Original Research

Suicidal Ideation in Inpatients With Acute

Schizophrenia
Vassilis Kontaxakis, MD
1
, Beata Havaki-Kontaxaki, MD
2
, Maria Margariti, MD
2
,
Sophia Stamouli, MD
2
, Costas Kollias, MD
2
, George Christodoulou, MD, FICPM, FRCPsych
3
Key Words: schizophrenia, suicidal ideation, depression, motor side effects, inpatients
T
he increased risk of suicide among schizophrenia
patients is well documented (1,2), and schizophrenia is
recognized as a disease that reduces the life expectancy of
those afflicted by approximately 10 years (3). To date,
suicide research in schizophrenia has primarily focused on
attempted or completed suicide; it has been estimated that
30% of patients with schizophrenia attempt suicide, and
10% are successful (24). These 2 groups of patients have
been excessively studied with regard to frequency of occur-
rence, psychopathological state, and sociodemographic
characteristics.
Data on suicidal thoughts in schizophrenia patients are scarce.
However, it is worth noting that suicidal ideation and planning
are important steps in a process of suicide characterized by a
stepwise hierarchy of actions with an underlying gradient of
severity: ideation precedes planning, which may result in an
attempt that perhaps leads to death (5).
It should therefore be clinically valuable to consider the risk
factors associated with suicidal ideation. This study investi-
gates the prevalence of recent suicidal thoughts and attempts
in a population of inpatients with acute schizophrenia and
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WCan J Psychiatry, Vol 49, No 7, July 2004
Objective: Schizophrenia has been associated with a high rate of suicide. This study investigates
the prevalence of suicidal ideation in a population of inpatients with acute schizophrenia, together
with the clinical parameters associated with suicidal thoughts.
Method: We assessed 93 schizophrenia patients. We matched subjects for age and sex and
compared subjects with and without suicidal thoughts. We performed stepwise multiple regression
analysis to assess the association between specific clinical symptoms and suicidal ideation.
Results: Of the patients, 20.4% reported suicidal thoughts during the last 15 days. Severity of
depressive symptoms, motor retardation, guilt feelings, pathological guilt, and self-depreciation
predicted the patients suicidal ideation.
Conclusions: Suicidal thoughts are frequent among inpatients with acute schizophrenia. Prevention
of suicidal behaviour should include helping patients improve their self-esteem and reducing
depression and guilt feelings.
(Can J Psychiatry 2004;49:476479)
Information on author affiliations appears at the end of the article.
Clinical Implications
Suicidal thoughts are frequent among inpatients with acute schizophrenia. Special attention should be
paid to this high-risk population.
There is a strong relation between severity of depression and the presence of suicidal thoughts.
The clinical parameters associated with suicidal ideation may be useful in suicide-prevention measures.
Limitations
The study used a relatively small sample size.
Suicidal ideation rating was based on the Calgary Depression Scale for Schizophrenia suicidality item,
which was included in the calculation of the total depression score.
Comparing results across studies is difficult because of variations in research methodologies.
seeks to reveal the clinical parameters associated with suicidal
ideation.
Material and Methods
Patients
Our sample comprised 93 schizophrenia patients (69% men,
31% women) consecutively admitted to Eginition Hospital,
Department of Psychiatry, University of Athens, between
October 1996 and November 1997. All patients and their rela-
tives provided informed consent to participate in the study.
The patients were given a diagnosis according to DSM-IVcri-
teria (6) by 2 independent psychiatrists with similar levels of
education and experience. These diagnoses were reviewed on
the day of discharge; all informationcollectedduring the inpa-
tient period was taken into account. The patients mean age
was 30.3 years (SD 8.9). They had a mean of 12.3 years (SD
2.5) of education and a mean duration of illness of 7.2 years
(SD 7.5). We excluded fromthe study patients with any other
diagnosis on Axis I of DSM-IV, with current alcohol or drug
abuse, with serious physical (especially neurological) illness,
or with mental retardation. At the time of assessment, the
patients were receiving the following medications:
antipsychotic drugs (76%), antiparkinsonian agents (56%),
anxiolytics (51%), antidepressants (14%), and mood
stabilizers (2%).
Of the patients taking antipsychotic drugs, 63% used conven-
tional antipsychotics, 19% used an atypical antipsychotic as
monotherapy, and 18% used atypical antipsychotics concur-
rently with conventional antipsychotics. It should be noted
that all patients taking antidepressants belonged to the
depressed-suicidal group.
Measures
We assessed patients on admission (during the first week),
using the Calgary Depression Scale for Schizophrenia
(CDSS; 7,8), the Positive and Negative Syndrome Scale
(PANSS; 9,10), the Rating Scale for Extrapyramidal Side
Effects (RSESE; 11), the Barnes Rating Scale for Drug-
Induced Akathisia (BARS; 12), and the Abnormal Involun-
tary Movement Scale (AIMS; 13).
The CDSS is considered a specific, reliable, and valid mea-
sure of depression in schizophrenia. It comprises 9 items
selected fromthe Hamilton Depression Rating Scale (HDRS)
and the Present State Examination (PSE) and assesses symp-
toms of depression at any stage of the disease. Each itemhas a
4-choice response format (0 to 3). The total possible score is
between 0 and 27.
Three psychiatrist-raters trained in the use of the instruments
evaluated patients within a period of a few hours. The first
rater assessed depressive symptomatology, using the CDSS,
and akathisia, using the BARS. The second independent rater
assessed positive symptoms, negative symptoms, and general
psychopathology, using the PANSS, and extrapyramidal
symptoms, using the RSESE. The third rater assessed abnor-
mal involuntary movements, using the AIMS. Astandardized
data schedule that included social, clinical, and pharmaco-
logic parameters was completed for each patient.
Reported suicidal thoughts and attempts were derived from
the CDSS item8 (suicidality). The ratings were as follows:
0 = absent; 1 = frequent thoughts of being better off dead or
occasional thoughts of suicide; 2 = deliberately considered
suicide with a plan, but made no attempt; 3 = suicide attempt
apparently designed to end in death.
Statistical Methods
Schizophrenia patients rating 1 or more on the CDSS item
suicidality (Group A; n = 19, mean age 31.3 years) were
compared on manysocial and clinical parameters with schizo-
phrenia patients matched for age and sex and scoring 0 on the
same item (Group B; subjects without suicidal thoughts, n =
19, mean age 31.2 years). We used Wilcoxon matched pairs
signed-rank tests and paired t tests when appropriate.
Because clinical symptoms potentially associated with sui-
cidal thoughts are interrelated, we performed stepwise multi-
ple regression analyses to assess their independent effect on
suicidal ideation. We included all PANSS and CDSS items in
the regression analysis. Statistical significance was set at P
0.05. Values are expressed as mean (SD). Data were analyzed
with the Statistical Package for Social Sciences (SPSS) (14).
Results
Of the patients, 20.4% reported any suicidal thought during
the last 15 days; 11.8% reported frequent thoughts of being
better off dead or occasional thoughts of suicide; and 6.4%
reported deliberate suicide with a plan but made no attempt.
Two subjects (2.2%) had attempted suicide during the last 15
days. All subjects reported both the more intense and the less
intense suicidal feelings.
Table 1 compares schizophrenia patients with suicidal
thoughts with those without suicidal thoughts in terms of the
severity of psychopathological parameters and motor side
effects. In all parameters, there were no significant differ-
ences between the 2 matched groups of patients, with 1 excep-
tion: patients with suicidal thoughts scored higher than
control subjects on the CDSS (10.52 vs 3.52, P < 0.0001).
There were no statistically significant differences between
Group A and Group B patients in many social and clinical
parameters, that is, in marital status (single, 84% vs 95%),
education (years of schooling, 12.1 vs 13.2), employment sta-
tus (unemployed, 79%vs 74%), duration of illness (years, 4.8
vs 6.6) duration of hospitalizations (years, 0.40 vs 0.45),
Suicidal Ideation in Inpatients With Acute Schizophrenia
Can J Psychiatry, Vol 49, No 7, July 2004 W 477
number of hospitalizations (2.55 vs 2.73), use of neuroleptics
(58% vs 68%), history of electroconvulsive therapy (16% vs
15%), and mean daily dosage of neuroleptics (chlor-
promazine equivalents in mg, 747.0 vs 770.3).
Stepwise multiple regression analyses revealed that the fol-
lowing scores predicted the patients suicidality: on the
PANSS, the items depression ($ = 0.408, P < 0.01), guilt
feelings ($ = 0.402, P < 0.008), and motor retardation ($ =
0.369, P = 0.01); and on the CDSS, the items pathological
guilt ($ = 0.603, P < 0.001) and self-depreciation ($ =
0.513, P < 0.01).
Discussion
To our knowledge, this is the first report on the prevalence and
characteristics of inpatients with acute schizophrenia and sui-
cidal thoughts that uses the CDSS, a specific instrument for
assessing aspects of depression in schizophrenia. Until now
several scales, such as the HDRS, have been used to estimate
the depressive symptomatology of schizophrenia patients.
However, all these scales have been standardized only for
patients suffering from depression (1518).
Limitations of this study include the relativelysmall sample of
patients and the basing of suicidal ideation rating on the CDSS
suicidality item, which was included in the calculation of
the total depression score. However, the validity of the results
is supported by the multivariate statistical methods used, as
well as by the established reliabilityof the rating of depressive
symptoms in schizophrenia patients.
According to our findings, suicidal thoughts are frequent
among inpatients with acute schizophrenia. Recent suicidal
ideation was reported by 20.4%of
the entire group of patients, and
2.2% reported a suicide attempt in
the 15 days before hospital
admission.
Other authors have also reported
high rates of suicidal thoughts
among schizophrenia patients.
Amador and others (19) pointed
out that 22% of schizophrenia
patients reported yes to the
question of suicidal thoughts and
behaviour in the past, while
Dassori and others (20) reported
that 32% of the schizophrenia
patients in their sample exhibited
death wishes with or without sui-
cidal plans or attempts. Fenton
and others (21) reported that 40%
of the schizophrenia patients stud-
ied expressed suicidal ideation at
some time during a 19-year follow-up, and Grave mentioned
that, among patients with psychotic disorders, 30% were
reported to have suicidal thoughts, threats, and (or) attempts
before or during their index hospitalization (22).
Risk factors for suicide in schizophrenia include several
social and clinical parameters, such as young age, male sex,
single and (or) unemployed status, having a high level of
premorbid functioning, and having depression, severe
psychopathology, previous suicide attempts, and multiple
relapses (1,2,2328).
There is, however, no information on risk factors for schizo-
phrenia patients with suicidal thoughts. Moreover, there are
few data regarding the relation between the presence of sui-
cidal ideation and future suicidal behaviour. According to
Funahashi and others, the presence of suicidal ideation was
revealed as a predictor of suicide in their clinical investigation
of 80 suicides by schizophrenia sufferers (29). Conversely,
Young and others reported that lowlevels of suicidal ideation
may predict future suicidal behaviour better than depressed
mood (30). Suicide has been described as a process of differ-
ent stages, starting with thoughts of death and suicide and end-
ing in self-inflicted death. Most efforts to prevent suicide have
been directed to those who have already made an attempt.
However, primary prevention should involve people with sui-
cidal thoughts.
According to our study results, there is a close relation
between suicidal ideation and the presence of depression,
guilt feelings, pathological guilt, self-depreciation, and motor
retardation. Although most suicide ideators tend not to go
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WCan J Psychiatry, Vol 49, No 7, July 2004
The Canadian Journal of PsychiatryOriginal Research
Table 1 Psychopathological parameters and motor side effects in acute
schizophrenia inpatients with (Group A) and without (Group B) suicidal thoughts
Group A
Mean (SD)
Group B
Mean (SD)
Calgary Depression Scale for Schizophrenia 10.52 (5.18) 3.52 (3.11)*
Positive and Negative Syndrome Scale
Total 70.99 (7.73) 71.82 (6.42)
Negative symptoms 18.52 (8.71) 18.99 (7.43)
Positive symptoms 18.89 (5.90) 18.84 (5.87)
General psychopathology 36.57 (10.98) 34.00 (8.13)
Rating Scale for Extrapyramidal Side Effects 0.93 (0.79) 0.81 (0.59)
Barnes Akathisia Rating Scale 0.36 (0.49) 0.21 (0.41)
Abnormal Involuntary Movement Scale 0.43 (0.94) 0.21 (0.51)
*P < 0.0001 significantly different from Group A
through subsequent steps in the suicidal process, prevention
of suicidal behaviours in schizophrenia patients should proba-
bly focus on reducing depressive and guilt feelings and on
helping the individual to enhance self-esteem.
Our study focused on describing the clinical characteristics of
inpatients with acute schizophrenia and suicidal ideation. The
degree to which these characteristics represent risk factors rel-
evant to future suicide behaviours remains unknown. A
long-term follow-up study could provide an answer to this
crucial question.
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Manuscript received January 2003, revised, and accepted May 2003.
1
Associate Professor of Psychiatry, University of Athens, Eginition
Hospital, Athens, Greece.
2
Lecturer in Psychiatry, University of Athens, Eginition Hospital, Athens,
Greece.
3
Professor of Psychiatry, University of Athens, Eginition Hospital, Athens,
Greece.
Address for correspondence: Dr VP Kontaxakis, Department of
Psychiatry, University of Athens, Eginition Hospital, 74, Vas. Sophias
Avenue, 11528 Athens, Greece.
e-mail: bkont@eexi.gr, bkont@cc.uoa.gr
Suicidal Ideation in Inpatients With Acute Schizophrenia
Can J Psychiatry, Vol 49, No 7, July 2004 W 479
Rsum : Idation suicidaire chez les patients hospitaliss souffrant de schizophrnie aigu
Objectif : La schizophrnie est associe un taux de suicide lev. Cette tude examine la prvalence de
lidation suicidaire dans une population de patients hospitaliss souffrant de schizophrnie aigu et les
paramtres cliniques associs aux ides suicidaires.
Mthode : Nous avons valu 93 patients schizophrnes. Nous avons assorti des sujets selon lge et le sexe,
et compar les sujets avec et sans ides suicidaires. Nous avons excut une analyse de rgression multiple
par degrs pour valuer lassociation entre les symptmes cliniques spcifiques et lidation suicidaire.
Rsultats : Parmi les patients, 20,4 % ont dclar avoir eu des ides suicidaires au cours des 15 jours
prcdents. La gravit des symptmes dpressifs, le retard moteur, les sentiments de culpabilit, la culpabilit
pathologique et lautodprciation prdisaient lidation suicidaire des patients.
Conclusions : Les ides suicidaires sont frquentes chez les patients hospitaliss souffrant de schizophrnie
aigu. La prvention du comportement suicidaire doit entre autres consister aider les patients amliorer
leur estime de soi ainsi qu rduire la dpression et les sentiments de culpabilit.