Schizophrenia Research 75 (2005) 77 – 81 www.elsevier.com/locate/schres
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Suicidal behavior in schizophrenia and depression: a comparison Enrique Baca-Garciaa,b, M. Mercedes Perez-Rodriguezb, Carmen Diaz Sastreb, Jeronimo Saiz-Ruizb, Jose de Leonc,* a Department of Psychiatry, Ramo´n y Cajal Hospital and University of Alcala, Madrid, Spain Department of Psychiatry, Fundacio´n Jime´nez Dı´az Hospital, Universidad Auto´noma, Madrid, Spain c Mental Health Research Center at Eastern State Hospital, Lexington, KY, USA
b
Received 3 March 2004; received in revised form 26 August 2004; accepted 31 August 2004 Available online 30 October 2004
Abstract The aim of this study was to compare the frequencies and suicide attempt characteristics in patients with schizophrenia (N=25) and major depression in absence of schizophrenia (N=107). There were no significant differences in attempt methods, but attempters with schizophrenia reported a lower number of life events influencing the attempt (2.0 vs. 2.6), less influence of life events on the attempt (42% vs. 83%) and lower GAF scores (36 vs. 50). Schizophrenia was not associated with higher impulsivity scores but with significantly more lethal attempts (40% vs. 29%) and with a trend toward ( p=0.08) higher scores in aggressive behavior history. D 2004 Elsevier B.V. All rights reserved. Keywords: Schizophrenia; Suicide; Suicide attempts; Depression; Risk factors
1. Introduction It has been estimated that up to 20–50% of patients with schizophrenia will attempt suicide, a rate comparable to patients with mood disorders, and over 20 times higher than that in the general population (Radomsky et al., 1999; Roy et al., 1984). Patients with schizophrenia represent 25–30% of all psychi* Corresponding author. Mental Health Research Center at Eastern State Hospital, 627 West Fourth St., Lexington, KY 40508, USA. Tel.: +1 859 246 7487; fax: +1 859 246 7019. E-mail address:
[email protected] (J. de Leon). 0920-9964/$ - see front matter D 2004 Elsevier B.V. All rights reserved. doi:10.1016/j.schres.2004.08.028
atric patients who commit suicide, and have an 8–15% risk of dying of a suicide-related cause (Osby et al., 2000; Heila et al., 1997). Patients with major depression also have a significantly higher risk of attempting suicide than the general population, with a lifetime risk of around 15% (Angst et al., 1999; Guze and Robbins, 1970). However, an increasing number of authors claim that these published risk estimations of attempting or completing suicide are far too high in major depression and schizophrenia (Blair-West et al., 1998; Inskip et al., 1998; Bostwick and Pankratz, 2000).
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Patients with schizophrenia share several suicide risk factors with the general population including male gender, Caucasian race, lack of social support, poor psychosocial functioning, depression, prior history of suicidal behavior, impairment following a good pre-morbid adjustment and significant losses. Other risk factors appearing more specific for schizophrenia including illness chronicity, multiple acute psychotic exacerbations and remissions, a high level of positive symptoms (particularly, suspiciousness and delusions), awareness of the illness disabling effects and fear of further disability, and loss of confidence or negative attitude towards treatment (Harkavy-Friedman et al., 2001; Kreyenbuhl et al., 2002). Despair and/or a higher level of insight have also been related to suicidal behavior (Amador et al., 1996), but no correlation has been found between insight and despair measures. Surprisingly, little research has compared suicidal behavior in patients with schizophrenia and major depression. The aim of this study was to compare suicide attempt characteristics in patients with schizophrenia and major depression in absence of schizophrenia.
2. Methods The Hospital Ramon y Cajal triages all emergencies in a catchment area of 500,000 persons in Madrid (Spain). During 1999, using the US National Institute of Health’s recommended definition (O’Carroll et al., 1996), there were 258 consecutive suicide attempters (Baca-Garcia et al., 2002) of which 93% (240/258) signed a consent form and were assessed within the first 24 h post-attempt. The Mini International Neuropsychiatric Interview version 4.4 (Sheehan et al., 1998), a brief structured interview, provided the DSM-IV diagnosis of major depression in absence of schizophrenia (107 attempters) and schizophrenia (25 attempters). In the 25 attempters with schizophrenia, 48% (12/25) also met criteria for major depression and 52% (13/25) did not. The remaining 108 patients from the 240 attempters had heterogeneous diagnoses. The Lethality Rating Scale rated the medical consequences of different suicide methods (Beck et al., 1974). Attempt methods were classified as violent
and non-violent (Arora and Meltzer, 1989). Beck’s Suicidal Intent Scale (SIS) measured the attempt characteristics (Beck et al., 1974). The SIS factor analysis provided two factors, bexpected lethalityQ and bplanningQ (Diaz et al., 2003). Personality impulsivity traits were measured by the total score of the Barratt Impulsiveness Scale (BIS) (Oquendo et al., 2001), which has three subscales: cognitive, motor and nonplanning impulsiveness. The Brown–Goodwin (Brown et al., 1979) measured the history of aggressive behaviors. The validated Spanish version of the Holmes–Rahe scale assessed the patients’ life events (Holmes and Rahe, 1967; Gonza´lez de Rivera and Morera, 1983). This scale included 43 items, each scored from 0 to 100 units of life change and provides two global scores: (1) the life events index (LEI) or total number of items (life events) for each patient and (2) the life change index (LCI) that results of the addition of all units of life change from all items. Two additional extension studies were carried out. The 3-year mortality after the emergency room visit was obtained from a death registry. To try to estimate the prevalence of suicidal behavior among all patients seen at the emergency room with schizophrenia and depression in absence of schizophrenia, a pilot study was carried out in the same hospital over a 3-month period (September–December 2000) on 298 patients. The Statistical Package for Social Sciences (SPSS) was used for statistical analyses. All categorical variables were dichotomized to increase the statistical power. Cross tabulations were used to calculate Fisher’s exact tests, odds ratios (OR) and 95% confidence intervals (CI). This sample had a 95% power to establish medium effect sizes (difference of proportions greater than 25%) and 62% power to establish small effects (difference of proportion greater than 15%) using dichotomous variables. Ttests were used for continuous variables.
3. Results Attempters with schizophrenia had lower GAF scores and were less likely to have children or higher education levels than attempters with depression in absence of schizophrenia (Table 1). There were no significant differences in means of Barrat Impulsivity Scale total scores but Motor Impulsivity Subscale
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Table 1 Clinical characteristics in attempters with schizophrenia and major depression Variable Age Holmes and Rahe Life Event Index Holmes and Rahe Life Change Index SIS Total Expected lethality subscale Planning subscale Barratt impulsivity scale Motor subscale Global assessment of functioning (GAF) Brown–Goodwin agressivity scale
Gender: Female Male Marital status: Other Married Education level: No or primary Secondary or higher Income perceived: None Salary or disability Children: No Yes Beck’s Lethality score: Low (V2) High (N2) Method: Overdose by sedative drugs Other Violent method: No Yesa Certainty of the lethality of the attempt: bDeath is impossibleQ bDeath is possibleQ Previous suicide attempts: No Yes Suicide attempts during prior year: No Yes Completed suicide family history: No Yes Suicide attempt family history: No Yes Current delusions: No Yes Commanding hallucinations: No Yes Only alcohol use: No Yes Alcohol and other drug use: No Yes Other drugs use and no alcohol: No Yes Attempt related to life events: No Yes a
Schizophrenia
Major depression
Mean (S.D.)
Mean (S.D.)
37.9 (15.5) 2.0 (1.5) 79.8 (66.1) 19.7 (19.6) 15.3 (20.2) 4.5 (2.6) 54.9 (20.9) 16.4 (8.9) 36 (19) 12.6 (5.6)
36.9 (13.7) 2.6 (1.3) 105.7 (60.5) 19.2 (21.5) 13.5 (18.8) 5.6 (10.4) 59.2 (16.3) 21.0 (7.2) 50 (12) 14.6 (4.8)
Percentage
Percentage
64% 36% 76% 24% 60% 40% 40% 60% 76% 24% 60% 40% 92% 8% 80% 20%
65% 35% 61% 39% 36% 64% 44% 56% 48% 52% 81% 29% 93% 7% 85% 15%
39% 61% 39% 61% 46% 54% 88% 12% 83% 17% 87% 13% 87% 13% 88% 12% 92% 8% 84% 16% 58% 42%
62% 38% 49% 51% 67% 33% 93% 7% 77% 23% 99% 1% 100% 0% 76% 24% 80% 20% 68% 32% 17% 83%
Some patients used a violent method and took a sedative drug overdose.
Mean difference 1.0 0.6 25.9 0.5 1.8 1.1 4.3 4.6 14 1.9 % difference
95% CI
P
5.2 to 7.3 1.2 to 0.1 53 to –1.2 9.2 to 10.2 6.8 to10,5 5.3 to 3.2 3.3 to 11.9 1.2 to 7.9 20 to 8 4.1 to 0.3 95% CI
0.75 0.03 0.06 0.92 0.68 0.61 0.3 0.008 b0.01 0.08 P
1
22 to 20
0.99
15
4 to 34
0.17
24
45 to
4
25 to 17
28
47 to
21
0 to 44
3
0.02 0.82
9
0.009 0.03
1
13 to 6
0.55
5
7 to 22
0.58
23 10
2 to 44
0.04
11 to 31
0.49
21
11 to 42
0.06
5
9 to 19
0.40
6
11 to 23
0.60
12
1 to 25
0.02
13
0 to 25
0.006
12
27 to 3
0.28
12
25 to 1
0.24
16
33 to 1
0.16
41
62 to
20
b0.001
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score were significantly lower in schizophrenic attempters. The Brown–Goodwin aggressivity scale score was almost ( p=0.08) significantly higher in schizophrenic attempters. There were no significant differences in attempt methods and characteristics, but attempters with schizophrenia reported less life events influencing the suicide attempt (Table 1). Regarding prior history, schizophrenics were more likely to have attempted suicide in the year prior to the study. Three patients with major depression (2.8%; CI 1– 8%) died because of suicide within the 3-year followup period. One patient with schizophrenia (4%; CI 1– 20%) died due to medical illnesses. The prevalence of suicide attempts in schizophrenic patients seen at the emergency room in the 3-month extension study was low (4%, 2/51; CI 1– 13%) and significantly lower (v 2=7.5, df=2, p=0.02) than in patients with major depression in absence of schizophrenia (18%, 35/138; CI 11–28%).
4. Discussion The demographic variable differences are compatible with the greater impairment associated with schizophrenia (Heila et al., 1997). Kreyenbuhl et al. (2002) argue that some people with schizophrenia try to commit suicide, but lack the opportunity to follow through with the attempt. Others propose that suicide is impulsive in schizophrenia (Johns et al., 1986). Our study did not verify that, despite using two impulsivity measures: attempt and attempter impulsivity. The SIS planning factor measures the opposite of attempt impulsivity (impulsive attempts have very low planning scores), finding no differences between patients with schizophrenia and those with depression. The BIS measures impulsivity personality traits. If anything, schizophrenic patients had less (not more) impulsive traits in the BIS motor subscale. To our knowledge, no prior studies compare aggressive behavior scores between patients with schizophrenia and major depression, but our relatively small sample suggested that attempters with schizophrenia tend to have more aggressive behaviors than attempters with depression. To date, eight retrospective studies reported on life events and completed or attempted suicide in schizophrenia (Heila et al., 1999) and reported 12–64% of subjects who had experienced life events before the
suicidal act. As in our study, some of these prior studies reported fewer life events in patients with schizophrenia compared to those without schizophrenia (Breier and Astrachan, 1984; Heila et al., 1999). Our knowledge of the influence of life events on suicide in schizophrenia is limited because life event scales were not developed to be used in schizophrenia and lack life events important for schizophrenia (such as treatment changes). Moreover, the tendency of patients with schizophrenia to report less life events may have contributed to our findings of less life events in attempters with schizophrenia vs. those with major depression in absence of schizophrenia. Similar to Kreyenbuhl et al. (2002) and Heila et al. (1997), we found no significant differences in attempt methods. This is in disagreement with the belief that attempters with schizophrenia use more violent methods of suicide. However, attempts by patients with schizophrenia appeared to be associated with higher lethality (Table 1). This has been previously reported and interpreted as a lack of ambivalence about the decision to complete the act (Breier and Astrachan, 1984; Harkavy-Friedman et al., 1999). As a matter of fact, in our study, patients with schizophrenia were more likely to think that death was possible, probable or certain (Table 1). Not surprisingly, active psychotic symptoms were more frequent in patients with schizophrenia (Table 1). Three patients with schizophrenia (12.5%) attempted suicide in the context of command hallucinations. These rates are within published ranges of 4% (Wilkinson and Bacon, 1984) to 22.7% (Altamura et al., 2003). Our study’s strengths include consecutive patient recruitment during 1 year and the relative lack of sample selection biases. The most important limitation was the small sample size leading to a possible lack of detection of small size effects. The schizophrenic sample was too small to allow us to divide it by the presence of major depression. The study’s main clinical implication is that suicide attempts in schizophrenics and depressed patients may have similar characteristics. The principal differences may be that the attempt lethality may be higher in patients with schizophrenia, while attempts may be more frequently associated with life stressors in depressive patients. Prospective studies with larger samples are needed to verify these findings and assess
E. Baca-Garcia et al. / Schizophrenia Research 75 (2005) 77–81
the possible differences in suicide mortality rate between schizophrenic and depressive patients.
Acknowledgements The study was supported by a 1999 and 2001 National Alliance for Research on Schizophrenia and Depression (NARSAD) Young Investigator Awards and Young Investigator Awards to Enrique BacaGarcia M.D. Margaret T. Susce, R.N. M.L.T. helped with editing of this article.
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