Depression and suicidal ideation in schizophrenia spectrum disorder: a cross-sectional study from a lower middle-income country

Abstract

Objectives

Depression has long been considered a significant feature of schizophrenia and is associated with more frequent psychotic episodes, increased service utilisation, substance misuse, poor quality of life and completed suicide. However, there is a distinct lack of literature on this comorbidity from low- and middle-income countries or non-western cultural backgrounds.

Methods

This is a cross-sectional analysis of baseline data from a large randomised controlled trial, examining the prevalence of depression and suicidal ideation in patients with schizophrenia spectrum disorder. A total of 298 participants were recruited from inpatient and outpatient psychiatric units in Karachi, Pakistan. Participants completed the Calgary Depression Scale for Schizophrenia (CDSS), Positive and Negative Syndrome Scale (PANSS), Euro Qol (EQ-5D) and Social Functioning Scale (SFS).

Results

Data indicate that 36% of participants in the study were depressed and 18% endorsed suicidal ideation. Depression was associated with higher positive symptom scores and reduced quality of life, but no significant difference in negative symptoms and social functioning.

Conclusions

Depression and suicidal ideation are prevalent in Pakistani patients diagnosed with schizophrenia spectrum disorder. Evaluation of depressive symptoms in this group may help identify individuals at higher risk of completed suicide, allowing for targeted interventions to improve outcomes.

Key points

• To our knowledge, this is the first study describing the prevalence of depression and suicidal ideation in individuals with schizophrenia from Pakistan.

• Our data indicate that 36% of individuals with schizophrenia in our sample were depressed and 18% endorsed suicidal ideation.

• Depression in schizophrenia was associated with poorer quality of life and higher positive symptom burden.

• This study adds to the scarce literature from low- and middle-income countries where the burden of mental illness is great and where the majority of suicide deaths occur.

• Addressing social inequality, food insecurity, high rates of unemployment and low levels of literacy in these settings may have a profound effect on population mental health and suicide risk.

Keywords:

• Schizophrenia
• depression
• suicide
• low and middle income
• psychosis Pakistan

Acknowledgements

This study was funded by the Stanley Medical Research Institute. The sponsor of the study had no role in the study design, data collection, analysis of the data, data interpretation or writing of the manuscript. The study was supported in part by an Academic Scholars Award from the Department of Psychiatry, University of Toronto to MIH.

Ethics approval and consent to participate

Ethical approval was obtained from DUHS (Dow University of Health Sciences, Karachi) research Ethics Committee (Reference: (IBR-185/DUHS-10) and from the ethics committee of the Pakistan Institute of Learning and Living (PILL/SMRI/10410)). Confidentiality was protected by anonymizing data. No participant was identified in any analysis. Data protection considerations were fully complied with. Any participant who wished to withdraw for any reason from the project had the right to do so at any time with no negative impact on their ongoing management.

Author contributions

M.O.H., A.B.K., Z.K. and M.I.H. contributed to the interpretation of results and drafted the manuscript. The idea of the study was conceived by M.O.H., I.B.C., N.H., N.H. and I.B.C. shared responsibility for the training and supervising researchers as well as preparing the manuscript. A.B.K. and T.K. contributed to recruitment of participants in the primary study and carrying out assessments. T.K. also contributed to the draft of the manuscript. P.B. contributed to statistical analysis and writing of the manuscript. R.U. made intellectual contribution to the interpretation and assisted in writing of the manuscript. All authors have read and approved the final manuscript.

Disclosure statement

None of the authors have any conflicts of interest related to the present work.

IBC and NH have given lectures and advice to Eli Lilly, Bristol Myers Squibb, Lundbeck, Astra Zeneca and Janssen pharmaceuticals for which they or their employing institution have been reimbursed. IBC, MIH and NH were previously trustees of the Pakistan Institute of Living and Learning. MIH is a principal investigator for a clinical trial sponsored by COMPASS Pathways Limited. NH is chair of board of Trustees of Manchester Global Foundation.

Data availability statement

The datasets used and/or analysed during the current study are available from the corresponding author on reasonable request.

Additional information

Funding

Stanley Medical Research Institute funded the primary study. The sponsors had no role in the study design, collection of data, data analysis, data interpretation or writing of the manuscript.