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Suicide and suicidal behaviour are major problems in schizophrenia. Our aim was to review the recent literature on risk factors for suicide in schizophrenia from genes to clinical characteristics to identify different pathways leading to suicide and present a life-span developmental model for suicide in schizophrenia.
We performed a database search in four databases (Medline, PubMed, PsycInfo and Web of Science) with the keywords suicide AND schizophrenia. A comprehensive hand search was also performed.
There seem to be five main pathways for schizophrenia patients leading to suicide: First is comorbid depression that leads to suicide. Second, there is a group of patients with a difficult, chronic course of illness and many relapses and exacerbations. They lose their hope progressively over time. Third group comprises patients (mostly young males) with impulsiveness, dysphoric affect and substance abuse. Fourth is a relatively small but theoretically interesting and clinically important group of mainly young patients with high premorbid functioning and above average intellectual capacity. Fifth pathway, failure in treatment, comprises patients lacking social support whose treatment has failed. We also propose a life span model showing these five different pathways to suicide in schizophrenia.
There are different pathways leading to suicide in schizophrenia. These suicidal trajectories could be useful in clinical work when evaluating patients’ possible suicide risk and treating them. They might also provoke some further research ideas and hypotheses.
We study the predictive power and associations of several psychological scales with respect to hospitalisations due to schizophrenic psychoses.
Temperament and Character Inventory, Physical Anhedonia Scale, Social Anhedonia Scale, Perceptual Aberration Scale, Hypomanic Personality Scale, Bipolar II Scale, and Schizoidia Scale were included in the 31-year follow-up survey of the prospective Northern Finland 1966 Birth Cohort (N=4,926). We compared subjects without any previous hospitalisations to those with previous hospital diagnoses (concurrent validity) and to those who in the eight year long follow-up were hospitalised due to schizophrenic psychosis (predictive validity). We also compared the subjects with schizophrenic psychoses and subjects with other psychiatric disorders (discriminant validity).
In most scales, subjects with schizophrenic psychoses differed from healthy subjects. The Perceptual Aberration Scale was the best scales for concurrent (Effect Size, d = 1.89) and discriminant validity (d = 0.64). Subjects having a high score in Hypomanic Personality Scale were in the highest risk for schizophrenic psychoses (OR 10.72; 95% CI 2.87-40.06).
Subjects with schizophrenic psychoses differed in most of the scales from healthy controls and from subjects with other psychiatric disorders. Many of the scales were useful predictors for future hospitalisations due to schizophrenic psychoses; however scales were not very diagnosis specific. The predictive power of the scales is limited, these scales are probably not useful as screening instruments but can be used in several ways when studying e.g. risk factors or genetics of schizophrenic psychoses.
Higher lifetime antipsychotic exposure has been associated with poorer cognition in schizophrenia. The cognitive effects of adjunctive psychiatric medications and lifetime trends of antipsychotic use remain largely unclear. We aimed to study how lifetime and current benzodiazepine and antidepressant medications, lifetime trends of antipsychotic use and antipsychotic polypharmacy are associated with cognitive performance in midlife schizophrenia.
Sixty participants with DSM-IV schizophrenia from the Northern Finland Birth Cohort 1966 were examined at 43 years of age with an extensive cognitive test battery. Cumulative lifetime and current use of psychiatric medications were collected from medical records and interviews. The associations between medication and principal component analysis-based cognitive composite score were analysed using linear regression.
Lifetime cumulative DDD years of benzodiazepine and antidepressant medications were not significantly associated with global cognition. Being without antipsychotic medication (for minimum 11 months) before the cognitive examination was associated with better cognitive performance (P = 0.007) and higher lifetime cumulative DDD years of antipsychotics with poorer cognition (P = 0.020), when adjusted for gender, onset age and lifetime hospital treatment days. Other lifetime trends of antipsychotic use, such as a long antipsychotic-free period earlier in the treatment history, and antipsychotic polypharmacy, were not significantly associated with cognition.
Based on these naturalistic data, low exposure to adjunctive benzodiazepine and antidepressant medications does not seem to affect cognition nor explain the possible negative effects of high dose long-term antipsychotic medication on cognition in schizophrenia.
Due to the paucity of previous studies, we wanted to elucidate the pharmacoepidemiology of antipsychotics in schizophrenia in a general population sample, and the association between long-term antipsychotic use and outcomes.
The sample included 53 schizophrenia subjects from the Northern Finland Birth Cohort 1966 with at least ten years of follow-up (mean 18.6 years since illness onset). Data on lifetime medication and outcomes (remission, Clinical Global Impression [CGI], Social and Occupational Functioning Assessment Scale [SOFAS]) were collected from medical records, interviews, and national registers.
During the first two years 22 (42%), between two to five years 17 (32%), and between five to ten years 14 (26%) subjects had used antipsychotics less than half of the time. Drug-free periods became rarer during the follow-up. The mean lifetime daily dose of antipsychotics was 319 mg in chlorpromazine equivalents. A high lifetime average and cumulative dose and antipsychotic polypharmacy were associated with a poorer outcome in all measures, whereas having no drug-free periods was associated with a better SOFAS score and a low proportion of time on antipsychotics with a better CGI score.
In our population-based sample, the use of antipsychotics increased during the first five years of illness and was relatively stable after that. Our results suggest that both low dose and proportion of use, and having no drug-free periods, are associated with better outcomes, which concords with current treatment recommendations and algorithms. High long-term doses and polypharmacy may relate to poor outcomes.
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