Suicide Risk in Schizophrenia-A Follow-Up Study after 20 Years: Part 1: Outcome and Associated Social Factors

Article excerpt

Suicide has been identified as a common and serious complication of schizophrenia. Emil Kraepelin states: 'Suicide, especially in the first period of the malady, is not infrequent and occurs, sometimes without any recognisable cause.' (1) The incidence of completed suicide in the general population is estimated to be 14.5/100 000 per year worldwide and substantially higher at 32/100 000 per year in sub-Saharan Africa. (2) Recent research consistently indicates the incidence in people suffering from schizophrenia to be at least 20 times higher. (1,3,4) More than half of schizophrenics contemplate suicide at some stage, approximately 40% attempt suicide, and 10% die by suicide. (5) Suicide is one of the major contributors to the two to three times higher mortality in this population. (6)

A smaller proportion of suicide attempts in people suffering from schizophrenia than in those without the illness are planned--approximately 20% as against 47%. (7) Compared with people who do not have schizophrenia, modes of suicide attempts in schizophrenics are often more active or violent, (8) resulting in higher rates of mortality in both sexes.

In an extensive review by Hawton et al. (9) of risk factors for suicide in schizophrenia, it was found that the presence of previous depressive disorders, previous suicide attempts, drug misuse, agitation or motor restlessness, fear of mental disintegration, poor treatment adherence and recent loss were associated with an increased risk of suicide. Hallucinations were associated with reduced risk. Only 5 cohort studies were included in this review, (9-14) of which only 3 were prospective in design. (9-12)

A 1989 study by Roos et al., (15) the control group of which became the subjects for the present study, was also included in Hawton et al.'s review, (9) because the control group consisted exclusively of individuals at high risk of suicide. The present study seeks to add information on the subject to the few prospective and retrospective studies mentioned by Hawton et al. (9) by re-evaluating suicide risk in high-risk individuals 20 years after initial contact, with relevant information on demographics, illness course, and treatment of these subjects over the preceding 20 years having also been retrospectively gathered.

In this article--the first of two--we report on the current suicide risk in the cohort and its association with the following factors: (i) subsequent suicides, suicide attempts and self-harm behaviour since the initial (1989) study, with relevant information surrounding these incidents; and (ii) socio-demographic data, including significant socio-demographic changes and their impact.

Method

In 1992 Roos et al. (15) published the retrospective empirical study, entitled 'Suicide among patients with schizophrenia' (translated). Thirty-three Caucasian subjects who had committed suicide and suffered from schizophrenia were compared with a control group of high-risk subjects with schizophrenia of the same ethnic background treated at Weskoppies Hospital, Pretoria.

Individuals from the control group of Roos et al.'s (15) study who could be traced formed the cohort that was re-evaluated in the current study. The study protocol was approved by the Research Ethics Committee of the Faculty of Health Sciences of the University of Pretoria. Permission for the use of patient records was obtained in terms of the Promotion to Access to Information Act (2002).

Contact details from patient records were utilised, as well as information from local clinics. In many cases these details were outdated and insufficient, since a significant number of subjects had disengaged from services provided at Weskoppies Hospital many years earlier. The frequent socio-economic difficulties and high mobility of this patient population further hindered our ability to find many of the subjects.

Fourteen of the 33 subjects on record were traced. …