Depression and Suicide

Essential Concepts

Schizophrenia is a disease with at least 5% mortality: you can die from it young, not merely with it 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; and psychosis itself.
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 ramifications 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 when patients become demoralized when their symptoms do not improve. The treatment of demoralization is giving hope. This requires your time and commitment.

“There is but one truly serious 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

“The most serious of schizophrenic symptoms is the suicidal drive.”

—Eugen Bleuler, 1911

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.

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.

Most modern studies suggest that around 5% of patients diagnosed with schizophrenia die from suicide (Palmer et al., 2005). 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 prevalent 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. Accordingly, most suicides occur in the first several years following diagnosis. However, suicide can occur at any time point. In longstanding schizophrenia, another risk factor for suicide is 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, depression, and psychosis.

The first risk factor you should evaluate is substance use because of its effect on impulse control and mood.

The next risk factor you should consider is depression, which occurs often in the course of schizophrenia (Hafner et al., 2005). Depressive symptoms are very common in early-course schizophrenia. Further, a period of depression can coincide with or follow the resolution of positive symptoms, when patients are getting better. Such depressive symptoms and syndromes in the setting of improving or residual schizophrenia are sometimes called “post-psychotic depression,” an admittedly
poorly defined entity without clear time boundaries, severity definitions, or neurobiologic understanding. 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), leading to suicide attempts. Though you might think that 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. 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.

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 (Crumlish et al., 2005). 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.

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