies, Centre for Addiction and Mental Health, Toronto, Ontario, Canada Institute of Medical Science, University of Toronto, Toronto, Ontario, Canada
Ali Bani-Fatemi
Affiliation:
Group for Suicide Studies, Centre for Addiction and Mental Health, Toronto, Ontario, Canada Institute of Medical Science, University of Toronto, Toronto, Ontario, Canada
Isaac Sakinofsky
Affiliation:
Department of Psychiatry, University of Toronto, Toronto, Ontario, Canada Psychiatry and Public Health Sciences, University of Toronto, Toronto, Ontario, Canada Head, High Risk Consultation Clinic, Centre for Addiction and Mental Health, Toronto, Ontario, Canada
Vincenzo De Luca*
Affiliation:
Group for Suicide Studies, Centre for Addiction and Mental Health, Toronto, Ontario, Canada Department of Psychiatry, University of Toronto, Toronto, Ontario, Canada
*
*Address correspondence to: Vincenzo De Luca, Centre for Addiction and Mental Health, Department of Psychiatry, University of Toronto, 250 College Street, Toronto, Ontario, Canada M5T 1R8. (E-mail:[email protected])
Get access Rights & Permissions [Opens in a new window]

Abstract

The risk of suicide is greatly increased in individuals with schizophrenia. Previous research has identified several potential risk factors for suicidal behavior in schizophrenia, although their ability to independently predict suicide is limited. The objective of this review was to systematically analyze and identify the interaction between the proposed risk factors in the literature that may predict suicidal behavior in schizophrenia. Articles that explored suicidal behavior and suicide risk in schizophrenia that were published between 1980 and August of 2015, indexed in PubMed, MEDLINE, and Scopus were systematically reviewed. Many studies proposed a range of biopsychosocial risk factors that may independently lead to suicide in schizophrenia. These risk factors appear to be mainly related to stress, a history of suicidal behavior, and psychotic symptoms. It is clear, however, that many of these factors do not act independently and in fact require the reciprocal interaction of several of them to pose a risk for suicide in schizophrenia. Independently, the power of many risk factors to predict suicide is limited. Future studies should continue to adopt a multidimensional approach by considering the interaction of several factors in assessing the risk for suicide in schizophrenia.

Keywords

Schizophreniasuicidestressgeneticschildhood trauma
Type
Review Article
Information
CNS Spectrums , Volume 23 , Issue 4 , August 2018 , pp. 253 - 263
Copyright
© Cambridge University Press 2017 

Access options

Get access to the full version of this content by using one of the access options below. (Log in options will check for institutional or personal access. Content may require purchase if you do not have access.)

References

1. Hawton, K, van Heeringen, K. Suicide. Lancet. 2009; 373(9672): 1372–1381.Google Scholar
2. Brown, S, Inskip, H, Barraclough, B. Causes of the excess mortality of schizophrenia. Br J Psychiatry. 2000; 177: 212–217; http://bjp.rcpsych.org/content/177/3/212.long. Accessed January 23, 2017.Google Scholar
3. Phan, SV, Kreys, TJ. Adjunct mirtazapine for negative symptoms of schizophrenia. Pharmacotherapy. 2011; 31(10): 1017–1030.Google Scholar
4. Hawton, K, Sutton, L, Haw, C, Sinclair, J, Deeks, JJ. Schizophrenia and suicide: systematic review of risk factors. Br J Psychiatry. 2005; 187: 9–20; http://bjp.rcpsych.org/content/187/1/9.long. Accessed January 23, 2017.Google Scholar
5. Palmer, BA, Pankratz, VS, Bostwick, JM. The lifetime risk of suicide in schizophrenia: a reexamination. Arch Gen Psychiatry. 2005; 62(3): 247–253; http://jamanetwork.com/journals/jamapsychiatry/fullarticle/208392. Accessed January 23, 2017.Google Scholar
6. Alaraisanen, A, Miettunen, K, Rasanen, P, Fenton, W, Koivumaa-Honkanen, HTJ, Isohanni, M. Suicide rate in schizophrenia in the Northern Finland 1966 Birth Cohort. Soc Psychiatry Psychiatr Epidemiol. 2009; 44(12): 1107–1110; Epub ahead of print Mar 25.Google Scholar
7. Heilä, H, Haukka, J, Suvisaari, J, Lonnqvist, J. Mortality among patients with schizophrenia and reduced psychiatric hospital care. Psychol Med. 2005; 35(5): 725–732.Google Scholar
8. Cohen, CI, Abdallah, CG, Diwan, S. Suicide attempts and associated factors in older adults with schizophrenia. Schizophr Res. 2010; 119(1–3): 253–257; Epub ahead of print Apr 10. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4095823/. Accessed January 23, 2017.Google Scholar
9. Montross, LP, Kasckow, J, Golshan, S, Solorzano, E, Lehman, D, Zisook, S. Suicidal ideation and suicide attempts among middle-aged and older patients with schizophrenia spectrum disorders and concurrent subsyndromal depression. J Nerv Ment Dis. 2008; 196(12): 884–890.Google Scholar
10. Hor, K, Taylor, M. Suicide and schizophrenia: a systematic review of rates and risk factors. J Psychopharmacol. 2010; 24(Suppl. 4): 81–90; https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2951591/. Accessed January 23, 2017.Google Scholar
11. Gómez-Durán, EL, Martin-Fumadó, C, Hurtado-Ruíz, G. Clinical and epidemiological aspects of suicide in patients with schizophrenia. Actas Esp Psiquiatr. 2012; 40(6): 333–345; Epub ahead of print Nov 1. http://www.actaspsiquiatria.es/repositorio//14/80/ENG/14-80-ENG-333-345-594611.pdf. Accessed January 23, 2017.Google Scholar
12. van Os, J, Kapur, S. Schizophrenia. Lancet. 2009; 374(9690): 635–645.Google Scholar
13. Carlborg, A, Winnerback, K, Jonsson, EG, Jokinen, J, Nordstrom, P. Suicide in schizophrenia. Expert Rev Neurother. 2010; 10(7): 1153–1164; http://www.tandfonline.com/doi/pdf/10.1586/ern.10.82?needAccess=true. Accessed January 23, 2017.Google Scholar
14. Togay, B, Noyan, H, Tasdelen, R, Uçok, A. Clinical variables associated with suicide attempts in schizophrenia before and after the first episode. Psychiatry Res. 2015; 229(1–2): 252–256; Epub ahead of print Jul 15.Google Scholar
15. Melle, I, Barrett, EA. Insight and suicidal behavior in first-episode schizophrenia. Expert Rev Neurother. 2012; 12(3): 353–359; http://www.tandfonline.com/doi/full/10.1586/ern.11.191. Accessed January 23, 2017.Google Scholar
16. Linden, M, Godemann, F. The differentiation between “lack of insight” and “dysfunctional health beliefs” in schizophrenia. Psychopathology. 2007; 40(4): 236–241.Google Scholar
17. Staring, AB, van der Gaag, M, van den Berge, M, Duivenvoorden, HJ, Mulder, CL. Stigma moderates the associations of insight with depressed mood, low self-esteem, and low quality of life in patients with schizophrenia spectrum disorders. Schizophr Res. 2009; 115(2–3): 363–369; Epub ahead of print Jul 17.Google Scholar
18. Addington, J. The promise of early intervention. Early Interv Psychiatr. 2007; 1(4): 294–307.Google Scholar
19. Popovic, D, Benabarre, A, Crespo, JM, et al. Risk factors for suicide in schizophrenia: systematic review and clinical recommendations. Acta Psychiatr Scand. 2014; 130(6): 418–426; Epub ahead of print Sep 18.Google Scholar
20. Caldwell, CB, Gottesman, II. Schizophrenics kill themselves too: a review of risk factors for suicide. Schizophr Bull. 1990; 16(4): 571–589.Google Scholar
21. Fenton, WS. Depression, suicide, and suicide prevention in schizophrenia. Suicide Life Threat Behav. 2000; 30(1): 34–49.Google Scholar
22. Pompili, M, Amador, XF, Girardi, P, et al. Suicide risk in schizophrenia: learning from the past to change the future. Ann Gen Psychiatry. 2007; 6: 10. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1845151/. Accessed January 23, 2017.Google Scholar
23. Amador, XF, Kronengold, H. Understanding and assessing insight. In: Amador X, David A, eds. Insight and Psychosis, 2nd ed. New York: Oxford University Press; 2004. P. 3–30.Google Scholar
24. López-Moriñgo, JD, Ramos-Ríos, R, David, AS, Dutta, R. Insight in schizophrenia and risk of suicide: a systematic update. Compr Psychiatry. 2012; 53(4): 313–322.Google Scholar
25. Friedman, AS, Terras, A, Zhu, W, McCallum, J. Depression, negative self-image, and suicidal attempts as effects of substance use and substance dependence. J Addict Dis. 2004; 23(4): 55–71.Google Scholar
26. Pompili, M, Lester, D, Dominici, G, et al. Indications for electroconvulsive treatment in schizophrenia: a systematic review. Schizophr Res. 2013; 146(1–3): 1–9; Epub ahead of print Mar 15.Google Scholar
27. Qin, P, Nordentoft, M. Suicide risk in relation to psychiatric hospitalization: evidence based on longitudinal registers. Arch Gen Psychiatry. 2005; 62(4): 427–432; http://jamanetwork.com/journals/jamapsychiatry/fullarticle/208501. Accessed January 23, 2017.Google Scholar
28. Kao, YC, Liu, YP. Suicidal behavior and insight into illness among patients with schizophrenia spectrum disorders. Psychiatr Q. 2011; 82(3): 207–220.Google Scholar
29. 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(2–3): 127–134.Google Scholar
30. Wong, Z, Öngür, D, Cohen, B, Ravichandran, C, Noam, G, Murphy, B. Command hallucinations and clinical characteristics of suicidality in patients with psychotic spectrum disorders. Compr Psychiatry. 2013; 54(6): 611–617; Epub ahead of print Jan 31.Google Scholar
31. Hellerstein, D, Frosch, W, Koenigsberg, HW. The clinical significance of command hallucinations. Am J Psychiatry. 1987; 144(2): 219–221.Google Scholar
32. Hu, WH, Sun, CM, Lee, CT, Peng, SL, Lin, SK, Shen, WW. A clinical study of schizophrenic suicides: 42 cases in Taiwan. Schizophr Res. 1991; 5(1): 43–50.Google Scholar
33. Pješčić, KD, Nenadović, MM, Jašović-Gašić, M, Trajković, G, Kostić, M, Ristić-Dimitrijević, R. Influence of psycho-social factors on the emergence of depression and suicidal risk in patients with schizophrenia. Psychiatr Danub. 2014; 26(3): 226–230; http://www.hdbp.org/psychiatria_danubina/pdf/dnb_vol26_no3/dnb_vol26_no3_226.pdf. Accessed January 23, 2017.Google Scholar
34. Pompili, M, Innamorati, M, Lester, D, et al. Suicide attempts in acute psychiatric referrals with substance use disorders. Riv Psichiatr. 2012; 47(4): 313–318; http://www.rivistadipsichiatria.it/articoli.php?archivio=yes&vol_id=1139&id=12559. Accessed January 23, 2017.Google Scholar
35. Harkavy-Friedman, JM, Nelson, EA, Venarde, DF, Mann, JJ. Suicidal behavior in schizophrenia and schizoaffective disorder: examining the role of depression. Suicide Life Threat Behav. 2004; 34(1): 66–76.Google Scholar
36. Sokya, M. Substance misuse, psychiatric disorders and violent and disturbed behavior. Br J Psychiatry. 2000; 176(4): 345–350; http://bjp.rcpsych.org/content/176/4/345.long. Accessed January 23, 2017.Google Scholar
37. Zai, CC, Zai, GC, Tiwari, AK, et al. Association study of GABRG2 polymorphisms with suicidal behaviour in schizophrenia patients with alcohol use disorder. Neuropsychobiology. 2014; 69(3): 154–158; Epub ahead of print Apr 26.Google Scholar
38. McGirr, A, Turecki, G. What is specific to suicide in schizophrenia disorder? Demographic, clinical and behavioral dimensions. Schizophr Res. 2008; 98(1–3): 217–224; Epub ahead of print Oct 22, 2007.Google Scholar
39. Reutfor, J, Brandt, L, Jonsson, EG, Ekbom, A, Sparen, P, Osby, U. Risk factors for suicide in schizophrenia: findings from a Swedish population-based case-control study. Schizophr Res. 2009; 108(103): 231–237; Epub ahead of print Jan 26.Google Scholar
40. Nordentoft, M, Laursen, TM, Agerbo, E, Oin, P, Hoyer, EH, Mortensen, PB. Change in suicide rates for patients with schizophrenia in Denmark, 1981–1997: nested case-control study. BMJ. 2004; 329(7460): 261 https://www.ncbi.nlm.nih.gov/pmc/articles/PMC498022/. Accessed January 23, 2017.Google Scholar
41. Enns, MW, Cox, BJ, Afifi, TO, De Graaf, R, Ten Have, M, Sareen, J. Childhood adversities and risk for suicidal ideation and attempts: a longitudinal population-based study. Psychol Med. 2006; 36(12): 1769–1778; Epub ahead of print Sep 26.Google Scholar
42. Melle, I. History of depression and previous suicide attempt predict increased risk of suicide attempt following diagnosis of first-episode psychosis. Evid Based Ment Health. 2013; 16(3): 67.Google Scholar
43. Roy, A. Reported childhood trauma and suicide attempts in schizophrenic patients. Suicide Life Threat Behav. 2005; 35(6): 690–693.Google Scholar
44. Funahashi, T, Ibuki, Y, Domon, Y, Nishimura, T, Akehashi, D, Sugiura, H. A clinical study of suicide among schizophrenics. Psychiatry Clin Neurosci. 2000; 54(2): 173–179.Google Scholar
45. Uçok, A, Bikmaz, S. The effects of childhood trauma in patients with first-episode schizophrenia. Acta Psychiatr Scand. 2007; 116(5): 371–377.Google Scholar
46. Meltzer, HY, Alphs, L, Green, AI, et al. Clozapine treatment for suicidality in schizophrenia: International Suicide Prevention Trial (InterSePT). Arch Gen Psychiatry. 2003; 60(1): 82–91; http://jamanetwork.com/journals/jamapsychiatry/fullarticle/207092. Accessed January 23, 2017.Google Scholar
47. Fu, Q, Heath, AC, Bucholz, KK, et al. A twin study of genetic and environmental influences on suicidality in men. Psychol Med. 2002; 32(1): 11–24.Google Scholar
48. Glowinski, AL, Bucholz, KK, Nelson, EC, et al. Suicide attempts in an adolescent female twin sample. J Am Acad Child Adolesc Psychiatry. 2001; 40(11): 1300–1307; https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1474069/. Accessed January 23, 2017.Google Scholar
49. Bondy, B, Buettner, A, Zill, P. Genetics of suicide. Mol Psychiatry. 2006; 11(4): 336–351; http://www.nature.com/mp/journal/v11/n4/pdf/4001803a.pdf. Accessed January 23, 2017.Google Scholar
50. McGuffin, P, Marusic, A, Farmer, A. What can psychiatric genetics offer suicidology? Crisis. 2001; 22(2): 61–65.Google Scholar
51. Roy, A, Segal, NL. Suicidal behavior in twins: a replication. J Affect Disord. 2001; 66(1): 71–74.Google Scholar
52. Qin, P, Agerbo, E, Mortensen, PB. Suicide risk in relation to family history of completed suicide and psychiatric disorders: a nested case-control study based on longitudinal registers. Lancet. 2002; 360(9340): 1126–1130.Google Scholar
53. Trémeau, F, Staner, L, Duval, F, et al. Suicidal behavior in schizophrenia and family history of suicide. Dialogues Clin Neurosci. 2001; 3(2): 120–121; https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3181650/. Accessed January 23, 2017.Google Scholar
54. Ljung, T, Lichtenstein, P, Sandin, S, et al. Parental schizophrenia and increased offspring suicide risk: exploring the causal hypothesis using cousin comparisons. Psychol Med. 2013; 43(3): 581–590; Epub ahead of print Jun 18, 2012.Google Scholar
55. Chistiakov, DA, Kekelidze, ZI, Chekhonin, VP. Endophenotypes as a measure of suicidality. J Appl Genet. 2012; 53(4): 389–413; Epub ahead of print Sep 2.Google Scholar
56. Mann, JJ. Role of the serotonergic system in the pathogenesis of major depression and suicidal behavior. Neuropsychopharmacology. 1999; 21(Suppl. 2): 99S–105S.Google Scholar
57. Anguelova, M, Benkelfat, C, Turecki, G. A systematic review of association studies investigating genes coding for serotonin receptors and the serotonin transporter, II: suicidal behavior. Mol Psychiatry. 2003; 8(7): 646–653; http://www.nature.com/mp/journal/v8/n7/full/4001336a.html. Accessed January 23, 2017.Google Scholar
58. Buttenschøn, HN, Flint, TJ, Foldager, L, et al. An association study of suicide and candidate genes in the serotonergic system. J Affect Disord. 2013; 148(203): 291–298; Epub ahead of print Jan 11.Google Scholar
59. Judy, JT, Seifuddin, F, Mahon, PB, et al. Association study of serotonin pathway genes in attempted suicide. Am J Med Genet B Neuropsychiatr Genet. 2012; 159(1): 112–119; Epub ahead of print Dec 13, 2011. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4021704/. Accessed January 23, 2017.Google Scholar
60. Serretti, A, Drago, A, De Ronchi, D. HTR2A gene variants and psychiatric disorders: a review of current literature and selection of SNPs for future studies. Curr Med Chem. 2007; 14(19): 2053–2069.Google Scholar
61. Tsai, SJ, Hong, CJ, Liou, YJ. Recent molecular genetic studies and methodological issues in suicide research. Prog Neuropsychopharmacol Biol Psychiatry. 2011; 35(4): 809–817; Epub ahead of print Oct 23, 2010.Google Scholar
62. Ertugrul, A, Kennedy, JL, Masellis, M, Basile, VS, Jayathilake, K, Meltzer, HY. No association of the T102C polymorphism of the serotonin 2A receptor gene (HTR2A) with suicidality in schizophrenia. Schizophr Res. 2004; 69(2–3): 301–305.Google Scholar
63. Tan, EC, Chong, SA, Chan, AO, Tan, CH. No evidence for association of the T102C polymorphism in the serotonin type 2A receptor with suicidal behavior in schizophrenia. Am J Med Genet. 2002; 114(3): 321–322.Google Scholar
64. Paik, I, Toh, K, Kim, J, Lee, C. TPH gene may be associated with suicidal behavior but not with schizophrenia in the Korean population. Hum Hered. 2000; 50(6): 365–369.Google Scholar
65. Saetre, P, Lundmark, P, Wang, A, et al. The tryptophan hydroxylase 1 (TPH1) gene, schizophrenia susceptibility, and suicidal behavior: a multi-centre case-control study and meta-analysis. Am J Med Genet B Neuropsychiatr Genet. 2010; 153B(2): 387–396.Google Scholar
66. De Luca, V, Voineskos, D, Wong, GW, et al. Promoter polymorphism of second tryptophan hydroxylase isoform (TPH2) in schizophrenia and suicidality. Psychiatry Res. 2005; 134(2): 195–198.Google Scholar
67. Bayle, FJ, Leroy, S, Gourion, D, et al. 5HTTLPR polymorphism in schizophrenic patients: further support for association with violent suicide attempts. Am J Med Genet B Neuropsychiatr Genet. 2003; 119B(1): 13–17.Google Scholar
68. Hung, CF, Lung, FW, Chen, CH, et al. Association between suicide attempt and a tri-allelic functional polymorphism in serotonin transporter gene promoter in Chinese patients with schizophrenia. Neurosci Lett. 2011; 504(3): 242–246; Epub ahead of print Sep 22.Google Scholar
69. Božina, N, Jovanović, N, Podlesek, A, et al. Suicide ideators and attempters with schizophrenia: the role of 5-HTTLPR, rs25531, and 5-HTT VNTR Intron 2 variants. J Psychiatr Res. 2012; 46(6): 767–773.Google Scholar
70. Contreras, J, Hernandez, S, Quezada, P, et al. Association of serotonin transporter promoter gene polymorphism (5-HTTLPR) with depression in Costa Rican schizophrenic patients. J Neurogenet. 2010; 24(2): 83–89.Google Scholar
71. Lindholm Carlström, E, Saetre, P, Rosengren, A, et al. Association between a genetic variant in the serotonin transporter gene (SLC6A4) and suicidal behavior in patients with schizophrenia. Behav Brain Funct. 2012; 8: 24 https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3527134/pdf/1744-9081-8-24.pdf. Accessed January 23, 2017.Google Scholar
72. De Luca, V, Tharmalingam, S, Muller, DJ, Wong, G, de Bartolomeis, A, Kennedy, JL. Gene–gene interaction between MAOA and COMT in suicidal behavior: analysis in schizophrenia. Brain Res. 2006; 1097(1): 26–30.Google Scholar
73. De Luca, V, Tharmalingam, S, Zai, C, et al. Association of HPA axis genes with suicidal behaviour in schizophrenia. J Psychopharmacol. 2010; 24(5): 677–682; http://journals.sagepub.com/doi/abs/10.1177/0269881108097817?url_ver=Z39.88-2003&rfr_id=ori:rid:crossref.org&rfr_dat=cr_pub%3dpubmed. Accessed January 23, 2017.Google Scholar
74. Feldcamp, LA, Souza, RP, Romano-Silva, M, Kennedy, JL, Wong, AH. Reduced prefrontal cortex DARPP-32 mRNA in completed suicide victims with schizophrenia. Schizophr Res. 2008; 103(1–3): 192–200; Epub ahead of print Jun 24.Google Scholar
75. Garbett, K, Gal-Chis, R, Gaszner, G, Lewis, DA, Mirnics, K. Transcriptome alterations in the prefrontal cortex of subjects with schizophrenia who committed suicide. Neuropsychopharmacol Hung. 2008; 10(1): 9–14.Google Scholar
76. Mann, JJ. Neurobiology of suicidal behavior. Nat Rev Neurosci. 2003; 4(10): 819–828.Google Scholar
77. Passos, IC, Mwangi, B, Cao, B, et al. Identifying a clinical signature of suicidality among patients with mood disorders: a pilot study using a machine learning approach. J Affect Disord. 2016; 193: 109–116; Epub ahead for pint Jan 1.Google Scholar