Suicide in schizophrenic patients .pptx

Ppt on schizophrenia and suicide

1. SCHIZOPHRENIA AND SUICIDE PRESENTED BY- JABEEN AKHTAR KHAN 1 ST YEAR M.PHIL. TRAINEE DEPT. OF CLINICAL PSYCHOLOGY MHI (CoE) SCB MCH 2 ND SEPT. 2024

2. CONTENT INTRODUCTION CAUSES AND RISK FACTORS SCREENING AND ASSESSMENT TREATMENT PREVENTION PROTECTIVE FACTORS 1 2 3 4 5 6 7 NEURO-BIOLOGICAL FACTORS

3. INTRODUCTION 01

4. Schizophrenia is often chronic and difficult to treat . It is usually associated with intense psychological dependence, profound vulnerability, and a threat of disintegration In 1911, Bleuler recognized “ the suicidal drive ” as the “most serious of all schizophrenic symptoms”. According to him, death resulted from the indirect consequences of psychosis i.e., refusal of food, intentional or unintentional injuries, suicide, tuberculosis and other diseases resulting from an unhygienic way of life. Back in 1942, Lipschutz warned that every schizophrenic patient is a potential suicide victim , and he discussed the importance of the physical setting in prevention. The long-term suicide risk in subjects without mental disorders is 0.3% , whereas the risk measured among mentally ill patients ranges from 3.4% for people affected by one mental disorder to 6.2% for people reporting more than one psychiatric disorder : each additional psychiatric diagnosis seems to contribute significantly to increase risk of suicide

5. Considerable evidence suggests that schizophrenia decreases the longevity by about 10 years [White, J.; Gray, R.; Jones, M., 2009]. Suicide is the largest contributor to the decreased life expectancy in individuals with schizophrenia. Suicide is also the most frequent cause of premature death in patients with schizophrenia ( Allebeck 1989; Caldwell and Gottesman 1990). Schizophrenia is associated with a risk of suicide higher than that found in the general population (Caldwell and Gottesman 1990; Fawcett et al. 1991; Siris 1991) Harris and Barraclough included 28 studies in their meta-analysis and found that the risk of suicide among patients diagnosed with schizophrenia exceeded than that in the general population more than eight fold. Suicidal behavior in schizophrenia is an underestimated event , with 25–50% of these patients attempting suicide in their lifetime. ( Shrivastava A, et.al., 2010)

6. Suicide may occur at any time during the clinical course of schizophrenia, although several studies have suggested that the highest suicide risk occurs during the first 10 years of illness . ( Steblaj A, et.al., 1999) Compared to general population, suicidal intent is generally strong among individual with schizophrenia, and the majority of those who attempt suicide have made multiple attempts. In addition, the methods used to attempt suicide are considered more lethal than those used by suicidal persons in the general population Kelly et al.(2004) found that 73% of the individuals of their sample committed suicide by violent methods such as jumping from height, drowning, cutting, gunshot wounds or hanging. Thorup et al. (2007) investigated gender differences in age at first onset, duration of untreated psychosis, psychopathology, social functioning and self-esteem in a group of 578 young adults with a first-episode schizophrenia spectrum disorder. They found that the women made more suicide attempts and experienced lower self-esteem in spite of better social functioning

7. CAUSES AND RISK FACTORS 02

8. Risk factors for suicide in schizophrenia are similar to those in the general population. There are, however, other risk factors that are specific to the disorder (Siris, 2001). In majority of the cases, the mental health professionals involved in treatment had not believed that there was a risk of suicide during their last contact with the patient (Saarinen P.I. et.al., 1999) The professionals who had treated the suicide victims had not assessed the schizophrenia to be as severe as it proved to be in retrospect. They knew that their patients had schizophrenia, but the fact that the illness weakens functional capacity and depresses and disrupts personality was not seen to be related to the risk of suicide. Potential self-destructiveness had not been assessed (Saarinen P.I. et.al., 1999) Patients who commit suicide are generally unmarried, have good pre-morbid function, have post-psychotic depression, and have a history of suicide attempts and substance abuse . This latter behavior complicates the management of the patient at risk of suicide.(Hunt IM, et.al., 2006) When health deteriorates in individuals with good pre-morbid functioning, suicide can result from the awareness that performances previously achieved cannot be maintained.

9. Hawton et al. (2005) provided a systematic review of risk factors for schizophrenia and suicide. They identified seven robust risk factors including previous depressive disorder, previous suicide attempts, drug misuse, agitation or motor restlessness, fear of mental disintegration, poor treatment adherence and recent loss. Fenton et al. and Fenton (2000) described the high-risk patient as a white, young male, with a history of good adolescent functioning and high aspirations, late age at first hospitalization, higher intelligence, with a paranoid or non-deficit form of schizophrenia, who retains the capacity for abstract thinking and who may be painfully aware of the impact of a deteriorating illness on his aspirations and life trajectory Suicide was less associated with the core symptoms of psychosis and more with affective symptoms, agitation and an awareness that the illness was affecting mental function.( Pompili et.al.,2008)

10. DEPRESSION Depression related to schizophrenia often remained unrecognized . Retrospective assessment indicated that 59 percent of the patients were clinically depressed at the time of suicide (Saarinen P.I. et.al., 1999) Depression and especially hopelessness are probably the most important factors predisposing patients with chronic schizophrenia to suicide (Roy 1985; Drake and Cotton 1986; Maltsberger 1986; Westermeyer and Harrow 1989; Jones et al. 1994; Azorin 1995). Patients' withdrawal from human relationships because of depression was related to loss of the treatment professionals' concern for the patients. Karvonen et al .(2007) noticed that male patients with schizophrenia and concomitant depression often committed suicide immediately after discharge Psychological symptoms of depression, rather than biological symptoms of depression, differentiated the suicide completers from the suicide attempters

11. Gupta and colleagues(1998) reported that, in their sample of patients with schizophrenia, suicide attempts were associated with the number of lifetime depressive episodes . Depression has been recognized as a major risk factor among persons with schizophrenia who have attempted suicide Difficulty in recognizing both depression and risk of suicide in patients with schizophrenia is further complicated by the fact that depressive withdrawal from personal relationships may be misinterpreted as a negative symptom of the primary illness (Siris 1991; Taiminen 1994). A lack of concern was especially associated with secondary depression. The professional's loss of concern about a schizophrenia patient's psychic situation may be interpreted by the patient as indifference and in turn increases the risk of suicide.

12. INSIGHT Some investigators have suggested that in the remission stage of schizophrenia, patients' insight into the chronic nature of their illness and into the limitations the illness imposes on quality of life induces depression and increases risk of suicide ( Farberow et al. 1965; Drake et al. 1984; Cotton et al. 1985) It was found that insight at baseline increases the risk for suicide while a good level of insight at 1-year follow-up (due to psycho-educational interventions) decreases the same risk. This may indicate that early insight is quantitatively different from insight after 1 year of treatment. ( Lysaker PH, et.al., 2013) Patients who subsequently completed suicide also expressed higher performance expectations, consistent with their awareness of the illness and accurate perceptions of their functional status.

13. PSYCHOTIC SYMPTOMS One study has shown that paranoid ideas in psychotic patients are a specific risk factor for suicide ( Axelsson and Lagerkvist-Briggs 1992) Meissner (1978) has described the relationship between paranoid states and depression, emphasizing that those who have paranoid ideas often have self-destructive ideas as well. According to Meissner (1978), the more unrealistic the delusional thoughts, the greater the self-destructive aggression in the background. A number of studies have found that the active and exacerbated phase of the illness and the presence of psychotic symptoms [ Heila 1997,Hu WH 1991, Westermeyer JF 1991 & De Hert M, 2001], as well as paranoid delusions and thought disorder [ Krupinski M, 2000], are associated with a high risk of suicide Kelly, et al, 2004 reported that a large proportion of their schizophrenic patients who committed suicide had poor control of thoughts or thought insertion, loose associations and flight of ideas as compared to those who died by other means of death.

14. Patients may commit suicide under the influence of persecutory delusions or hallucinatory demands (Carter et al. 1996). Self-destructiveness could be explained by identification with the aggressor. Suicidal attacks would then represent freedom from fear by unconscious identification with a dreaded enemy ( Kernberg 1984).

15. AGE OF ONSET The situation in life of young people with first episode schizophrenia is often much more unstable since they are not used to the disorder and since, as adolescents, they are also facing the typical problems and conflicts of young people beginning a new phase in life Krausz et al .(1995) investigated suicide in patients showing symptoms of schizophrenic disorders between 14 and 18 years of age during a follow-up of between 5 and 11 years [ Westermeyer JF, et.al., 1991]. The suicide rate of 13.1% was significantly higher than in studies of patients who developed a schizophrenic psychosis later in life.

16. DRUGS AND TREATMENT ADHERANCE The effect of poor compliance with antipsychotics on suicide rates among patients with schizophrenia was noted by an early review [Drake RE,et.al ., 2006], as well as by meta-analysis that concluded that poor compliance with antipsychotics more than triples the suicide risk in these patients The sensitivity of patients with schizophrenia to changes in treatment has been linked to increased risk of suicide ( Farberow et al. 1965). A study found that poisoning with organo-phosphate compounds and medications is a common form of deliberate self-harm in the developing world ( Banwari GH, Vankar GK, Parikh MN , 2013) In contrast to other suicide victims, the patients with schizophrenia used drug overdose as the most common suicide method . This characteristic of the schizophrenia sample might be explained by the finding that schizophrenic patients were in psychiatric care and therefore had relatively easy access to drugs.

17. FIRST EPISODE OF PSYCHOSIS Nordentoft et al. (2002) found that suicidal behavior and suicidal ideation occur very frequently among patients with first-episode schizophrenic psychoses. Even if suicidal ideation may be present in different stages of disease, some differences have been described between the risk of suicide in patients experiencing first episode of psychosis and those with long-term schizophrenia. It is particularly higher during the first year of illness and reaches a steady decline over the following years The suicide risk is twofold higher at the onset of psychotic illness than in the later course ( Nordentoft M, 2015)

18. The first episode of psychosis (FEP) can be divided in four phases: prodromic phase or emerging psychosis, untreated psychosis (UP) (the duration of untreated psychosis is labeled as DUP), acute psychosis and its treatment, and post-psychotic recovery. Each phase is characterized by different risk of suicide

19. In the Indian population, there is limited literature on suicide attempts in patients with schizophrenia in a large sample. A study looked into suicide attempts in schizophrenia spectrum disorders and affective disorders. They found the following factors as significant: age < 30 years, female sex, being married, urban background, past suicide attempts, presence of psychotic symptoms, stressors, and perceived stress due to mental illnesses . This study also emphasized the increased suicidal risk in patients with auditory hallucinations, specifically command hallucinations (Singh H, Chandra PS, Reddi VSK, 2016) Compared with Western countries, under-reporting suicide related behaviors is more common in India due to fear of stigmatization. Furthermore, there is also fear of legal punishment, as suicide attempt was a punishable offense under the Indian Penal Code (Sect. 309) until 2018 ( Radhakrishnan R, Andrade C., 2012)

20. NEUROBIOLOGICAL PERSPECTIVE 03

21. Low concentrations of the serotonin metabolite 5-hydroxyindoleacetic acid (5-HIAA) in cerebrospinal fluid (CSF) are associated with suicidal behavior in patients with depressive illness and schizophrenia. In a prospective study, Cooper et al. [1992] measured 5-HIAA in the CSF taken from 30 schizophrenic patients in a drug-free state and followed these patients for 11 years. Ten patients made suicide attempts during the follow-up period. Suicide attempters have been reported as having significantly lower concentrations of CSF 5-HIAA at initial evaluation than non-attempters. These findings provide further evidence of the relation between serotonergic dysfunction and suicide and suggest a role for drugs with serotonergic effects in schizophrenia. Total rapid eye movement sleep seems to be altered in suicidal schizophrenic patients but there are contradictory findings on the nature of such sleep changes and their association with increased risk of suicide ( Pompili , 2007) Keshavan et al. [1994] found that those schizophrenic patients who exhibited suicidal behavior had increased overall REM activity and REM time.

22. These authors suggested that, since serotonergic functions act to suppress REM sleep, reduced serotonergic function in schizophrenia could explain the association between suicidal behavior and REM time/activity observed by other authors It has been demonstrated that a blunted prolactin secretion in response to D-fenfluramine (D-FEN) is associated with suicidal behavior in schizophrenic patients ( Correa H, et.al., 2002) Plocka-Lewandowska et al. [2001] found an association between results of the DST and suicide attempts in schizophrenic patients, suggesting a possible association between a hyperactive hypothalamo -pituitary-adrenal (HPA) axis and suicidal behavior in schizophrenic patients. Jones et al. [1994] found that non-suppression in the DST was associated with suicidal behavior in a sample of schizophrenic patients, and non-suppression of the DST differentiated suicide attempters from non-attempters.

23. PREVENTION 04

24. It has been suggested that in terms of suicide prevention in patients with schizophrenia, many types of treatment events or characteristics (e.g., change of mental health professional, transfer from one ward to another, rehabilitation, transfer to another hospital, temporary treatment discontinuance, and time of discharge) are significant and need careful evaluation in each case ( Niskanen et al. 1974; Farberow et al. 1976; Crammer 1984; Drake etal . 1989). In all cases, the situation immediately preceding suicide is critical to suicide prevention ( Farberow and Shneidman 1965; Lonnqvist 1977; Tahka ' 1993; Saarinen 1995) In preventing suicide among patients with schizophrenia, professionals must understand the intensity of the patients' dependence on treatment and their extreme sensitivity to any alterations in it (Cohen et al. 1964; Farberow et al. 1965; Niskanen et al. 1974; Farberow et al. 1976; Virkkunen 1976; Crammer 1984; Drake et al. 1984, 1989; Cotton et al. 1985; Volkan 1995). Needs for intensive therapeutic relationships were evident in connection with the patients' responses to alterations in treatment relationships or systems. Suicide prevention and the identification of specific risk factors for suicide in first-episode psychosis are of paramount importance and point to early intervention among young schizophrenia patients

25. While patients from communities that did not have an early psychosis detection program showed rates of suicidal behavior in the expected range, the early detection group had significantly lower rates . The study thus indicates that an early detection program, by lowering the threshold for first treatment contact and bringing patients into treatment earlier, can reduce rates of serious suicidal behavior at the point of first contact ( Harkavy -Friedman JM, 2006) Great caution is required in the period after hospital discharge because schizophrenic patients usually experience hopelessness and demoralization at that time . For these patients, discharge often means losing the hospital environment and the people who have become central in their life. The number of psychiatric admissions, which is usually higher among patients who have attempted suicide, may be indicative of a severe relapsing illness. Proper education on how to treat empathically and recognize suicide risk must be delivered to Psychiatrist and Mental Health Professionals (MHP) . (Saarinen PI, 1999) Dealing with suicidal patients may lead nurses and MHP to feel overwhelmed and detach themselves in an attempt to deal with the stress. Staff must be informed and supported to cope with job stress

26. Nurses and paramedics may become a proxy family, especially for inpatients with schizophrenia. They should treat the patient accordingly in order to avoid frustration and, in turn, increased suicide risk (Pompili,2005) Suicidal ideation, obviously, is a predictor of suicide and the basis of suicide prevention in schizophrenia . As most patients overdosed on their own medication as it was easily accessible to them, it would be important for the caregivers to supervise medication intake , especially in patients in their early stages of illness and during their symptomatic phases. Family members are often stigmatized by having connections with a schizophrenic individual. Their social interaction may be dramatically reduced and frustration may be overwhelming. They may, therefore, show hostility toward the sick member and hinder a possible positive outcome. Specific programs for families should be delivered (Phelan, 1998) Members of the community can play an important role in whether they support or fight stigmatization . Accepting these patients is crucial for improving the patients’ adherence to treatment, to promote positive outcome and to reduce suicide risk (Corrigan, 2004)

27. When people are educated about psychosis, they are more likely to seek treatment when symptoms occur. This finding underscores the potential utility of psycho-educational approaches leading to decreased morbidity and mortality. Corrigan (2004) provided a comprehensive analysis on how stigma interferes with mental healthcare . He stressed that, despite the plethora of evidence-based interventions, many people with mental illness never pursue treatment and others begin treatment but fail to fully adhere to the prescribed services. Stigma is one of the reasons for this. Mentally ill people may be subjected to stigma derived from stereotypes, prejudice and discrimination.

28. SCREENING AND ASSESSMENT 05

29. A number of instruments have been developed to estimate suicide risk in schizophrenia. Taiminen et al. (2001) proposed the research-based 25-item Schizophrenia Suicide Risk Scale (SSRS), although the authors noted that the scale was too insensitive or too nonspecific for general use as screening device Turner et al. (1998)proposed a semi-structured Interview for Suicide in Schizophrenia (ISIS) based on chart review, staff reports and information from families. The 140-item third revision of the ISIS was tested on 270 schizophrenia patients [ Korslund KE , 2001], yielding satisfactory sensitivity and specificity. Hansen and Kingdon (2004) investigated 40 patients (39 with a diagnosis of schizophrenia, one with a diagnosis of schizoaffective disorder according to the International Classification of Diseases [ICD]-10). Patients were tested using the Health of the Nation Outcome Scale ( HoNOS ), the Comprehensive Psychopathological Rating Scale (CPRS) and a validated suicidality rating scale – the International Suicide Prevention Trial ( InterSePT ) Scale for Suicidal Thinking (ISST), a new instrument for the assessment of current suicidal ideation in patients with schizophrenia [80]. These authors demonstrated a highly robust association between the two suicidality items from the CPRS, HoNOS and the InterSePT scale.

30. The ISST was derived from the Scale for Suicide Ideation, a 19-item scale, which has been validated and has proven reliable in a depressed population , but not in patients with schizophrenia. The present version is a 12-item scale, which is rated on three levels of increasing intensity (0, 1 or 2). The total score is computed by adding the 12 individual item scores. It quantifies current conscious and overtly expressed suicidal thinking in schizophrenic patients by assessing various suicidal thoughts and wishes during a 20–30-min semi-structured interview Routine use of HAM-D scale to assess depressive symptoms in schizophrenia may be useful in early diagnosis of depression and reduction of suicide risk in patients with schizophrenia

31. TREATMENT 06

32. A comprehensive review by Nasrallah and Newcomer [2004] noted that, since the 1950s, pharmacotherapy for schizophrenia involved administration of dopaminergic receptor antagonists with antipsychotic activity , for example, conventional antipsychotics such as haloperidol or chlorpromazine [ Nagamoto HT , 2001]. During the last decade, however, atypical antipsychotics with unique pharmacologic profiles involving modulation of not only dopamine but other neurotransmitters, including serotonin (5-hydroxytryptamine; 5-HT), have become available. With the significant and possibly broader spectrum of clinical efficacy seen with atypical antipsychotics, coupled with a lower risk of extra pyramidal symptoms (EPS), these agents have rapidly gained acceptance and have become the standard of care for patients with schizophrenia or a schizoaffective disorder Usage of Clozapine in treatment-resistant patients to reduce the risk of suicide in schizophrenia.   Usage of depot antipsychotics may also help in improving compliance to treatment and reduction of risk of suicide.

33. PHARMACOLOGICAL TREATMENT ANTI- PSYCHOTICS LITHIUM MOOD STABILIZER ANTI- DEPRESSANTS ANXIOLYTICS

34. NON-PHARMACOLOGICAL TREATMENTS Electroconvulsive therapy (ECT) has been recognized as one of the most successful interventions for mood disorders, particularly depression with psychotic features. ECT as monotherapy or as an adjunct to antipsychotic medication is not more effective in schizophrenic patients than antipsychotic medication alone Combining drug treatment with psychosocial–psychotherapeutic interventions may be very important for a better outcome. The daily difficulties faced by schizophrenic patients can be addressed with specific programs, and having a psychotherapist as a key figure may give these patients the possibility of overcoming difficult periods as well as coping better with their conflicts Clinicians should acknowledge the patient’s despair, discuss losses and daily difficulties, and help to establish new and accessible goals.

35. Individuals with good pre-morbid functioning are at greater risk of suicide. Interventions such as social skills training, vocational rehabilitation and supportive employment are, therefore, probably very important in the prevention of suicide in schizophrenic patients. Hogarry et al.(1995,1997) proposed Personal Therapy , which includes three levels of treatment with defined criteria for progression from basic to more challenging. Treatment spans from early months after discharge, which aims at clinical stabilization and therapeutic joining, to a later phase, which promotes introspection and an understanding of the relationship between stressors and maladaptive response. An intermediate phase promotes skills remediation, relaxation training, role playing and psycho-education. Supportive, reality-orientated therapies are generally of great value in the treatment of patients with schizophrenia Supportive psychotherapy aims at offering the patient the opportunity to meet with the therapist and discuss the difficulties encountered in daily activities. Patients are encouraged to discuss concerns about medications and side effects, as well as issues such as social isolation, money and stigma. The therapist plays an active role, giving suggestions and sharing good and bad periods empathically

36. Psychosocial interventions including cognitive-behavioral therapy, cognitive remediation, supportive therapy, supported education, training, and employment are important for successful management of schizophrenia. Family interventions may reduce the risk of suicidal behavior, and therefore, should be a necessary component of a treatment plan of each patient with schizophrenia [98,99]. Such interventions considerably lessen rates of readmission and relapse in individuals with psychotic disorders and enhance their social and vocational performance [98,99]. Family interventions usually increase adherence to pharmacological therapy (McFarlane, 2003 & Onwumere , J., 2011)

37. PROTECTIVE FACTORS 07

38. Adherence to therapy Family support for the illness and against the stigma that arises from it Suitable antidepressant therapy Possibility of talking about the intention to commit suicide Family history negative for suicide Simple and hebephrenic subtypes of schizophrenia Psychological well-being – specific treatments for hopelessness and psychological pain Training in the development of social and cognitive skills Not being stigmatized

39. CASE VIGNETTE A single man of about 40 years of age cut his carotid artery at home. He had suffered from chronic schizophrenia, dominated by paranoid symptoms, for 20 years. During his illness, the suicide victim had spent a total of 12 years in mental hospitals; individual hospitalizations had varied in duration. While he was hospitalized, his bizarre delusions of altered body states and his experiences of being controlled by external, often invisible, agents rapidly disappeared. The patient had had death wishes and suicidal thoughts since the onset of his schizophrenia. Death wishes also stopped soon after hospitalization. Over the years, opinion about the patient changed and his condition began to be regarded as hopeless. He was difficult to treat; he accused personnel, was unreliable, acted pretentiously, and reacted by acting out. Four years before committing suicide, the patient had to be transferred to another mental hospital. Two years before his death, he was transferred to a halfway house belonging to the hospital, because the staff feared that his dependence on the hospital might become excessive. After his transfer to outpatient care, his suicidal tendencies increased. Six months before committing suicide, the patient lost his long-term nurse. Subsequent treatment consisted of occasional office visits with a psychologist or psychiatrist. Just before committing suicide, the patient tried to enter the hospital where he had been during the initial phases of his illness. He had suffered increasingly for a few months from paranoid fears of being murdered. He threatened to commit suicide unless he was admitted to the hospital, but the threat was considered demonstrative and hospitalization was brief. The day before he committed suicide, the patient visited his childhood home and became afraid that a group of men had surrounded the house. He repeated his wish to enter a mental hospital. During his final night, the patient's state changed. According to his father, the patient was exceptionally calm on the day of his death. The father said, "He no longer seemed afraid of anything."

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42. “ If you are walking on a path thick with brambles and rocks, a path that abruptly twists and turns, it’s easy to get lost, or tired, or discouraged. You might be tempted to give up entirely. But if a kind and patient person comes along and takes your hand, saying, ‘I see you’re having a hard time — here, follow me, I’ll help you find your way,’ the path becomes manageable, the journey less frightening.” — Elyn R. Saks, “The Center Cannot Hold: My Journey Through Madness” THANK YOU!