Abstract
Suicidal behavior and suicide is prevalent in schizophrenia, with an estimated lifetime risk of approximately 5%. The risk is particularly high in the early phases of the disorder, and especially during the years around treatment initiation. Suicide attempts before first treatment contact are also prevalent, with the risk of suicide attempt associated with the length of untreated illness. Several risk factors are in common with the general population, and include previous suicide attempts, impulsive personality traits, substance abuse, depression and feelings of hopelessness. Recent research examines how patients’ subjective experiences, including their insight into having a severe mental illness and their beliefs about mental illnesses, may influence suicidal behavior. In this article, we will present a review of studies illustrating the complex background of suicide risk in schizophrenia, with a particular emphasis on the role of insight in the early phases of schizophrenia.
Methods & limitations
This review is based on a comprehensive literature search in Medline and PsycLit using the search terms “suicide” or “suicidal” and “schizophrenia”. For the first part and general part, the review is selective based on the authors’ choice of what, by most, are considered key publications in the field. For the second and more specific part, the first search was narrowed down using the search terms “first episode psychosis”, “insight” and “beliefs about psychosis”. The review does not use meta-analytic techniques.
Suicidal behavior in the general population
Suicidal behaviors are complex phenomena, influenced by the individual’s psychology, biology, culture, and social and political environment Citation[1]. They vary in severity, from suicidal ideas through to gestures, risky lifestyles, suicidal plans and suicidal attempts to completed suicide Citation[2]. A common definition of suicide is self-inflicted death, with explicit or implicit evidence that the person intended to die Citation[3], while suicide attempts usually involve self-injurious behavior with the intent to die. Suicidal ideas are thoughts of serving as the agent of one’s own death and vary in their severity depending on the specificity of suicidal plans and degree of suicidal intent Citation[4].
Suicide accounts for approximately 1.5% of all deaths, making it the tenth leading cause of death worldwide Citation[5]. The prevalence of suicide varies between regions and countries, with the lowest annual rates in Latin America and Muslim countries (<6.5 suicides per 100,000 persons per year), the highest rates in Eastern Europe (>27 suicides per 100,000 persons per year) Citation[6] and with the rates in the UK, USA and most of the Nordic countries in the mid-range (12–18 per 100,000 persons per year for men) Citation[1]. Suicide rates in immigrants tend to be more similar to rates in their native country than to rates in their current country of residence Citation[7,8]. Suicide rates are usually highest in the elderly, even if they have increased in the young and decreased in the elderly over the past 50 years Citation[9]. Men generally die by suicide more often than women (2–4:1 ratio) Citation[10], while suicide attempts on the other hand are more prevalent among women Citation[11].
There are no national or international surveillance systems for the monitoring of suicide attempts Citation[12], which are actually believed to be more prevalent than successful suicides (an estimated 10–25:1 ratio) Citation[2]. Suicidal thoughts are even more common, as nearly 15% of American youths report having seriously considered suicide within the previous year Citation[4]. The different suicidal behaviors are linked to each other, as suicidal thoughts are related to increased risk for suicide attempts Citation[13], the risk of attempts is higher in the context of a suicidal plan Citation[14,15], one suicide attempt increases the risk for later attempts and a history of suicide attempts is the strongest risk factor for later death by suicide. There are indications of previous attempts present in approximately 40% of deaths by suicide Citation[10,16].
The risk of suicidal behavior is related to personality traits, in particular to impulsive and aggressive traits. Risk is also related to cognition, in particular to disadvantageous decision-making processes, affective lability and stress response disturbances Citation[17–19]. The search for possible biomarkers has focused on serotonergic neurotransmission, as earlier studies have reported an association between suicidal behavior and low levels of the serotonin metabolite 5-hydroxyindoleacetic acid in the cerebrospinal fluid in depressed patients. However, more recent studies fail to show such associations for other patient groups outside of patients with depression Citation[20,21]. Low serum cholesterol levels have been associated with increased suicide risk. Suggested mechanisms behind this increased risk have included interactions between cholesterol and serotonergic function in the CNS Citation[22].
Twin and adoption studies show a clear genetic influence on suicide risk Citation[23,24]. Most molecular genetic studies carried out so far have been candidate gene studies of the serotonergic system, with reports of possible associations between several genetic variants in suicidal behavior, but current results are partly conflicting Citation[25]. Other studies have focused on the genetics of neurotrophins (proteins that induce the survival and development of neurons); again with conflicting results Citation[26,27].
Suicidal behavior in severe mental disorders
More than 90% of individuals who die by suicide in Europe and the USA have a mental disorder at the time of death Citation[16,28]. Mood disorders (in particular depression) are most commonly associated with suicide, followed by substance use-related disorders (in particular, alcohol use disorders), schizophrenia and personality disorders (in particular, borderline and antisocial personality disorders) Citation[28,29]. Comorbidity of disorders increases the suicide risk.
Patients with schizophrenia spectrum psychotic disorders have a particularly high prevalence of suicide and suicidal behaviors. Suicide is the leading single cause of premature death among patients with schizophrenia, with a 12-times increased risk of dying by suicide compared with the general population Citation[30] and estimates that 5–13% of patients with schizophrenia will die by suicide Citation[31,32]. While the 13% risk gives the percentage of a sample who died by suicide at the point of follow-up (proportional mortality), the 5% risk reflects the percentage of an original sample who died by suicide (case–fatality rate). As proportionate mortality estimates assume a constant suicide risk over a lifetime, it overestimates the suicide risk in schizophrenia and the 5% figure is therefore probably the most accurate. The prevalence of nonfatal suicidal behavior in schizophrenia is significantly higher, with suicidal ideation and suicide attempts seen in approximately 50% of patients Citation[33]. When a patient with schizophrenia brings up the issue of suicide, this should always raise clinical concern.
General risk factors for suicide & suicidal behavior in schizophrenia
Models of suicidal behavior in severe mental disorders must address questions about both factors that contribute to long-term vulnerability, precipitating factors in the here-and-now, and factors that might be both trait and state dependent Citation[34]. The most consistent demographic risk factor for suicide across all populations is being white and male. The case is the same in schizophrenia, even if gender differences are less pronounced Citation[35,36]. While the absolute risk for suicide is also highest in older patients with schizophrenia, patients die by suicide at a younger age, with the highest relative risk (compared with the general population) in the age range 22–40 years Citation[36].
The most important risk factor for suicide in patients with schizophrenia is previous suicide attempts, and these attempts appear to be more serious than in the general population. Other major risk factors shared with the general population are the presence of depression, feelings of hopelessness and lack of social support Citation[36,37], higher levels of impulsive–aggressive personality traits Citation[38], and drug misuse or dependency Citation[35,39].
Illness-related risk factors for suicide in schizophrenia
Patients with a more severe course of illness have an increased suicide risk. This includes patients with more relapses, using higher doses of medication and/or with more frequent or longer hospitalizations, and the risk is higher within the first few weeks after hospital discharge Citation[36]. In addition, poor treatment adherence to medical or psychosocial treatments is associated with an increase in suicide rates Citation[35]. The presence of an active psychotic illness (i.e., relapses or exacerbations with high levels of psychotic symptoms) is also associated with increased suicide risk Citation[40–42]. However, studies of the relationship with specific psychotic symptoms, such as delusions or hallucinations, have inconsistent findings Citation[43,35,36]. There are indications that a clinical picture characterized mainly by hallucinations rather than delusions is associated with an increased risk Citation[44,45], and there have been reports of attempted Citation[46] or completed suicides Citation[47] as a result of command hallucinations. Patients with monosymptomatic hallucinations or patients experiencing command hallucinations are relatively rare, so these are not common causes of suicidal behavior in schizophrenia Citation[36].
Cognitive impairments, including episodic memory, processing speed, verbal fluency, attention, executive function and working memory dysfunctions, are highly prevalent in schizophrenia, independent of clinical symptoms and antipsychotic medications. Suicidality in schizophrenia has been found to be associated with higher IQ in some, but not all, studies examining this relationship Citation[48–50]. There are also few and inconsistent findings regarding the relationship between suicidality and specific cognitive domains; while some find indications of better executive functioning in patients with a history of suicide attempts Citation[48–50], others do not find any associations with suicidal behaviors Citation[51].
Suicidal behavior in the early phases of schizophrenia
The risk for suicide is highest in the early phases of schizophrenia spectrum disorders Citation[32,52]. Even if the risk continues over the course of the disorder Citation[53], most deaths by suicide take place within the first decade after treatment starts, with approximately 50% occurring within the first 2 years Citation[36]. Parallel patterns are seen in severe affective disorders, including major depression Citation[54] and bipolar disorder Citation[10]. This is somewhat at odds with the view that suicidal behavior is primarily due to the negative consequences of a chronic disorder. One reason for the early risk may be that important risk factors, such as depression Citation[35] and substance use Citation[55], are prevalent both in the early treated period and before treatment starts Citation[56,57]. Other subjective experiences with possible relations to suicidal behavior, such as self disorders, are also prevalent in this phase of illness Citation[58].
There are also clear indications of an increased risk of suicidal behavior before the start of a first treatment, and 14–28% of patients with first-episode psychosis have attempted suicide prior to their first treatment contact Citation[59–61]. There are even indications that untreated psychotic patients have higher risks for violent and potentially lethal methods of attempting suicide than treated patients Citation[62]. The period between onset of the first psychotic episode and the start of treatment (the period of untreated psychosis) can, in some cases, be alarmingly long. Studies indicate that 7–14% of patients attempt suicide or are engaged in self-harm in this period Citation[61,63–65]. Some find that a longer duration of untreated psychosis is associated with increased risk for suicidal behavior Citation[63,65,66], but this finding is not consistent Citation[64,67–69]. Focusing explicitly on this period, we found that a longer duration of untreated psychosis was associated with more attempts in this period, but not before onset of psychosis Citation[61]. This supports the view that shortening the duration of untreated psychosis may reduce the risk of severe suicidal behavior at the start of first treatment Citation[70].
Insight, subjective experiences & suicidal behavior
Poor insight, or lack of awareness of being ill, is considered a key feature of psychosis and has been seen by many as the actual defining characteristic of a psychotic disorder. Traditionally, insight was viewed as a unitary concept and an ‘all or none’ phenomenon, comprising the patients’ experience of their disorder. More recently, insight has been viewed as a multidimensional and continuous construct. David defined insight along three overlapping dimensions: the individual’s recognition of having a mental illness; compliance with treatment; and ability to relabel unusual mental events as pathological Citation[71]. Poor insight is found in all psychotic disorders, and is most pronounced in schizophrenia and bipolar disorder Citation[72,73]. As many as 50–80% of patients with schizophrenia do not believe they have any disorder at all Citation[74]. Lack of insight does not seem to be a static phenomenon. Although it may persist in some patients Citation[75], insight may also improve during treatment Citation[76].
Overall, insight has been found to have contradictory associations with outcome. Higher insight is associated with lower symptom levels Citation[77], better treatment adherence and social functioning Citation[78], and better work performance Citation[79]. However, for some patients, higher insight is also associated with more feelings of depression Citation[77] and hopelessness Citation[80], and a lower quality of life Citation[81]. In patients with delusions, low insight is associated with better self acceptance, and a higher sense of autonomy and personal growth than high insight Citation[82]. Insight has also been related to suicidal behavior. Several studies indicate that high levels of insight, or aspects of insight, may increase the risk for suicidal behavior Citation[60,64,83–86]. Others find no relationships between insight and suicidality Citation[35,87], and a few studies report a protective effect of insight Citation[88,89], possibly through increasing compliance with treatment.
Another possible explanation for the association between high insight and suicidality is that individuals with good premorbid adjustment and high insight are more demoralized by their illness, a model that receives some support from empirical studies Citation[87]. Another hypothesis in line with this is that of the assumed consequences of psychotic disorders (i.e., fear of mental disintegration may increase the risk for suicide) Citation[35]. One possible explanation for the apparently contradictory findings regarding insight is thus that the impact of insight depends on meanings attached to the disorder Citation[90], or in other words, the patients’ beliefs about psychotic disorders. While insight into psychosis involves acceptance of a personal illness regardless of knowledge and facts about their illness Citation[71], beliefs about psychosis are cognitions about causation, treatment options and prognosis of psychotic disorders Citation[91].
In general, beliefs about psychotic disorders seem to be highly negative, and schizophrenia in particular appears to be among the most stigmatized of mental disorders Citation[92]. People with schizophrenia are considered unpredictable and dangerous; elicit uneasiness, uncertainty and fear in other people; and pessimistic beliefs about the course of schizophrenia prevail. In addition, very negative views about pharmacological treatments for mental disorders are common Citation[93]. Beliefs about illness may shape the emotional responses to illness and the ensuing health-related behavior. It is not unlikely that patients who receive a diagnosis of schizophrenia can be influenced by the existing negative beliefs about schizophrenia. Studies show that negative illness perceptions have been related to depression and post-psychotic depression, anxiety and low self-esteem Citation[94–96], and to suicidality Citation[97].
It is therefore possible that the impact of insight on suicidality will depend upon the individual’s beliefs about psychosis. A patient who believes that having a psychotic disorder necessarily leads to a deteriorating mental state can react differently to the insight of having this disorder with a more optimistic view on the course of the disorder. In line with this, several studies indicate that beliefs about psychosis can moderate the association between insight and other aspects of outcome, as patients with high insight and low levels of stigmatizing beliefs report lower levels of depression, more hope, better self-esteem and better quality of life than patients with high insight and high levels of negative beliefs Citation[91,98].
A relatively current review suggests that reports of associations between insight and previous suicidal attempts in cross-sectional studies may be based on selection and recall bias in depressed patients Citation[99]. However, in a more recent study, we examined the moderating effect of beliefs about psychosis on the relationship between insight and current suicidal behavior. Here, we found that high levels of both insight and of negative beliefs had an independent negative influence on suicidal behavior, without signs of statistical mediation or moderation. This effect was present even after correcting for current levels of depression, indicating that apparent insight or negative beliefs were not just epiphenomena of depressive mood Citation[100].
Expert commentary
Suicidal behavior is a significant clinical problem in the treatment of schizophrenia in general, and in the treatment of people with first-episode psychosis in particular. Several significant risk factors, such as substance abuse and depression, are prevalent in this particular patient population, and their evaluation should be a significant part of clinical risk assessment Citation[101]. Specific to psychotic disorders is the possible link between high insight and suicidality, particularly in patients with negative beliefs about psychotic illnesses. The combination of previous suicide attempts, negative views on course and outcome, depression and hopelessness in the context of increasing insight and increasing suicidal ideation should be taken as indications of high suicide risk.
The clinical consequences of this are that suicidal behavior, level of depression, feelings of hopelessness and level of insight should be monitored closely during treatment. Clinical depression should be treated adequately. While the emergence of insight is a positive sign associated with remission of psychotic symptoms, patients in this phase of development should be monitored even more closely for indications of suicidal behavior. Patients are often transferred from inpatient to outpatient treatment at this point in time, so the emergence of insight may also coincide with the perceived loss of important treatment and social contacts. It is important to ensure continuity of care to the next treatment level. Adequate treatment of psychotic symptoms, with the simultaneous aim of reducing stressful side effects such as akathisia, is of essence. The use of clozapine might be considered for patients with persistent severe suicidal behavior. We also need to pay attention to possible side effects of psychosocial interventions. Information given to increase knowledge about psychotic disorders within the framework of psychoeducational interventions may be interpreted negatively by patients. It is important that the patients’ perception of the information is discussed, and that there are efforts to install realistic hopes of a positive outcome. Moreover, therapists should be aware that an increase in cognitive insight through cognitive behavioral therapy may temporarily increase suicidal ideation.
Five-year view
There are currently several lines of development that are important for progress in this area. Several large prospective studies of first-episode patients are expected to publish results on long-term course and outcome within the next few years. These studies will give us important new data on the development of suicide risk over the course of the disorders and on the relevant risk factors at different points in time. In addition, the current explorations of the role of subjective experiences in relation to suicidal behavior may help to identify personal markers of increased suicide risk, which can be used in treatment settings and for personal risk assessments. Finally, the immense research activity in molecular genetics, including genome-wide association studies, will hopefully give us new information on the biological underpinnings of suicide risk. This may aid the development of clinically useful biomarkers.
Key issues
• Suicide and suicidal behaviors are common in schizophrenia and related psychotic disorders.
• Suicide attempts in schizophrenia are often with more violent and lethal methods.
• The early treated phase of the disorder is a period of particularly high risk.
• Risk factors for suicide and suicidal behaviors are, to a large extent, the same as in the general population.
• These risk factors include previous suicide attempts, impulsive personality traits, drug abuse, depression and feelings of hopelessness.
• While a more severe course of illness may increase risk, there are no clear indications of a particular risk associated with specific psychotic symptoms, such as delusions and hallucinations. Insight into having a severe mental illness may increase suicide risk.
• Negative beliefs about psychotic disorders may increase suicide risk.
Financial & competing interests disclosure
The authors have no relevant affiliations or financial involvement with any organization or entity with a financial interest in or financial conflict with the subject matter or materials discussed in the manuscript. This includes employment, consultancies, honoraria, stock ownership or options, expert testimony, grants or patents received or pending, or royalties.
No writing assistance was utilized in the production of this manuscript.
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