Managing suicide risk in patients with schizophrenia

Abstract

The management of suicide risk in patients with schizophrenia poses many challenges for clinicians. Compared with the general population, these patients have an 8.5-fold greater risk of suicide. This article reviews the literature dealing with the treatment of at-risk patients with schizophrenia. An integrated psychosocial and pharmacological approach to managing this population of patients is recommended. Although there is at least modest evidence suggesting that antipsychotic medications protect against suicidal risk, the evidence appears to be most favourable for second-generation antipsychotics, particularly clozapine, which is the only medication approved by the US FDA for preventing suicide in patients with schizophrenia. In addition, treating depressive symptoms in patients with schizophrenia is an important component of suicide risk reduction. While selective serotonin receptor inhibitors (SSRIs) ameliorate depressive symptoms in patients with schizophrenia, they also appear to attenuate suicidal thoughts. Further research is needed to more effectively personalize the treatment of suicidal thoughts and behaviours and the prevention of suicide in patients with schizophrenia.

Fig. 1

Results from the InterSePT (International Suicide Prevention Trial)[95] with Kaplan-Meier estimates of the probability of a suicide attempt or hospitalization to prevent suicide. The p-value refers to the Cox proportional hazards regression model. The model included treatment, number of previous suicide attempts, active substance or alcohol abuse, country, sex and age group at baseline. The model showed that there was a 26% reduction in risk for suicide attempt or hospitalization to prevent suicide for those randomized to clozapine vs those randomized to olanzapine. The hazard ratio was 0.74 (95% CI 0.57, 0.96) [reproduced from Meltzer et al.,[95] with permission from the Archives of General Psychiatry].