Risk factors for suicide in young people suffering from schizophrenia: a long-term follow-up study

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Abstract

Ten per cent of patients with schizophrenia commit suicide, but assessment of risk is difficult. Large case–control studies with a long follow-up period are needed. These should focus on patients from one age group to give clinicians the details required to identify those at highest risk.

We present a case–control study of 63 patients who committed suicide and 63 controls from a consecutive admission series of patients with a diagnosis of schizophrenia. All patients were under the age of 30 at admission.

Risk factors for suicide were male gender, chronic illness with frequent relapses (OR 6.0), frequent short hospitalisation, a negative attitude towards treatment (OR non-compliance 7.0), impulsive behaviour (OR acting out 6.4, OR involuntary commitment 17), parasuicide (OR suicide attempt 4.8, OR highly lethal suicide attempt 11), high pre-morbid IQ (OR 4.3), psychosis (OR 7.0) and depression (OR 36). However, early onset of a defect state (OR 6.3) and a daily activity (OR 4.2) were protective factors.

Identified risk factors could help clinicians to target high-risk patients and form the basis for interventions aimed at reducing suicide.

Introduction

Suicide is the most common cause of death in schizophrenia (Allebeck, 1989, Barraclough et al., 1974, Caldwell and Gottesman, 1990, Caldwell and Gottesman, 1992, De Hert, 1995, De Hert and Peuskens, 2000, Drake et al., 1985, Modestin et al., 1992, Tsuang et al., 1980, Wilkinson, 1982). There is a 10% lifetime risk. Preventing suicide is one of the main targets of care. Indeed, a reduction in suicide among the seriously mentally ill was one of the UK Government's health targets (Secretary of State for Health, 1992), and in Belgium, the high rate of suicide in young adults is a major priority for the Flemish Health Ministry.

The suicide rate in schizophrenia is influenced by changes in society. A recent reported increase in suicide in young people suffering from schizophrenia may, in part, be a reflection of population trends (Charlton et al., 1993). Individual risk factors may also change because of the changing social environment. Detailed contemporary information on risk factors is needed if clinicians are to be able to prevent suicide in sufferers of schizophrenia.

Studies attempting to identify risk factors for suicide in schizophrenia have had a number of shortcomings. Small patient groups and small numbers of suicides have reduced the power of studies, and a number of methodological problems have made results difficult to interpret. Most studies have investigated a mixture of age groups with predominately older patients; the relevance of these results to younger patients is questionable. Other studies have employed a cross-sectional design, have observed only inpatients, have studied few variables or have not used a control group (Caldwell and Gottesman, 1990, De Hert, 1995, De Hert and Peuskens, 1998, De Hert and Peuskens, 2000).

Studies to date have characterised the high-risk patient as a young male early in an illness characterised by frequent exacerbations and remissions (Caldwell and Gottesman, 1990, De Hert, 1995, De Hert and Peuskens, 1998, De Hert and Peuskens, 2000, Drake et al., 1985, Roy et al., 1986, Westermeyer et al., 1991). But so many patients could fit this description that it may not help clinicians to identify high-risk patients in need of appropriate care and supervision. It remains difficult for clinicians to predict which patients are at risk of suicide.

We have used a case–control design to identify more specific risk factors for suicide in a large cohort of young patients with schizophrenia enrolled in a long-term follow-up study. This study is devoid of the methodological problems most often encountered in the literature because of the large sample size, the use of longitudinal information, the length of follow-up and its focus on one group of patients.

Section snippets

Subjects and methods

Patients who were under 30 years of age at index admission and had been given a diagnosis of schizophrenia or schizoaffective disorder were selected from a consecutive admission series of 1119 psychotic patients hospitalised between 1973 and 1992 to two treatment and rehabilitation wards at University Centre St Jozef, Kortenberg, Belgium.

Index demographic and clinical data were used to establish a database.

One researcher, M.D.H., contacted all patients in 1994. Information from the case notes

Results

Eight-hundred and seventy patients were eligible for the study (536 men and 334 women). Minimal data, i.e. whether the patients were alive or dead and where they were living, were available for all patients. There were 63 cases and 63 controls. Full data were available on all those selected for the case–control study. All controls were alive when contacted. The mean duration of follow-up was 11.4 years (S.D. 5.3 years).

Discussion

This study confirms the high risk for suicide in young patients suffering from schizophrenic psychosis. They kill themselves at relatively young age, 28.5 years, often using highly lethal methods shortly after admission or discharge (Barraclough et al., 1974, Roy et al., 1986, Drake et al., 1984; Allebeck, 1989, Black and Winokur, 1988, De Hert, 1995, De Hert and Peuskens, 1998, De Hert and Peuskens, 2000, Peuskens et al., 1997, Westermeyer et al., 1991).

Some of the factors which are associated

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