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30. Depression and Suicide
Keywords
SuicideRisk factorsStress-diathesis modelCDC terminologyPsychacheSuicide assessmentDepressionDemoralizationClozapineEssential Concepts
Schizophrenia is a disease with premature mortality in about 5% of patients: you can die from it young, not merely with is in old age. The cause of death is suicide.
Most suicides by patients with schizophrenia occur in the first few years after diagnosis.
Risk factors for suicide in schizophrenia are the known risk factors for suicide in other conditions: particularly drug use, depression, or demoralization but also psychosis itself.
Use behavioral dissection (a step-by-step account of the suicide attempt), and try to understand the nature of the crisis, including the patient’s intolerable mind state (“psychache”).
Depression is common in schizophrenia particularly in the early years of the illness.
Demoralization can occur early in the course of illness as well if the illness does not get better and its ramification on a patient’s life become obvious to the patient.
Clozapine reduces suicidality in schizophrenia.
Schizophrenia brings many elements of caring for patients with chronic illness into sharp focus, particularly that some patients can become demoralized when their symptoms do not improve. The treatment of demoralization is giving hope. This requires time and commitment, including by the patient’s community.
“There is but one truly serous philosophical problem, and that is suicide. Judging whether life is or is not worth living amounts to answering the fundamental question of philosophy.”
– Albert Camus (“The Myth of Sisyphus”), 1942 [1]
“The most serious of schizophrenic symptoms is the suicidal drive.”
– Eugen Bleuler, 1911 [2]
The early prognosis in schizophrenia quo ad vitam (“with regard to life”) is largely determined by suicide. Suicide is, in fact, the number one cause of premature death in schizophrenia patients in the age group from 15 to 24 years [3]. Suicide is closely followed by accidents until natural causes of death take over the statistic in midlife and beyond. Increasingly, unnatural deaths from drug use have become a major concern in first-episode cohorts [4]. Taken together, young patients with schizophrenia face a high premature mortality that is comparable to the mortality risk of patients in their 70s [5].
The great Swiss psychiatrist Eugen Bleuler recognized suicide as a key clinical concern at a time when psychiatrists were just beginning to study schizophrenia. Today, we can only imagine how much some patients must have suffered in Bleuler’s time when incessant, unrelenting auditory hallucinations drove them to suicide to silence the voices, as no treatment was available to quell them. Incessant voices are one instance where the self-medication hypothesis has some face validity, in patients who drink excessively to literally drown the voices.
Most modern studies suggest that around 5% of patients diagnosed with schizophrenia die from suicide [6]. Of note, the 5% figure represents the case fatality rate from suicide which is lower than the often-quoted proportionate mortality rate of 10–15% [7]; the former reflects better a patient’s individual lifetime risk. Although most practitioners recognize that schizophrenia is disabling, it is often not considered to be potentially lethal, so we need to focus on this important statistic: schizophrenia is a disease with 5% mortality. You can die from schizophrenia as opposed to merely dying with it in old age. This risk of death from suicide is comparable to that of patients with primarily depressive disorders and many potentially lethal medical disorders.
Suicide attempts are even more common than completed suicides. As many as half of the patients with schizophrenia that you encounter will have attempted suicide. This suicide risk is not stable over a patient’s life. The risk is greatest in the first few years of the illness, including the prodromal period [8]. Accordingly, most suicides occur in the first several years following diagnosis. However, suicides occur at any age [9]. In long-standing schizophrenia, another risk factor for suicide is relapse and hospitalization. The risk of suicide increases shortly before going to the hospital (while acutely ill), while the patient is in the hospital, and shortly after discharge, particularly if the patient is socially isolated.
Risk Factors for Suicide
What mediates suicidality in schizophrenia? Importantly, most risk factors are the same as the risk factors in other patient populations, namely, substance use, a prior history of a suicide attempt and depression [10]. Psychosis itself is a risk factor unique to this population. Importantly, no one risk factor supersedes another risk factor in importance; the key to understanding individual risk lies in appreciating the interplay between the various risk factors present in a patient (see below for an example) [11].
The first risk factor you should evaluate is substance use because of its effect on impulse control and mood. While not always possible, clinicians should also determine if a patient accidentally overdosed on drugs or if it was a suicide attempt.
The next risk factor you should consider is depression, which occurs often in the course of schizophrenia. Depressive symptoms are very common in early course schizophrenia to the point of being part and parcel of the early illness course. Usually, depressive symptoms resolve in parallel with the resolution of positive symptoms. However, a period of depression can follow the resolution of positive symptoms, when patients are getting better. Such depressive symptoms and syndromes in the setting of improving or residual schizophrenia following an acute psychotic episode are sometimes called “post-psychotic depression,” an admittedly poorly defined entity without clear time boundaries or severity definitions [12]. In addition to this purported connection to resolving or resolved psychosis, patients can develop a depressive episode at any point in their lives. Schizophrenia does not render one immune from depression.
The third key risk factor you should focus on is psychosis itself. Although probably less common today compared to the days of Bleuler, uncontrolled psychotic symptoms can still be responsible for unbearable psychologic pain (or psychache, as the father of American suicidology, Edwin Shneidman, calls it [13]), leading to suicide attempts. Though you might think that the so-called command hallucinations should be responsible for suicides, clinical studies suggest that this is true for a small minority of patients (about 10%), but not for most [14]. Some psychotic patients die by accident in response to hallucinations or delusions. I treated a patient who jumped off a bridge not because he wanted to die, but in response to God’s voice asking him, as a test of faith, to jump to prove his worthiness.
Tip
Make sure you understand a patient’s acute mental suffering: his or her “psychache.” This psychache might come from acute psychosis; from clinical depression with its distorted self-loathing and gloomy views; or from hopelessness. The psychache can be made worse by anxiety, which could stem from your treatment, in the form of akathisia. Relieve acute suffering acutely by treating aggressively with medications (and by hospitalizing somebody, if necessary).
The patient’s emotional and cognitive response to receiving a diagnosis of schizophrenia is also important. Receiving a (stigmatizing) diagnosis of schizophrenia is traumatic. The diagnosis brings fear and leads to a severe feeling of loss: the loss of one’s future and standing in society. The way people see themselves and their role in society matters greatly. Imagined or real social exclusion can lead to a state of alienation and lack of purpose in life, which can result in what sociologists call anomic suicide. This seems to be particularly relevant for those patients who develop a good understanding of their predicament and its consequences, particularly if they had good academic achievements before the onset of schizophrenia. They are often the most intact patients who, in theory, have the best chances of substantial recovery and good long-term outcome. Having “insight into illness” turns out to be a double-edged sword: insight is generally helpful in active disease management, but it might increase the suicide risk [15]. Conversely, patients who are unaware of their symptoms, who are not bothered by their disability, and who have little understanding of their predicament are probably at lower risk for suicide.
Key Point
Demoralization is the loss of hope and loss of meaning and purpose in life. Demoralized people feel isolated from people and society. Demoralization is not the same as depression, although they can come together and there is some obvious overlap. One of the hallmarks of demoralization is a complaint of suicidality. The treatment for demoralization is giving hope and decreasing isolation.
What do you want to accomplish over the next year?
What are your hopes for the future?
You have your whole life in front of you; what do you want to do with the time?
Keep in mind that patients with negative symptoms might have little to say to these questions.
A helpful model to put together various risk factors, including biology, life circumstances, life experience, and psychological reactions, is Mann’s stress-diathesis model of suicide [16]. In this model, no one single factor leads to a suicide. Instead, it is the confluence of factors, some biological, some characterological, and some external that determine a person’s proneness to suicide. In this scheme, an adolescent patient with schizophrenia, for example, might become acutely distressed with hallucinations (a state-dependent stressor) and attempt suicide because of a biological predisposition toward impulsive action (neurocognitive impairment associated with schizophrenia) but also because of a lack of resilience (problem-based coping ability that he never acquired as he became sick at a young age); the latter two factors represent trait-dependent susceptibilities. Treatment can target each of those risk factors to reduce suicide risk.
Assessment of Suicidality
First, language matters, and I recommend using the CDC definition for self-injurious behaviors like a suicide attempt. The CDC defines a suicide attempt as “a non-fatal, self-directed, potentially injurious behavior with an intent to die as a result of the behavior; might not result in injury” [17]. This definition clearly links ideation (the wish to be dead) with the act. It avoids the inflationary extension of the term suicide attempt to include risk-taking activities that could result in death (excessive speeding, substance use, smoking). I would not use terms like “passive suicidality” and similarly imprecise constructs (suicide gesture, parasuicide).
Suicide assessment: the ABCs of suicide
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