Schizophrenia and Suicidal Tendencies
Yes, schizophrenia is strongly associated with suicidal tendencies, with approximately 10% of individuals with schizophrenia dying by suicide and suicide attempts occurring at 2-5 times that rate. 1, 2
Magnitude of Suicide Risk
The suicide rate in schizophrenia is greatly increased compared to the general population, making it the leading cause of premature death in this disorder. 3, 4
Approximately 10-13% of deaths in schizophrenia are explained by suicide, despite widespread availability of antipsychotic treatments. 1, 4
The risk of suicide or accidental death directly due to psychotic thinking is at least 5% in early-onset schizophrenia, though this may underestimate lifetime risk. 3
Mental health professionals who care for individuals with schizophrenia must be aware of their substantially greater risk for suicide. 3
High-Risk Periods Throughout the Illness Course
Suicide risk is greatest early in the course of schizophrenic illness but continues throughout life. 5
Patients with schizophrenia are at substantially elevated suicide risk throughout the first decade of their disorder, though they continue to be at elevated risk during their entire lives with times of worsening or improvement. 1
High-risk periods include: early phase of the disease, active illness phase, periods of relapse, during depressive episodes, and shortly after hospital discharge. 2, 4
Key Risk Factors Specific to Schizophrenia
Demographic and Psychosocial Factors
Younger age, male sex, being unmarried, living alone, and being unemployed increase suicide risk. 1, 2
Paradoxically, higher intelligence, better education, good premorbid adjustment, and high personal expectations increase risk—particularly when patients understand that life's expectations are not likely to be met. 1, 2
Recent life events (within past 3 months), poor work functioning, and access to lethal means (especially firearms) elevate risk. 1
Clinical and Symptom-Related Factors
Comorbid depression is one of the most important contributors to suicide risk in patients with schizophrenia. 1, 2
Active psychotic symptoms, severe panic-like symptoms, and awareness of symptoms (especially awareness of delusions, anhedonia, asociality, and blunted affect) increase risk. 5, 1, 2
History of previous suicidal behavior is a strong predictor, and contrary to common belief, schizophrenic patients often communicate their suicidal intents shortly before death. 1, 4
Hopelessness, reduced self-esteem, stigma, isolation, and recent loss or stress are major contributors. 2, 4
Treatment-Related Factors
Treatment non-adherence and negative feelings about treatment are associated with greater suicide risk. 1, 2
Neuroleptic-induced akathisia and akinesia can trigger suicidal behavior and must be avoided. 5, 2, 4
Being recently discharged from the hospital represents a particularly high-risk period. 2
Critical Clinical Management Approach
The American Psychiatric Association recommends that patients with schizophrenia be treated with clozapine if the risk for suicide attempts or suicide remains substantial despite other treatments. 3
Effectively treating positive symptoms and depression, reducing substance abuse, avoiding akathisia, addressing demoralization, and instilling hope are essential elements in reducing suicidality. 5
Atypical antipsychotics (particularly clozapine) and cognitive behavioral therapy appear useful in reducing suicidality in schizophrenia. 5, 2
Additional interventions may be needed to address comorbid conditions or associated sequelae of the disorder, such as substance abuse, depression, and suicidality. 3
Important Clinical Pitfalls
Do not assume that absence of depression means absence of suicide risk—almost half of suicide attempts in schizophrenia occur outside of major depressive episodes. 6
The relatively low ratio of attempts to completed suicides in schizophrenia reflects greater lethality of means (more violent methods) and intents (less ambivalence) in this population. 4
Family history of suicide is associated with heightened risk and is independent of the psychiatric diagnosis. 4
The only reliable protective factor for suicide in patients with schizophrenia is provision of and compliance with comprehensive treatment. 1