A recent systematic review indicates that there are a number of reliable individual risk factors for schizophrenia and suicide as well as attempted suicide.Furthermore, people with schizophrenia do communicate their potential for suicide. A systematic review identified 8 strategies that were promising.
In addition, clinical practice guidelines have identified a number of evidence-based treatments related to reducing suicidality in schizophrenia.
In a Swedish 10-year longitudinal cohort study mortality was double that of the general population rate, with suicide being the leading cause of death
In a study following a Danish cohort of 9156 patients with schizophrenia admitted to the hospital for the first time, there were increasing rates of suicide in 3 successive 5-year cohorts after patients were discharged. There was a particularly high risk in the first year.
The suicide attempts by patients with schizophrenia were, on average, more medically dangerous than attempts made by patients with other diagnoses.
A recent systematic review of risk factors for schizophrenia and suicide identified 7 robust risk factors.
Table 1. Robust Risk Factors for Suicide in Schizophrenia
| Risk Factors |
| Previous depressive disorder |
| Drug misuse |
| Previous suicide attempts |
| Fear of mental disintegration |
| Agitation or motor restlessness |
| Recent loss |
| Poor treatment adherence |
Reduced risk was associated with hallucinations. This finding is consistent with a study that found that command auditory hallucinations were not more common in those who had attempted suicide. Overall, suicide was less associated with the core symptoms of psychosis and more with affective symptoms, agitation, and awareness that illness was affecting mental function. In a relatively small sample, those who had both suicide attempts and command hallucinations made more suicide attempts than those who did not. The authors hypothesized that command hallucinations were not an independent risk factor, but they increased the risk in those already predisposed to attempted suicide.
APA-Recommended Components for the Assessment of the Suicidal Patient
| Current presentation of suicidality |
| A. Mental disorder |
| B. History |
| C. Psychosocial situation |
| D. Individual strengths and vulnerability |
| Estimation of risk |
| Treatment plan |
The Calgary Depression Scale for Schizophrenia (CDSS) is specifically developed for schizophrenia, has been found to be reliable and valid and can be used to predict future suicidality in the context of a randomized clinical trial. It includes items that rate hopelessness and suicidality, which may have more specific predictive validity for suicidality than the total depression score.
In international survey of clinical experts in schizophrenia care identified 3 key questions that clinicians can use to screen for depression in schizophrenia:
- Have you been feeling down or depressed?
- Have you been feeling hopeless?
- Did you ever think of ending your life?
Clinical practice guidelines suggest that there is evidence to support both antidepressant pharmacotherapy and cognitive therapy for depression in schizophrenia. There is also evidence that second-generation antipsychotics are more effective than first-generation ones in reducing the level of depression in patients with schizophrenia
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