Treatment of Suicidality in Schizophrenia

Abstract

Between 4 and 13% of people with schizophrenia commit suicide and between 25 and 50% make a suicide attempt, a reflection of the devastating toll this syndrome takes on the quality of life, that is, the subjective and objective sense of well‐being. Many risk factors for suicide in schizophrenia have been identified, the most important of which are previous suicide attempts, depression, hopelessness, substance abuse, and male gender. Insight into having a serious mental illness and less severe cognitive impairment are also associated with increased risk for suicide in schizophrenia, most likely when accompanied by feelings of hopelessness. Typical neuroleptic drugs have not been shown to reduce the risk of suicide. However, several types of evidence suggest that clozapine, an atypical antipsychotic drug, appreciably reduces the suicide attempt and completion rates in schizophrenia and schizoaffective disorder, perhaps by as much as 75‐85%. Other atypical antipsychotic drugs may have a similar effect, but direct evidence is lacking. Improvement in positive and negative symptoms, reduced extrapyramidal side effects (EPS), a direct antidepressant action, improved cognitive function, and improved compliance may contribute to reduced suicidality. The International Suicide Prevention Trial (InterSePT) is a large prospective, randomized study intended to compare the effectiveness of clozapine with that of olanzapine in reducing suicide and suicide‐related events in schizophrenic and schizoaffective patients. Some information about suicidality in the patient sample is reported here.

Association of 14-3-3 ε gene haplotype with completed suicide in Japanese

“…In addition, lithium, which is thought to be efficacious in preventing suicide (Baldessarini et al 2001;Goodwin et al 2003;Muller-Oerlinghausen et al 2002), has been found to stimulate neurogenesis in the dentate gyrus of rodents (Chen et al 2000;Kim et al 2004). Clozapine, which is an atypical antipsychotic that has been suggested to have some efficacy in preventing suicide (Meltzer 2001;Meltzer et al 2003), was also reported to stimulate neurogenesis in the hippocampus of rats (Halim et al 2004). These lines of evidence support the relation of neurogenesis with suicide.…”

Uso de clozapina en trastorno bipolar refractario

“…La Esquizofrenia refractaria puede caracterizarse por la persistencia de síntomas positivos, alucinaciones y delirios, los cuales pueden ser más transitorios en las fases psicóticas del Trastorno Bipolar. Aunque la evidencia es limitada, la respuesta clínica de Clozapina en Trastornos Afectivos, sugiere que este antipsicótico atípico contaría con propiedades estabilizadoras del ánimo 12,14,19 . Clozapina demuestra efectividad no sólo como antipsicótico, como antimaníaco sino también en la prevención de la suicidabilidad.…”

“…Desde otra perspectiva la utilidad demostrada por Clozapina en la prevención de la conducta suicida en pacientes con esquizofrenia y trastorno esquizoafectivo abren una interesante perspectiva respecto a que este benefi cio terapéutico también pudiera extenderse a pacientes bipolares en quienes la conducta auto lesiva no muestre sufi ciente control mediante la terapia convencional 14 . La guía clínica sobre trastorno bipolar de la asociación psiquiátrica americana versión 2002, actualmente en vísperas de actualización, considera a Clozapina como un agente anti psicótico que podría ser muy efectivo en la enfermedad bipolar refractaria.…”

Prevention, assessment and treatment of suicidal behavior. [Prevención, evaluación y tratamiento de la conducta suicida]

“…In fact, according to these authors, it would be suitable to combine psychological intervention with pharmacological treatment in certain cases of mild or moderate depression, particularly in the child and youth population. Those behind this study insist that they are not contradicting the potential therapeutic benefits of antidepres- Meltzer et al, 2003). The most recent of these two research works (Meltzer et al, 2003) was a comparative study on the effects of clozapine against olanzapine (neuroleptic drug) in people who had attempted to take their own lives, which found that clozapine (neuroleptic) produced a significantly lower number of suicide attempts compared to the control groups.…”

“…Those behind this study insist that they are not contradicting the potential therapeutic benefits of antidepres- Meltzer et al, 2003). The most recent of these two research works (Meltzer et al, 2003) was a comparative study on the effects of clozapine against olanzapine (neuroleptic drug) in people who had attempted to take their own lives, which found that clozapine (neuroleptic) produced a significantly lower number of suicide attempts compared to the control groups. -In other meta-analysis studies based on 23 psychosocial and psychological research projects, Hawton et al (2008) found there to be no evidence to indicate that antidepressants (tricyclics and selective serotonin reuptake inhibitors-SSRIs) were generally effective at preventing repeat episodes of self-injury.…”