FREQUENCY OF SUICIDAL IDEATION IN DIAGNOSED PATIENTS OF SCHIZOPHRENIA.
Objective: To investigate the frequency of suicidal ideation in diagnosed patients of schizophrenia.
Methodology: This cross sectional analysis was conducted on 150 in-door patients of Department of Psychiatry, Fatima Jinnah Medical University, Lahore and Ganga Ram Hospital, Lahore, who were diagnosed with schizophrenia from March 2016 to September 2016. Beck scale for suicidal ideation was used to figure out the frequency of suicidal ideation. Data was entered and analyzed by using SPSS version 23.0.
Results: A total of 150 patients were selected. Among these, 87 (58%) were male patients and remaining 63 (42%) were females. Mean age of the patients was 28.21 +-5.91 years. Suicidal ideation was found in 38 (25.33%) of schizophrenic patients. Male patients having suicidal ideation were 26/87 (29.88%) and female patients having suicidal ideation were 12/63 (19.04%). Severe suicidal ideation was found in 01 (1.6%) female and 5 (5.7%) male patients.
Conclusion: Suicidal ideation was found in a significant number of patients with schizophrenia. Suicidal ideation was more common and more severe in male patients compared to females.
KeyWords: Schizophrenia, Suicidal ideation, Beck scale.
HSuicide is a stigmatized behavior occurring in all regions of the world, accounting for 1.4% of all deaths worldwide. Globally, it is the 17th leading cause of death. In United States, more than 30,000 lives are taken by suicide every year. Ratio of people seeking mental health specialty services, in the weeks preceding their death, is considerably lowA1. Intermediate phenotypes between genes and suicidal outcomes is thought to predispose people to commit suicideA2. The ever increasing rate of suicide indicates the insufficiency of available suicide risk assessment tools and a clear need of developing new strategies for prevention and early detection of suicidal behaviorsA3. In Pakistan, the increasing trend of committing suicide has made it a major public health problem. Though depression is an under-recognized and under-treated disease but it has a strong association with suicide4.
Schizophrenia is probably a mixture of several separate illnesses making it a severe, debilitating, persistent and complex psychiatric disorder. Disruption in perceptions, mood, thoughts and relationships with others are the various presentations of schizophrenic patients. As for as the prognosis is concerned, about 43% patients suffer from an increased severity of symptoms without complete remission and 9% with lasting impairment leading to a substantial economic burden5. Worldwide prevalence of schizophrenia is estimated to be about 4.0 per 10006. Life expectancy of schizophrenic patients is much lower than expected; up to 40% of their deaths are attributed to suicide and unnatural causes7. Highest risk of suicide occurs soon after a psychotic episode, but a person should not go unguarded by not assessing suicidal risk long after first 1st presentation8.
Incidence of suicidal attempt, re-attempt and lethality index of the attempt is quite high in patients with schizophrenia compared to other mood disorders. Though schizophrenia awareness leads to a better medical compliance, but it is also associated with increased suicide risk. Wide variations exist on the suicide rates of schizophrenic patients but the commonly cited suicide rate among these individuals is about 10%. Assessment and subsequent management of the risk for an impending disaster remains one of the fundamental skills in most aspects of clinical psychiatry but are still under debate. Suicide constitutes about 5-13% of all schizophrenic patients' deaths. Being young, white, unmarried, male, with a previous history of substance abuse and suicidal attempts, a state of high premorbid function and post-psychotic depression make a person more susceptible to committing suicide compared to others.
Social isolation, rejection, recent loss, hopelessness, hospitalization, treatment dependence, fear of further mental deterioration, no family support, stress, loss of faith in treatment, deteriorating health and economic instability are the further contributing risk factors for suicide in schizophrenia. Awareness of illness has a controversial role as a suicide risk factor. Protective factors should also be carefully evaluated in assessing suicide risk. Though neurobiological perspective offers but early recognition of suicidal tendency in schizophrenics is still not clearly possible 10. This study was done to provide basic literature on the frequency of suicidal ideation and attempts in schizophrenic patients in Pakistani population. It will be helpful in the early suspicion, detection and treatment of suicidal intention in schizophrenic patients.
One hundred and fifty patients were selected from the indoor unit of Department of Psychiatry, Fatima Jinnah Medical University, Lahore and Ganga Ram Hospital, Lahore, from March 2016 to September 2016. Sample size was calculated by online data source (openepi.com) using confidence interval at 95%, margin of error as 5% and p (percentage of previous study) as 9.7% suicidal attempts after schizophrenia. Inclusion criteria were diagnosed patients of schizophrenia of either gender and above 18 years of age. Patients with co-morbid psychiatric illnesses (anxiety disorders, mood disorders, somatoform disorders, as assessed by Diagnostic and Statistical Manual of Mental Disorders, fourth edition (DSM-IV); medical conditions (encephalitis, meningi-tis); history of substance abuse, mental retardation and those receiving anti-psychotic treatment during last 06 months were excluded from our study.
After explaining the nature of study to each patient, informed consent was taken. Ethical approval was obtained from ethical committee of hospital. Each patient was interviewed in a comfortable setting ensuring his privacy. Address and phone number was noted. All patients who met the diagnostic criteria of DSM IV, TR for schizophrenia were labeled as schizophrenics. Thoughts about suicide with a wish to die without suicidal attempt were considered under the label of suicidal ideation and they were assessed by using Beck's scale for suicide ideation. Patients having score equal to or greater than 7 were considered having suicidal ideation. History of suicidal attempts and ideation was taken from patient and attendant in accordance with the scale for suicidal ideation and the data was collected on a predesigned Performa. Data was entered andanalyzed by using software of SPSS version 23.0.
The quantitative variables like age were calculated as mean and standard deviation. Qualitative variables like gender,suicidal attempts and ideation were calculated for frequencies and percentages.
Table 1: Demographic variables and suicidal ideation (n=150).
Characteristics###Frequency/Mean +- SD
Age (years)###28.21+- 5.91
Age Groups###18-25 years###50(33.33%)
Table 2: Association between gender and severities of Ideation.
Gender###No###Severities of Ideation###Total
Female % within Patient Gender###51(81.0%)###7(11.1%)###4(6.3%)###1(1.6%)###63(100%)
Male % within Patient Gender###61(70.1%)###6(6.9%)###15(17.2%)###5(5.7%)###87(100%)
Total % within Patient Gender###112(74.7%)###13(8.7%)###19(12.7%)###6(4.0%)###150(100%)
A total of 150 patients were enrolled. Among these, 87 (58%) were male patients and remaining 63 (42%) were females. Mean age of the patients was 28.21 +- 5.91 years. Suicidal ideation was found in 38 (25.33%) of schizophrenic patients. Baseline Characteristics are shown in Table 1. Male patients having suicidal ideation were 26 out of 87 (29.88%) and female patients having suicidal ideation were 12 out of 63 (19.04%). Severe suicidal ideation was found in 6 patients; 01 (1.6%) female and 5 (5.7%) males. Severity of suicidal ideation as assessed by Beck suicidal ideation scale is shown in Table 2.
Suicidal ideation was found in 25.33% of our schizophrenic patients with variable severity in accordance with Beck suicidal ideation scale. Suicidal ideation was more common and more severe in male patients compared to females. Similarly, different studies have narrated variability in suicidal ideation rates in schizophrenic patients. In the study conducted by Radomsky et al 11, the reported percentage of suicidal ideation was 37.6%. A large number of studies exploring the proportion, rates and associations of suicide in schizophrenia since 2005 have been reviewed by Hawton et al 12. High IQ, high premorbid function and the first year of illness were found to be associated with increased suicidal risk in schizophrenic patients 12.
Similar results (10.1% of total schizophrenic deaths) were reported by Philips et al 13. However, a study conducted by Palmer et al 14 showed 4.9% life time risk of suicide in schizophrenic individuals and 22.3% of schizophrenic deaths were attributed to suicide by a study done by Osborn et al 15. Young, white, unmarried, male sufferings from schizophrenia are more susceptible to commit suicide. A previous state of good healthy life, depression after diagnosis, substance abuse, passivity phenomena, delusions, command hallucination and previous history of suicidal attempts are the factors associated with increased risk of both successful and unsuccessful suicide attempts 16. A randomized controlled trial narrated that suicidal thoughts and plans, drug misuse, depressive symptoms and previous suicide attempts are the strong predictors of suicide in schizophrenic patients soon after the first episode of psychosis 17.
The chances of committing suicide increase by almost seven-fold in patients scoring >2 by using Beck Depression Inventory 18. Contrary to other studies, delusions, auditory hallucinations and other positive symptoms were found to be associated with increased risk of suicide in schizophrenics in only one study 19. Out of all schizophrenic patients who committed suicide, almost three quarters of them had at least one appointment with concerning physician within a week of their suicide as stated by studies conducted in the Finland and United States. Though suicidal risk never return to baseline of normal individuals in schizophrenia persons but it peaks in the first three to six months of an episode and its inpatient management 20.
Lifetime risk of committing suicide in patients with schizophrenia is 4.9% in a recent meta analysis. A review by Pompili et al 21 found a suicide rate of 6.8% in schizophrenic patients. When compared with general population, about eight fold increased risk of suicide in schizophrenia was found in a meta-analysis by Harris et al 22. An increased death rate in schizophrenia from both natural and unnatural causes was shown. Suicide accounted for 28% of all excess deaths and 12% of all deaths in schizophrenia patients. Nordentoft et al 23 reported a decreased rate of suicide with an overall fall of suicide rate in general population of Danish people. Suicide attempts are much more common than successful suicides mounting up to 20-40% of schizophrenics.
Though WHO data show an increasing trend of suicide all around the world, the suicide rate of both general population and schizophrenics of Denmark and Norway is falling since 1990 24.
Our study had few limitations. It was conducted at a single center and on a targeted population. It was not a randomized control trial but a cross sectional analysis. The results of this study, therefore, cannot be generalized.
Suicidal ideation was found in about one-forth of the patients with schizophrenia. It was more common and more severe in male patients compared to females.
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