Persistent suicide risk in clinically improved schizophrenia patients: challenge of the suicidal dimension

Amresh Shrivastava¹, Megan E Johnston², Nilesh Shah³, Marco Innamorati⁴, Larry Stitt⁵, Meghana Thakar³, David Lester⁶, Maurizio Pompili^4,7
1Silver Mind Hospital and Mental Health Foundation of India, Mumbai, India; ²Department of Psychology, University of Toronto, Toronto, ON, Canada; ³Lokmanya Tilak Municipal General Hospital, University of Mumbai, India; ⁴Department of Neurosciences, Mental Health and Sensory Functions, Suicide Prevention Center, Sant’Andrea Hospital, Sapienza University of Rome, Rome, Italy; ⁵Department of Biostatistics, The University of Western Ontario, London, ON, Canada; ⁶The Richard Stockton College of New Jersey, Pomona, NJ, USA; ⁷McLean Hospital, Harvard Medical School, Boston, MA, USA

Background: Suicide is a major problem in schizophrenia, estimated to affect 9%–13% of patients. About 25% of schizophrenic patients make at least one suicide attempt in their lifetime. Current outcome measures do not address this problem, even though it affects quality of life and patient safety. The aim of this study was to assess suicidality in long-term clinically improved schizophrenia patients who were treated in a nongovernmental psychiatric treatment centre in Mumbai, India.
Method: Participants were 61 patients out of 200 consecutive hospitalized first-episode patients with schizophrenia diagnosed according to the Diagnostic and Statistical Manual of Mental Disorders who were much improved on the Clinical Global Impression Scale-Improvement (CGI-I) scale at the endpoint of a 10-year follow-up. Clinical assessment tools included the Positive and Negative Syndrome Scale for Schizophrenia, CGI-I, Global Assessment of Functioning, and suicidality.
Results: Many of the patients, although clinically improved, experienced emerging suicidality during the 10-year follow-up period. All of the patients reported significant suicidality (ie, suicide attempts, suicidal crises, or suicidal ideation) at the end of the study, whereas only 83% had reported previous significant suicidality at baseline. No sociodemographic and clinical variables at baseline were predictive of suicidal status at the end of the 10-year follow-up.
Conclusion: Schizophrenia is a complex neurobehavioral disorder that appears to be closely associated with suicidal behavior. Adequate assessment and management of suicidality needs to be a continual process, even in patients who respond well to treatment.

Keywords: schizophrenia, suicide risk, prevention