Acta Psychiatr Scand 2014: 130: 418–426 All rights reserved DOI: 10.1111/acps.12332
© 2014 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd ACTA PSYCHIATRICA SCANDINAVICA
Clinical overview
Risk factors for suicide in schizophrenia: systematic review and clinical recommendations Popovic D, Benabarre A, Crespo JM, Goikolea JM, Gonzalez-Pinto A, Gutierrez-Rojas L, Montes JM, Vieta E. Risk factors for suicide in schizophrenia: systematic review and clinical recommendations. Objective: To identify risk factors associated with suicide of patients with schizophrenia and provide clinical recommendations, which integrate research findings into a consensus based on clinical experience and evidence. Method: A task force formed of experts and clinicians iteratively developed consensus through serial revisions using the Delphi method. Initial survey items were based on systematic literature review published up to June 2013. Results: Various risk factors were reported to be implicated in suicide in schizophrenia. Our findings indicate that suicide risk in schizophrenia is mainly related to affective symptoms, history of a suicide attempt and number of psychiatric admissions. Other risk factors identified are given by younger age, closeness to illness onset, older age at illness onset, male sex, substance abuse and period during or following psychiatric discharge. Integrating the evidence and the experience of the task force members, a consensus was reached on 14 clinical recommendations. Conclusion: Identification of risk factors for suicide in individuals diagnosed with schizophrenia is imperative to improve clinical management and develop strategies to reduce the incidence of suicide in this population. This study provides the critical overview of available data and clinical recommendations on recognition and management of the above-mentioned risk factors.
D. Popovic1, A. Benabarre1,
J. M. Crespo2, J. M. Goikolea1, A. Gonzalez-Pinto3, L. GutierrezRojas4, J. M. Montes5, E. Vieta1 Bipolar Disorders Program, Hospital Clınic, IDIBAPS, CIBERSAM, University of Barcelona, Barcelona, Catalonia, 2Department of Psychiatry, Bellvitge Biomedical Research Institute (IDIBELL), CIBERSAM, University Hospital of Bellvitge, Barcelona, 3Department of Psychiatry, CIBERSAM, Kronikgune, EHU, Hospital Universitario de Alava, Vitoria, 4Psychiatry Service, San Cecilio University Hospital, Granada, and 5Department of Psychiatry, Centro de Investigacin Biomedica de Salud Mental, CIBERSAM, Hospital Universitario del Sureste, Madrid, Spain
1
Key words: schizophrenia; suicide; risk factors; clinical recommendations Eduard Vieta, Department of Psychiatry and Psychology, Hospital Clínic, 170 Villarroel st., 08036 Barcelona, Catalonia, Spain. E-mail: [email protected]
Accepted for publication August 14, 2014
Clinical recommendations
• In-patients and out-patients with diagnosis of schizophrenia present different risk factors for suicide. • Suicide risk in schizophrenia is mainly related to affective symptoms, history of a suicide attempt and •
number of psychiatric admissions. Other risk factors are younger age, closeness to illness onset, older age at illness onset, male sex, substance abuse and period during or immediately after psychiatric discharge. 14 clinical recommendations for recognition and management of risk factors for suicide in schizophrenia are provided derived from integration of evidence and expertise of 60 clinicians.
Additional comments
• Research on suicide in schizophrenia has brought to identify various, sometimes contradictory, risk factors for suicide, but most are not conclusive enough to identify a causal link.
• Issues related to the design of the original clinical trials may have influenced the results. Please also see editorial comment to this paper by Matthew Large (Acta Psychiatr Scand 2014;130:415–417).
418
Risk factors for suicide in schizophrenia Introduction
The characteristic symptoms of schizophrenia involve a wide range of cognitive, behavioural and emotional dysfunctions. The diagnosis involves a constellation of signs and symptoms associated with impaired occupational or social functioning (1). There is a close relationship between schizophrenia and suicide. The first commentary on the ‘mortality of lunacy in England and Wales’ goes back to 1662 (2). In 1911, Bleuler referred to the suicidal drive as ‘the most serious of schizophrenic symptoms’, and in 1919, Kraepelin noted that suicide occurred in the acute and chronic stages of the disorder (3). More recent studies, including a meta-analysis (4), have found a lifetime suicide mortality rate of 4–6% (1, 4–6), while earlier data suggested that 10–13% (7–9) of patients with schizophrenia commit suicide. Approximately 2–12% of all suicides are attributable to schizophrenia (10). Even in first psychotic episodes of schizophrenia, the rate of completed suicides is 2.4% in the first 5 years of the disease, with a rate of 0.48% year (11). The prevalence of schizophrenia among patients dying by suicide is even higher in in-patient settings (12, 13). Many factors are involved in the suicidal process, some of which differ from the general population (12–15). Knowing which factors are associated with suicide of patients diagnosed with schizophrenia could improve clinical management, guide further research and develop strategies to reduce the incidence of suicide in this population. As will be discussed in detail in the present paper, various studies have investigated risk factors for suicide in schizophrenia, with the identification of several, sometimes contradictory, findings. Most reported risk factors were not conclusive enough to identify a causal link, and extrapolating clinically helpful information remains challenging. For this reason, we have searched for a consensus arising from the experience and judgment of clinicians and academic experts on schizophrenia, guided by the available research findings. A steering committee formed of Spanish experts on the subject was formed to review the evidence base for suicide and schizophrenia and to formulate clinical recommendations based on a consensus derived through repeated iterations of findings. Subsequently, 52 clinicians with recognized clinical expertise on schizophrenia were gathered in a specific meeting and asked to express their consent with the proposed recommendations using a Delphi method.
Delphi method was created in the context of structuring a group communication process to allow a group of individuals, as a whole, to deal with a complex problem (16). Originating from the cold war era, the Delphi method was developed for defence technology forecasting (17) and, along with other expert panel methods for planning for the future, is currently widely utilized in health and social sciences, and lately, also in the field of psychiatry (18, 19). Aims of the study
The aims of the task force were to carry out a thorough and balanced review of research findings and to integrate them into a consensus based on clinical experience and judgment as well as evidence and to provide a synthesis of current knowledge and resulting clinical recommendations pertaining to this important topic. The present report represents a consensus statement from this endeavour.
Material and methods Search strategies
A comprehensive computerized literature search of all the articles on MEDLINE/PubMed, as well as conference abstracts published up to June 2013, was performed using the search terms ‘schizophren* AND suicid* AND clinical risk factors’. The search was supplemented by manually reviewing reference lists from the identified publications. Studies were included if they reported the characteristics of a sample of psychiatric patients diagnosed with schizophrenia who committed suicide, compared with a control group of psychiatric patients with similar characteristics who did not commit suicide, employed a case–control, nested case–control or cohort control design. Exclusion criteria included: absence of inadequate statistical analysis or power, conclusions not warranted by reported findings, use of unclear diagnostic or, in the presence of samples not entirely composed of patients with schizophrenia, lack of analysis regarding exclusively patients with schizophrenia, unclear or invalid outcome criteria, poorly described samples. The search yielded 262 articles, which were reduced to 216 when we limited the search to English-language articles and human studies. We also examined the lists of references in recently published reviews and hand-searched the reference lists of the studies located by electronic searches in English or Spanish language. All the articles were independently reviewed by two 419
Popovic et al. authors (DP and EV) regarding the overall methodological quality and relevance to the questions at hand. Discrepancies were resolved by consensus. The results were presented to the steering committee who reached a consensus regarding most relevant items to deduct from the systematic review and present to the expert group. Selection of factors
We aimed to examine risk factors that are likely to be routinely assessed in clinical practice. These included demographic, biologic and clinical factors (including aspects of patient’s psychiatric history, patient’s mental state, psychiatric diagnoses and treatment). To minimize the likelihood of Type I errors, we have included the factors reported in at least five studies and/or reported in meta-analysis. Delphi method
Following the systematic review, a survey using the Delphi method was performed to form the recommendations. It involved a formal iterative process used to develop consensus on relevant issues in clinical risk factors for suicide in schizophrenia. Delphi studies, which are used to clarify and enrich current knowledge in controversial issues, require that the participants rate the extent of their agreement with a series of statements/items (20–22). The participants responded anonymously, using a survey programme, and without knowing other participants’ responses. Statements or items on clinical risk factors for suicide in schizophrenia that could be relevant and useful for clinicians were gathered from the content of literature search. Endorsed items were the items rated as essential or important by at least 80% of participants and included in the recommendations. Re-rated items: Items rated as essential or important, which were included by 65–79% of panel experts, were included in the next survey for re-rating after first-round results feedback. Panel members could decide whether they wanted to maintain or change their previous rating on these controversial items. Items were only re-rated once, and if they did not achieve the criteria for endorsement, they were rejected. Rejected items were items with lower consensus levels than the above described (
© 2014 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd ACTA PSYCHIATRICA SCANDINAVICA
Clinical overview
Risk factors for suicide in schizophrenia: systematic review and clinical recommendations Popovic D, Benabarre A, Crespo JM, Goikolea JM, Gonzalez-Pinto A, Gutierrez-Rojas L, Montes JM, Vieta E. Risk factors for suicide in schizophrenia: systematic review and clinical recommendations. Objective: To identify risk factors associated with suicide of patients with schizophrenia and provide clinical recommendations, which integrate research findings into a consensus based on clinical experience and evidence. Method: A task force formed of experts and clinicians iteratively developed consensus through serial revisions using the Delphi method. Initial survey items were based on systematic literature review published up to June 2013. Results: Various risk factors were reported to be implicated in suicide in schizophrenia. Our findings indicate that suicide risk in schizophrenia is mainly related to affective symptoms, history of a suicide attempt and number of psychiatric admissions. Other risk factors identified are given by younger age, closeness to illness onset, older age at illness onset, male sex, substance abuse and period during or following psychiatric discharge. Integrating the evidence and the experience of the task force members, a consensus was reached on 14 clinical recommendations. Conclusion: Identification of risk factors for suicide in individuals diagnosed with schizophrenia is imperative to improve clinical management and develop strategies to reduce the incidence of suicide in this population. This study provides the critical overview of available data and clinical recommendations on recognition and management of the above-mentioned risk factors.
D. Popovic1, A. Benabarre1,
J. M. Crespo2, J. M. Goikolea1, A. Gonzalez-Pinto3, L. GutierrezRojas4, J. M. Montes5, E. Vieta1 Bipolar Disorders Program, Hospital Clınic, IDIBAPS, CIBERSAM, University of Barcelona, Barcelona, Catalonia, 2Department of Psychiatry, Bellvitge Biomedical Research Institute (IDIBELL), CIBERSAM, University Hospital of Bellvitge, Barcelona, 3Department of Psychiatry, CIBERSAM, Kronikgune, EHU, Hospital Universitario de Alava, Vitoria, 4Psychiatry Service, San Cecilio University Hospital, Granada, and 5Department of Psychiatry, Centro de Investigacin Biomedica de Salud Mental, CIBERSAM, Hospital Universitario del Sureste, Madrid, Spain
1
Key words: schizophrenia; suicide; risk factors; clinical recommendations Eduard Vieta, Department of Psychiatry and Psychology, Hospital Clínic, 170 Villarroel st., 08036 Barcelona, Catalonia, Spain. E-mail: [email protected]
Accepted for publication August 14, 2014
Clinical recommendations
• In-patients and out-patients with diagnosis of schizophrenia present different risk factors for suicide. • Suicide risk in schizophrenia is mainly related to affective symptoms, history of a suicide attempt and •
number of psychiatric admissions. Other risk factors are younger age, closeness to illness onset, older age at illness onset, male sex, substance abuse and period during or immediately after psychiatric discharge. 14 clinical recommendations for recognition and management of risk factors for suicide in schizophrenia are provided derived from integration of evidence and expertise of 60 clinicians.
Additional comments
• Research on suicide in schizophrenia has brought to identify various, sometimes contradictory, risk factors for suicide, but most are not conclusive enough to identify a causal link.
• Issues related to the design of the original clinical trials may have influenced the results. Please also see editorial comment to this paper by Matthew Large (Acta Psychiatr Scand 2014;130:415–417).
418
Risk factors for suicide in schizophrenia Introduction
The characteristic symptoms of schizophrenia involve a wide range of cognitive, behavioural and emotional dysfunctions. The diagnosis involves a constellation of signs and symptoms associated with impaired occupational or social functioning (1). There is a close relationship between schizophrenia and suicide. The first commentary on the ‘mortality of lunacy in England and Wales’ goes back to 1662 (2). In 1911, Bleuler referred to the suicidal drive as ‘the most serious of schizophrenic symptoms’, and in 1919, Kraepelin noted that suicide occurred in the acute and chronic stages of the disorder (3). More recent studies, including a meta-analysis (4), have found a lifetime suicide mortality rate of 4–6% (1, 4–6), while earlier data suggested that 10–13% (7–9) of patients with schizophrenia commit suicide. Approximately 2–12% of all suicides are attributable to schizophrenia (10). Even in first psychotic episodes of schizophrenia, the rate of completed suicides is 2.4% in the first 5 years of the disease, with a rate of 0.48% year (11). The prevalence of schizophrenia among patients dying by suicide is even higher in in-patient settings (12, 13). Many factors are involved in the suicidal process, some of which differ from the general population (12–15). Knowing which factors are associated with suicide of patients diagnosed with schizophrenia could improve clinical management, guide further research and develop strategies to reduce the incidence of suicide in this population. As will be discussed in detail in the present paper, various studies have investigated risk factors for suicide in schizophrenia, with the identification of several, sometimes contradictory, findings. Most reported risk factors were not conclusive enough to identify a causal link, and extrapolating clinically helpful information remains challenging. For this reason, we have searched for a consensus arising from the experience and judgment of clinicians and academic experts on schizophrenia, guided by the available research findings. A steering committee formed of Spanish experts on the subject was formed to review the evidence base for suicide and schizophrenia and to formulate clinical recommendations based on a consensus derived through repeated iterations of findings. Subsequently, 52 clinicians with recognized clinical expertise on schizophrenia were gathered in a specific meeting and asked to express their consent with the proposed recommendations using a Delphi method.
Delphi method was created in the context of structuring a group communication process to allow a group of individuals, as a whole, to deal with a complex problem (16). Originating from the cold war era, the Delphi method was developed for defence technology forecasting (17) and, along with other expert panel methods for planning for the future, is currently widely utilized in health and social sciences, and lately, also in the field of psychiatry (18, 19). Aims of the study
The aims of the task force were to carry out a thorough and balanced review of research findings and to integrate them into a consensus based on clinical experience and judgment as well as evidence and to provide a synthesis of current knowledge and resulting clinical recommendations pertaining to this important topic. The present report represents a consensus statement from this endeavour.
Material and methods Search strategies
A comprehensive computerized literature search of all the articles on MEDLINE/PubMed, as well as conference abstracts published up to June 2013, was performed using the search terms ‘schizophren* AND suicid* AND clinical risk factors’. The search was supplemented by manually reviewing reference lists from the identified publications. Studies were included if they reported the characteristics of a sample of psychiatric patients diagnosed with schizophrenia who committed suicide, compared with a control group of psychiatric patients with similar characteristics who did not commit suicide, employed a case–control, nested case–control or cohort control design. Exclusion criteria included: absence of inadequate statistical analysis or power, conclusions not warranted by reported findings, use of unclear diagnostic or, in the presence of samples not entirely composed of patients with schizophrenia, lack of analysis regarding exclusively patients with schizophrenia, unclear or invalid outcome criteria, poorly described samples. The search yielded 262 articles, which were reduced to 216 when we limited the search to English-language articles and human studies. We also examined the lists of references in recently published reviews and hand-searched the reference lists of the studies located by electronic searches in English or Spanish language. All the articles were independently reviewed by two 419
Popovic et al. authors (DP and EV) regarding the overall methodological quality and relevance to the questions at hand. Discrepancies were resolved by consensus. The results were presented to the steering committee who reached a consensus regarding most relevant items to deduct from the systematic review and present to the expert group. Selection of factors
We aimed to examine risk factors that are likely to be routinely assessed in clinical practice. These included demographic, biologic and clinical factors (including aspects of patient’s psychiatric history, patient’s mental state, psychiatric diagnoses and treatment). To minimize the likelihood of Type I errors, we have included the factors reported in at least five studies and/or reported in meta-analysis. Delphi method
Following the systematic review, a survey using the Delphi method was performed to form the recommendations. It involved a formal iterative process used to develop consensus on relevant issues in clinical risk factors for suicide in schizophrenia. Delphi studies, which are used to clarify and enrich current knowledge in controversial issues, require that the participants rate the extent of their agreement with a series of statements/items (20–22). The participants responded anonymously, using a survey programme, and without knowing other participants’ responses. Statements or items on clinical risk factors for suicide in schizophrenia that could be relevant and useful for clinicians were gathered from the content of literature search. Endorsed items were the items rated as essential or important by at least 80% of participants and included in the recommendations. Re-rated items: Items rated as essential or important, which were included by 65–79% of panel experts, were included in the next survey for re-rating after first-round results feedback. Panel members could decide whether they wanted to maintain or change their previous rating on these controversial items. Items were only re-rated once, and if they did not achieve the criteria for endorsement, they were rejected. Rejected items were items with lower consensus levels than the above described (
