Suicide and Life-Threatening Behavior 44 (2) April 2014 © 2013 The American Association of Suicidology DOI: 10.1111/sltb.12066

167

Attempted Suicide in a Xhosa Schizophrenia and Schizoaffective Disorder Population € MARLIZE LUCKHOFF , MBCHB, LIEZL KOEN, PHD, ESME JORDAAN, PHD, NIEHAUS, DMED

AND

DANIEL

Suicide risk behavior is a significant contributor to the mortality and morbidity of schizophrenia. We previously reported affected sibship status in a Xhosa schizophrenia or schizoaffective disorder sample to be protective in nature; given the counterintuitive nature of this finding, we expanded the sample size to seek further clarification. Subjects were assessed with the Diagnostic Interview for Genetic Studies and then stratified into two groups: with (n = 137) or without (n = 837) a previous suicide attempt. The presence of lifetime bizarre behavior (OR 1.5; 95%CI 1.12–1.87) or cannabis use or abuse (OR 1.2; 95%CI 10.01–1.47) was a significant predictor of suicide attempts, while a higher global alogia score (OR 0.84; 95%CI 0.74–0.96) was a protective factor. Our data seem to support that in this population, encouraging family members to report bizarre behavior and implementing dual diagnosis interventions for cannabis use or abuse could be an appropriate starting point toward developing a targeted suicide prevention program for further research.

Suicide risk behavior is one of the major contributors to the high morbidity and mortality rates in schizophrenia (Palmer, Pankratz, & Bostwick, 2005). Suicidal ideation has been reported by 40% to 50% of patients with schizophrenia, and 20% to 40% have a history of suicide attempts (Kasckow, Felmet, & Zisook, 2011). To modify this risk, it remains imperative to understand factors contributing to suicidal behavior in this population.

€ MARLIZE LUCKHOFF , LIEZL KOEN, and DANIEL NIEHAUS, Department of Psychiatry, Faculty of Medicine and Health Sciences, University of Stellenbosch, Tygerberg, South Africa; ESME JORDAAN, Biostatistics Unit, Medical Research Council, Bellville, South Africa. Address correspondence to Liezl Koen, Department of Psychiatry, Faculty of Medicine and Health Sciences, University of Stellenbosch, Tygerberg, 7505, South Africa; E-mail: [email protected]

Sociodemographic factors reported to increase the risk for suicide in this population include being young, male, Caucasian, and having a higher level of education (Carlborg, Winnerb€ack, J€ onsson, Jokinen, & Nordstr€ om, 2010; Hawton, Sutton, Haw, Sinclair, & Deeks, 2005; Hor & Taylor, 2010). Illness-related risk factors such as a family history of suicide, long duration of index hospitalization, recent hospital discharge or admission, the use of high doses of antipsychotics, and the presence of insight also seem to contribute to higher risk (Hor & Taylor, 2010; Kasckow et al., 2011). There is also strong evidence that schizophrenia patients with comorbid alcohol and drug misuse are at increased risk for suicide (Hor & Taylor, 2010; Roy & Pompili, 2009). In their systematic review, Hor and Taylor (2010) conclude that there is enough evidence supporting a positive association for both increased positive symptoms

168 (increase) and a lower level of negative symptoms (protective) in suicide risk behavior. However, this is in contrast to the findings reported earlier by Hawton et al. (2005), and the authors conclude that further studies are required to confirm this association. Pompili et al. (2009) identified a number of variables that may also constitute risk factors for suicide in a schizophrenia population: agitation, motor restlessness, self-devaluation, hopelessness, insomnia, and mental disintegration. While ethnic patterns in general population suicide rates exist, findings for schizophrenia are inconclusive, possibly because the majority of the available review data report on Caucasian populations (Hawton & Van Heeringen, 2009; Hor & Taylor, 2010). Reporting on mental health users’ risk factors for suicide based on ethnicity Bhui & Mckenzie (2008) found clear differences. While not a schizophrenia-specific finding, the importance that the clinical prediction of suicide risk for psychiatric patients may differ between ethnic groups is evident for clinicians. A previous study by our group remains the only one to specifically focus solely on suicide risk factors in an African (Xhosa) schizophrenia population. We reported that having an affected sib pair status was a protective factor (Niehaus et al., 2004). Due to the counterintuitive nature of our finding, we have since expanded our sample size considerably with a view to more definitively clarify whether risk factors exist for African schizophrenia populations that significantly differ from those generally reported. The Xhosa population, mainly based in the Eastern Cape, is the second largest cultural group in South Africa. The pattern of expression of certain psychiatric symptoms differs between cultural groups. The Xhosa people of South Africa have retained social cohesion through traditional custom, language, and especially the dominant role of ancestor worship, traditional medicine, and witchcraft in lifestyle and beliefs (Cheetham & Cheetham, 1976).

SUICIDE RISK BEHAVIOR METHODS

Design Each participant was interviewed by a psychiatrist (D. Niehaus) or an experienced, trained research sister (I. Mbanga). All interviews were conducted in Xhosa, the native language of this population. All information was collected via participant interviews as well as utilizing collateral from clinical notes, and family members when available. A diagnosis of schizophrenia or schizoaffective disorder was confirmed using the Diagnostic Interview for Genetic Studies (DIGS 2.0), a comprehensive clinical assessment interview specially developed for diagnosing major mood and psychotic spectrum disorders which also includes the Scales for the Assessment of Positive and Negative Symptoms (SAPS, SANS). (Andreasen, 1989; Andreasen, Arndt, Miller, Flaum, & Nopoulos, 1995; Nurnberger et al., 1994). The participants were then stratified into two groups: those with and those without a history of previous suicide attempts. A suicide attempt was defined as an intent to kill oneself. This definition corresponds with Silverman et al.’s (2007a, 2007b) revised nomenclature for suiciderelated thoughts and behaviors. According to this, a suicide attempt is defined as a behavior that is self-inflicted and potentially injurious with a nonfatal outcome for which there is evidence of intent to die. It may result in no injuries, injuries, or death. Demographic and illness variables (including lifetime presence of symptoms) were then compared across these groups. Substance use in particular was defined as lifetime use of specific substances, including symptoms of abuse and dependence. Significant cannabis use was defined as using cannabis at least 21 times in a single year as per DIGS structure. The relevant section of the DIGS was used to assess previous suicide attempts. Data used included age of first onset and number of attempts.

LUCKHOFF

ET AL.

Important factors related to the most serious attempt were highlighted. These included the method, intent, lethality, treatment needed, and the associated stressors and psychiatric symptoms. The lethality of the most serious attempt was also rated. This was scored between 0 and 6 ranging from no danger (no effects) to extreme danger (respiratory arrest or prolonged coma) as per DIGS structure.

DATA COLLECTION

Setting and Participants As part of an ongoing genetics study, our initial sample of 454 participants reported on in Niehaus et al. (2004) was enlarged to 981 participants by recruiting from hospitals (both in- and outpatients) as well as community treatment centers throughout the Cape Town Metropole. Inclusion and Exclusion Criteria Xhosa individuals (4/4 grandparents of Xhosa ethnicity) with a diagnosis of schizophrenia or schizoaffective disorder (DSM–IV TR; American Psychiatric Association, 2002) at all stages of illness were included in this study. Subjects who were unable to give informed consent were excluded. Ethical Considerations The study was approved by the Committee for Human Research, Faculty of Medicine and Health Sciences, University of Stellenbosch, South Africa (97/005), and all their regulations were strictly adhered to. Data Analyses In this cross-sectional comparative study, lifetime suicide attempts were measured as either present or not present (binary response). Demographic, substance use,

169 and SAPS and SANS variables were summarized separately for the suicide and nonsuicide groups according to their scale of measurement. Most of the symptom variables for SAPS and SANS were measured on a 6-point scale (0–5), and means and standard deviations were reported. Percentages were reported for the categorical variables. Multiple imputation modeling was used to impute missing variables. Univariate logistic regressions were performed to find the confounders and/or predictors for suicide, and Wald chi-square values were reported to indicate significant predictors (p < .05). After the initial univariate analysis, it was followed up by a multiple logistic regression analysis to find the independent predictors for suicide. Odds ratios were reported to measure the strength of the relationships.

RESULTS

Nine hundred and eighty-one participants were included in the study, of which seven reported cases (5.2%) lacked some critical data. Three participants withdrew or declined to participate in the study. Thus, data from 974 cases were analyzed (784 males and 190 females). Twenty-five of the cases had a diagnosis of schizoaffective disorder. The mean age at interview was 35 years (SD 10.5) and the duration of illness 12 years (SD 9.1). A total of 137 (115 males, 22 females) participants (14%) had a history of previous suicide attempts. Of these, 65.9% only made one attempt. The majority of the participants (84.7% (n = 116) allocated to the suicide group were single). Data captured on the most serious attempt showed that of the group who attempted suicide, 21% (n = 137) were admitted following the attempt, 85% wanted to die (n = 122), and 85% thought that their attempt would lead to death (n = 112). We assessed the lethality of the attempt as moderate to extreme (as per DIGS definition) in 38% of the cases

170

SUICIDE RISK BEHAVIOR

(n = 115). The most common psychiatric symptoms reported during the most serious attempt was psychosis (85%; n = 117), followed by depression (13%; n = 111). The age distribution at which patients had their first attempt shows that the highest peak was reached during their 20s. The majority of patients had their first attempt within 3 years of the onset of illness. In participants with a later age of onset (>29), their first attempt was significantly closer to age of onset (p < .0001). The univariate logistic regression model (Tables 1 and 2) supported marital status (married; p = .037) and global alogia (p = .049) as protective factors and cannabis use or abuse or dependency (p = .0008) and lifetime bizarre behavior (p = .009) as risk factors for suicidal behavior. After fitting multiple regression model (n = 958; Table 3), only three variables were demonstrated to be independent predictors for suicide attempts. Cannabis use or abuse (OR = 1.8) and lifetime history of bizarre behavior (OR = 2; p = .009) significantly increased the risk for suicidal behavior, while a higher current global alogia score (p = .049) decreased the risk. Our previously reported finding of affected sibship status being a protective factor could not be replicated.

DISCUSSION

International literature reports rates of 20% to 40% for suicidal risk behavior in schizophrenia samples, suggesting that the 14% in our sample is quite low (Kasckow et al., 2011). As social support has emerged as one of the protective factors that may mitigate suicide, one could speculate that the study prerequisite for having at least one living first-degree family member, with its accompanying impact on social support systems, could have been a contributor to the slightly lower rates. In contrast with our previous findings, sibship status could not be shown to significantly correlate with suicidal risk behavior (Montross, Zisook, & Kasckow, 2005; Radomsky, Haas, Mann, & Sweeney, 1999). Most available literature, including our own earlier data, supports earlier age of onset as a suicide risk factor, although some evidence exists suggesting a later age onset association (Hor & Taylor, 2010; Kuo, Tsai, Lo, Wang, & Chen, 2005). Our current study supported neither, but for participants with a later age of onset (>29), their first suicide attempt was significantly closer to the age of onset (p < .0001). In their 2012 review, Serafini et al. concluded that available literature supported cannabis use to be a relevant risk factor asso-

TABLE 1

Demographic Variables and Univariate Logistic Regression Demographic variables Gender Marital status Cannabis

Alcohol

Specifiers Males Females Single Married Use or abuse Dependence Use or abuse or dependence Abuse Dependence

Suicide group (%)

Control group (%)

84.0 16.1 94.4 5.1 31.3 11.0 47.5

80.0 20.1 88.9 11.1 27.2 4.7 35.5

11.8 5.1

13.6 2.2

n

Chi-square

p

981

1.31

.253

976

4.33

.037

956 972 980

1.02 8.49 7.15

.313 .004 .008

959 975

0.30 3.54

.583 .060

LUCKHOFF

ET AL.

171

TABLE 2

Mean SANS and SAPS Scores and Univariate Logistic Regression Symptom scales (5-point scale) SANS

SAPS

Lifetime symptoms

Subsymptoms Attention Anhedonia–associality Avolition–apathy Alogia Hallucinations Delusions Bizarre behavior Formal thought disorder Bizarre behavior

Suicide group mean (SD) or% 3.23 1.00 2.39 1.67 2.09 1.67 1.06 1.04

(1.58) (1.74) (1.21) (1.46) (2.01) (1.71) (1.45) (1.31)

28.2 (1)

Control group mean (SD) or% 3.24 1.11 2.57 1.95 1.86 1.54 1.15 1.06

(1.57) (1.79) (1.21) (1.56) (2.00) (1.65) (1.55) (1.45)

41.7 (1)

n

Chi-square

p

973 970 971 972 953 954 961 960

0.01 0.47 2.39 3.87 1.57 0.69 0.39 0.03

.973 .495 .122 .049 .210 .405 .531 .872

808

6.7

.009

SAPS, Scale for the Assessment of Positive Symptoms; SANS, Scale for the Assessment of Negative Symptoms TABLE 3

Multiple Logistic Regression Model (n = 958) Effect Marital status Cannabis use or abuse or dependence Alcohol dependence Global alogia Bizarre behavior (lifetime)

t 1.85 2.08 1.26 2.67 2.92

ciated with suicidal attempts and behaviors in both psychotic and nonpsychotic samples, and this was demonstrated in our sample as well. However, literature reporting specifically on schizophrenia suicidal risk behavior does not uniformly support cannabis misuse as a risk factor; rather significant associations have more often been demonstrated for alcohol misuse (Hor & Taylor, 2010; McLean, Gladman, & Mowry, 2012). Therefore, while dual diagnosis treatment programs would likely ameliorate risk, our findings seem to suggest that in this study population improved outcomes could be achieved if specific focus is placed on reducing cannabis use. Available data on suicide risk for schizophrenia sufferers as related to the

p

OR

95% Confidence interval

.070 .038 .207 .008 .005

0.69 1.22 1.34 0.84 1.45

0.46 1.01 0.85 0.74 1.12

1.03 1.47 2.10 0.96 1.87

presence of positive and negative symptoms remain inconclusive (Hawton et al., 2005; Hor & Taylor, 2010). Interestingly, our study showed global alogia to linearly decrease the risk for suicide attempts. This finding would make sense within the context that alogia has been shown to be positively associated with poor planning ability (Berebaum, Kerns, Vernon, & Gomez, 2008). A second consideration in the interpretation of the study results is that only a limited number of covariates were included in the final model. The variables chosen for the model were items of interest identified in our previous study (as per priori hypothesis; see Niehaus et al., 2004). However, the reader should take cognizance of the

172

SUICIDE RISK BEHAVIOR

fact that this study still only includes a limited number of covariates. The reasons for this include nonmeasurement and missingness. The mechanism of the data missingness is suspected to be nonrandom (not missing at random), making the analysis potentially spurious for some of the covariates. The presence of a stressor serves as one such example. Careful inspection of the stressor data revealed that the missing data are more likely to be from single people and much less likely to be part of a sibpair. In our study, the lifetime presence of bizarre behavior was associated with an increase in suicide risk. There is a paucity of literature on this subject, and the finding will require further study. Of interest, however, is a study by Castle, Duberstein, Meldrum, Conner, and Conwell (2004) where the presence of bizarre behavior (as reported by a family member questioned postmortem) was one of the factors that distinguished suicides (bizarre behavior present) from accidental deaths. Limitations The male predominance in this study should be taken into consideration when interpreting this data. Recruitment targeted all patients known at health services with a diagnosis of schizophrenia and their extended families. The male predominance thus seems to reflect a gender bias in health-seeking behavior in this ethnic group. However, this is not unique to our sample as the majority of genetic and treatment studies in schizophrenia show a male predominance (Derks, Allardyce, & Boks, 2012; Huang, Tsai, & Hwub, 2011). The reasons for this are unclear, but we hypoth-

esize that it may reflect wider societal bias in response to psychosis in men and women and the subsequent impact on health-seeking pathways. The generalizability of these findings may also be limited by the uniqueness of this specific population; however, future studies should compare the results found in this ethnic group with other groups of African descent to see whether the results apply to the general population of South Africa.

CONCLUSION

Developing suicide prevention strategies remains a complex issue. Seen universally, restricting access to means has the best documented evidence (Mann et al., 2005). In the schizophrenia population, factors such as encouraging treatment adherence and targeting of substance abuse have been shown to have broad value (Carlborg et al., 2010; Hor & Taylor, 2010; Roy & Pompili, 2009). In a recent review, Nortendoft (2011) presented some evidence in support of targeted prevention programs, but robust research findings remain lacking. Treatment should ideally incorporate pharmacotherapy, psychosocial treatments, and substance abuse counseling into a single comprehensive, integrated dual diagnosis treatment program (Green, Dake, Brunette, & Noordsy, 2007). Our data seem to support that in this population, encouraging family members to report bizarre behavior and implementing dual diagnosis interventions for cannabis use or abuse could be an appropriate starting point toward developing a targeted suicide prevention program for further research.

REFERENCE American Psychiatric Association. (2002). Diagnostic and statistical manual of mental disorders (4th ed., text rev.). Washington, DC: American Psychiatric Association.

ANDREASEN, N. C. (1989). The Scale for the Assessment of Negative Symptoms (SANS): Conceptual and theoretical foundations. British Journal of Psychiatry, 155(suppl. 7), 49–58.

LUCKHOFF

ET AL.

ANDREASEN, N. C., ARNDT, S., MILLER, D., FLAUM, M., & NOPOULOS, P. (1995). Correlational studies of the Scale for the Assessment of Negative Symptoms and the Scale for the Assessment of Positive Symptoms: An overview and update. Psychopathology, 28, 7–17. BEREBAUM, H., KERNS, J. G., VERNON, L. L., & GOMEZ, J. J. (2008). Cognitive correlates of schizophrenia signs and symptoms. Psychiatric Research, 159, 163. BHUI, K. S., & MCKENZIE, K. (2008). Rates and risk factors by ethic group for suicides within a year of contact with mental health services in England and Wales. Psychiatry Services, 59, 414–420. € € CARLBORG, A., WINNERBACK , K., JONSSON , € , P. (2010). E. G., JOKINEN, J., & NORDSTROM Suicide in schizophrenia. Expert Review of Neurotherapeutics, 10, 1153–1164. CASTLE, K., DUBERSTEIN, P. R., MELDRUM, S., CONNER, K. R., & CONWELL, Y. (2004). Risk for suicide in black and whites. Journal of Psychiatry, 161, 452–458. CHEETHAM, R. W. S., & CHEETHAM, R. J. (1976). Concepts of mental illness amongst the rural Xhosa people in South Africa. Australian and New Zealand Journal of Psychiatry, 10, 39–45. DERKS, E. M., ALLARDYCE, J., & BOKS, M. P. (2012). Kraepelin was right: A latent class analysis of symptom dimensions in patients and controls. Schizophrenia Bulletin, 38, 495–505. GREEN, A. I., DAKE, R. E., BRUNETTE, M. F., & NOORDSY, D. L. (2007). Schizophrenia and co-occurring substance use disorder. American Journal of Psychiatry, 164, 402–408. HAWTON, K., SUTTON, L., HAW, C., SINCLAIR, J., & DEEKS, J. J. (2005). Schizophrenia and suicide: Systematic review of risk factors. British Journal of Psychiatry, 187, 9–20. HAWTON, K., & VAN HEERINGEN, K. (2009) Suicide. Lancet, 373, 1372–1381. HOR, K., & TAYLOR, M. (2010). Suicide and schizophrenia: A systematic review of rates and risk. Journal of Psychopharmacology, 24(suppl 4), 81–90. HUANG, G. H., TSAI, H. H., & HWUB, H. G. (2011). Patient subgroups of schizophrenia based on the Positive and Negative Syndrome Scale: Composition and transition between acute and subsided disease states. Comprehensive Psychiatry, 52, 469–478. KASCKOW, J., FELMET, K., & ZISOOK, S. (2011). Managing suicide risk in patients with schizophrenia. CNS Drug, 25, 129–143. KUO, C. J., TSAI, S. Y., LO, C. H., WANG, Y. P., & CHEN, C. C. (2005). Risk factors for completed suicide in schizophrenia. Journal of Clinical Psychiatry, 66, 579–585.

173 MANN, J. J., APTER, A., BERTOLOTE, J., BEAUTRAIS, A., CURRIER, D., HAAS, A., ET AL. (2005). Suicide prevention strategies: A systematic review. Journal of the American Medical Association, 294, 2064–2074. MCLEAN, D., GLADMAN, B., & MOWRY, B. (2012). Significant relationship between lifetime alcohol use disorders and suicide attempts in an Australian schizophrenia sample. The Australian and New Zealand Journal of Psychiatry, 46, 132– 140. MONTROSS, L. P., ZISOOK, S., & KASCKOW, J. (2005). Suicide among patients with schizophrenia: A consideration of risk and protective factors. Annals of Clinical Psychiatry, 17, 173–182. NIEHAUS, D. J. H., LAURENT, C., JORDAAN, E., KOEN, L., OOSTHUIZEN, P., KEYTER, N., ET AL. (2004). Suicide attempts in an African schizophrenia population: An assessment of demographic risk factors. Suicide and Life-Threatening Behavior, 34, 320–327. NORTENDOFT, M. (2011). Crucial elements in suicide prevention strategies. Progress in Neuro-Psychopharmacology and Biological Psychiatry, 35, 848–853. NURNBERGER, J. I., BLEHAR, M. C., KAUFMANN, C. A., YORK-COOLER, C., SIMPSON, S. G., HARKAVY-FRIEDMAN, J., ET AL. (1994). NIMH genetics initiative: Diagnostic Interview for Genetic Studies: Rationale, unique features, and training. Archives of General Psychiatry, 51, 849– 859. PALMER, B. A., PANKRATZ, V. S., & BOSTWICK, J. M. (2005). The lifetime risk of suicide in schizophrenia: A re-examination. Archives of General Psychiatry, 62, 247–253. POMPILI, M., LESTER, D., GRISPINI, A., INNAMORATI, M., CALANDRO, F., ILICETO, P., ET AL. (2009). Completed suicide in schizophrenia: Evidence from a case-control study. Psychiatry Research, 167, 251–257. RADOMSKY, E. D., HAAS, G. L., MANN, J. J., & SWEENEY, J. A. (1999). Suicidal behavior in patients with schizophrenia and other psychotic disorders. American Journal of Psychiatry, 156, 1590–1595. ROY, A., & POMPILI, A. (2009). Management of schizophrenia with suicide risk. The Psychiatric Clinics of North America, 32, 863–883. SERAFINI, G., POMPILI, M., INNAMORATI, M., RIHMER, Z., SHER, L., & GIRARDI, P. (2012). Can cannabis increase the suicide risk in psychosis: A critical review. Current Pharmaceutical Design, 18, 5165–5187. SILVERMAN, M. M., BERMAN, A. L., SANDDAL, N. D., O’CARROLL, P. W., & JOINER, T. E., JR., (2007a). Rebuilding the tower of Babel: A revised nomenclature for the study of suicide

174 and suicidal behaviors part 1: Background, rationale, and methodology. Suicide and Life-Threatening Behavior, 37, 248–263. SILVERMAN, M. M., BERMAN, A. L., SANDDAL, N. D., O’CARROLL, P. W., & JOINER, T. E., JR., (2007b). Rebuilding the tower of Babel: A revised nomenclature for the study of suicide

SUICIDE RISK BEHAVIOR and suicidal behaviors part 2: Suicide-related ideations, communications, and behaviors. Suicide and Life-Threatening Behavior, 37, 264–277. Manuscript Received: February 21, 2013 Revision Accepted: August 6, 2013