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      Suicide and schizophrenia: a systematic review of rates and risk factors

      Journal of Psychopharmacology (Oxford, England)
      SAGE Publications
      Schizophrenia, suicide, systematic review

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          Risk assessment is a core skill in psychiatry. Risk prediction for suicide in schizophrenia is known to be complex. We undertook a systematic review of all original studies concerning suicide in schizophrenia published since 2004. We found 51 data-containing studies (from 1281 studies screened) that met our inclusion criteria, and ranked these by standardized quality criteria. Estimates of rates of suicide and risk factors associated with later suicide were identified, and the risk factors were grouped according to type and strength of association with suicide. Consensus on the lifetime risk of suicide was a rate of approximately 5%. Risk factors with a strong association with later suicide included being young, male, and with a high level of education. Illness-related risk factors were important predictors, with number of prior suicide attempts, depressive symptoms, active hallucinations and delusions, and the presence of insight all having a strong evidential basis. A family history of suicide, and comorbid substance misuse were also positively associated with later suicide. The only consistent protective factor for suicide was delivery of and adherence to effective treatment. Prevention of suicide in schizophrenia will rely on identifying those individuals at risk, and treating comorbid depression and substance misuse, as well as providing best available treatment for psychotic symptoms.

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          Most cited references53

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          Risk of suicide after suicide attempt according to coexisting psychiatric disorder: Swedish cohort study with long term follow-up

          Objective To investigate the impact of coexistent psychiatric morbidity on risk of suicide after a suicide attempt. Design Cohort study with follow-up for 21-31 years. Setting Swedish national register based study. Participants 39 685 people (53% women) admitted to hospital for attempted suicide during 1973-82. Main outcome measure Completed suicide during 1973-2003. Results A high proportion of suicides in all diagnostic categories took place within the first year of follow-up (14-64% in men, 14-54% in women); the highest short term risk was associated with bipolar and unipolar disorder (64% in men, 42% in women) and schizophrenia (56% in men, 54% in women). The strongest psychiatric predictors of completed suicide throughout the entire follow-up were schizophrenia (adjusted hazard ratio 4.1, 95% confidence interval 3.5 to 4.8 in men, 3.5, 2.8 to 4.4 in women) and bipolar and unipolar disorder (3.5, 3.0 to 4.2 in men, 2.5, 2.1 to 3.0 in women). Increased risks were also found for other depressive disorder, anxiety disorder, alcohol misuse (women), drug misuse, and personality disorder. The highest population attributable fractions for suicide among people who had previously attempted suicide were found for other depression in women (population attributable fraction 9.3), followed by schizophrenia in men (4.6), and bipolar and unipolar disorder in women and men (4.1 and 4.0, respectively). Conclusion Type of psychiatric disorder coexistent with a suicide attempt substantially influences overall risk and temporality for completed suicide. To reduce this risk, high risk patients need aftercare, especially during the first two years after attempted suicide among patients with schizophrenia or bipolar and unipolar disorder.
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            Effectiveness of antipsychotic treatments in a nationwide cohort of patients in community care after first hospitalisation due to schizophrenia and schizoaffective disorder: observational follow-up study.

            To study the association between prescribed antipsychotic drugs and outcome in schizophrenia or schizoaffective disorder in the community. Prospective cohort study using national central registers. Community care in Finland. Nationwide cohort of 2230 consecutive adults hospitalised in Finland for the first time because of schizophrenia or schizoaffective disorder, January 1995 to December 2001. Rates of discontinuation of drugs (all causes), rates of rehospitalisation, and mortality associated with monotherapy with the 10 most commonly used antipsychotic drugs. Multivariate models and propensity score methods were used to adjust estimates of effectiveness. Initial use of clozapine (adjusted relative risk 0.17, 95% confidence interval 0.10 to 0.29), perphenazine depot (0.24, 0.13 to 0.47), and olanzapine (0.35, 0.18 to 0.71) were associated with the lowest rates of discontinuation for any reason when compared with oral haloperidol. During an average follow-up of 3.6 years, 4640 cases of rehospitalisation were recorded. Current use of perphenazine depot (0.32, 0.22 to 0.49), olanzapine (0.54, 0.41 to 0.71), and clozapine (0.64, 0.48 to 0.85) were associated with the lowest risk of rehospitalisation. Use of haloperidol was associated with a poor outcome among women. Mortality was markedly raised in patients not taking antipsychotics (12.3, 6.0 to 24.1) and the risk of suicide was high (37.4, 5.1 to 276). The effectiveness of first and second generation antipsychotics varies greatly in the community. Patients treated with perphenazine depot, clozapine, or olanzapine have a substantially lower risk of rehospitalisation or discontinuation (for any reason) of their initial treatment than do patients treated with haloperidol. Excess mortality is seen mostly in patients not using antipsychotic drugs.
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              Increased mortality among patients admitted with major psychiatric disorders: a register-based study comparing mortality in unipolar depressive disorder, bipolar affective disorder, schizoaffective disorder, and schizophrenia.

              Persons suffering from severe mental disorder have an excess mortality compared to persons with no mental disorder. However, the magnitude of the excess mortality differs from one mental disorder to another, and the impact on mortality if a first-degree family member suffers from a mental disorder has never been examined in a population-based study. Our objective was to examine and compare mortality rates after admission with schizophrenia, schizoaffective disorder, unipolar depressive disorder, or bipolar affective disorder and to examine the impact of family history of psychiatric admission on mortality. We established a register-based cohort study of 5.5 million persons born in Denmark who were alive on or born after January 1, 1973 and alive on their 15th birthday. Mortality rate ratios were estimated by survival analysis, using Poisson regression. Unipolar depressive disorder, bipolar affective disorder, and schizoaffective disorder were associated with the same pattern of excess mortality. Schizophrenia had a lower mortality from unnatural causes of death and a higher mortality from natural causes compared to the 3 other disorders. Family history of psychiatric admission was associated with excess mortality. Patients suffering from the 4 disorders all had an excess mortality, but the pattern of excess mortality was not the same. There was an excess mortality associated with mental disorder in a first-degree family member, but this only explained a small part of the general excess mortality associated with the 4 mental disorders examined.

                Author and article information

                J Psychopharmacol
                Journal of Psychopharmacology (Oxford, England)
                SAGE Publications (UK )
                November 2010
                November 2010
                : 24
                : 4_supplement , Mortality in Schizophrenia - Emerging trends and mechanisms
                : 81-90
                [1-1359786810385490]NHS Scotland, Ballenden House, Edinburgh, UK.
                Author notes
                [*]Dr Taylor, Ballenden House, 28 Howden St, Edinburgh EH8 9HL, UK Email: marktaylor2@ 123456nhs.net
                © The Author(s) 2010. Published by SAGE. All rights reserved. SAGE Publications
                Funded by: Sponsorship details: This supplement was produced with the funding of Eli Lilly and Company. A publication fee was paid to the publisher. No financial honoraria payments were made to any of the contributing authors. Eli Lilly and Company funded a one-day authors' meeting near Coventry, United Kingdom (travel and overnight accommodation costs only, and a computer link up with Australia) where the supplement editor facilitated a forum with authors to discuss in detail the content and key themes running through the supplement. All the papers have been written by the named authors without editorial assistance. All the papers have been peer reviewed through the normal journal peer review process.

                Pharmacology & Pharmaceutical medicine
                systematic review,schizophrenia,suicide
                Pharmacology & Pharmaceutical medicine
                systematic review, schizophrenia, suicide


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