Original Research

Suicidal Ideation in Inpatients With AcuteSchizophrenia

Vassilis Kontaxakis, MD1, Beata Havaki-Kontaxaki, MD

2, Maria Margariti, MD

2,

Sophia Stamouli, MD2, Costas Kollias, MD

2, George Christodoulou, MD, FICPM, FRCPsych

3

Key Words: schizophrenia, suicidal ideation, depression, motor side effects, inpatients

The 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

476 Can 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 bepaid 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-IV cri-

teria (6) by 2 independent psychiatrists with similar levels of

education and experience. These diagnoses were reviewed on

the day of discharge; all information collected during 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 from the 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 from the Hamilton Depression Rating Scale (HDRS)

and the Present State Examination (PSE) and assesses symp-

toms of depression at any stage of the disease. Each item has 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. A standardized

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 item 8 (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 many social 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).

ResultsOf 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 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 relatively small 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 reliability of 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 low levels 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

478 Can J Psychiatry, Vol 49, No 7, July 2004

The Canadian Journal of PsychiatryOriginal Research

Table 1 Psychopathological parameters and motor side effects in acuteschizophrenia inpatients with (Group A) and without (Group B) suicidal thoughts

Group AMean (SD)

Group BMean (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.

References

1. Westenmeyer JF, Harrow M, Marengo JT. Risk for suicide in schizophrenia and

other psychotic and non-psychotic disorders. J Nerv Ment Dis 1991;179:259 66.

2. Caldwell GB, Gottesman JJ. Schizophreniaa high risk factor for suicide: clues

to risk reduction. Suicide Life Threat Behav 1992;22:47993.

3. Allebek P. Schizophrenia: a life-shortening disease. Schizophr Bull

1989;13:81 8.

4. Kontaxakis VP, Christodoulou GN, Havaki-Kontaxaki BJ, Skoumbourdis T.

Attempted suicide among schizophrenic outpatients in Athens. In: Ferrari and

others, editors. Suicidal behavior and risk factors. Bologna: Monduzzi Editore;

1990. p 62731.

5. Hawley CJ, James DV, Birkett PL, Baldwin DS, De Ruiter MJ, Priest RG.

Suicidal ideation as a presenting complaint. Br J Psychiatry 1991;159:232 8.

6. American Psychiatric Association. Diagnostic and statistical manual of mental

disorders. 4th ed. Washington (DC): APA; 1994.

7. Addington D, Addington J, Maticka Tyndale E. Assessing depression in

schizophrenia: the Calgary Depression Scale. Br J Psychiatry 1993(Suppl

22):39 44.

8. Kontaxakis VP, Havaki-Kontaxaki BJ, Margariti MM, Stamouli SS, Kollias CT,

Angelopoulos EK, and others. The Greek version of the Calgary Depression

Scale for schizophrenia. Psychiatry Res 2000;94:16371.

9. Kay SR. Positive and negative syndromes in schizophrenia: assessment and

research. New York: Brunner-Mazel Publishers; 1991.

10. Lykouras L, Botsis A, Oulis P. Positive and Negative Syndrome Scale.

Translationvalidityreliability. Athens: Tsiveriotis Editions; 1997.

11. Simpson GM, Angus JWS. A rating scale for extrapyramidal side effects. Acta

Psychiatr Scand 1970 (Suppl 212):119.

12. Barnes TRE. A rating scale for drug-induced akathisia. Br J Psychiatry

1989;154:6726.

13. Guy W. ECDEU assessment manual of psychopharmacologyrevised.

Washington (DC): DHEW; 1976.

14. Norusis MJ. SPSS/PC and advanced statistics 4.0. Chicago (IL): SPSS Inc; 1990.

15. Snaith P. What do depression rating scales measure? Br J Psychiatry

1993;163:2938.

16. Nakaya M, Komahashi T, Ohmori K, Suwa H. The composition of the

depressive syndrome in acute schizophrenia. Schizophr Res 1998;34:1517.

17. Kontaxakis VP, Havaki-Kontaxaki BJ, Stamouli SS, Margariti MM, Kollias CT,

Christodoulou GN. Comparison of four scales measuring depression in

schizophrenic patients. Eur Psychiatry 2000;15:2747.

18. Kontaxakis VP, Havaki-Kontaxaki BJ, Stamouli SS, Margariti MM, Kollias CT,

Christodoulou GN. Depression measures and motor-side-effects in patients with

acute schizophrenia. Schizophr Res 2002;56:1978.

19. Amador XF, Friedman JH, Kasapis C, Yale SA, Flaum M, Gorman JM. Suicidal

behavior in schizophrenia and its relationship to awareness of illness. Am J

Psychiatry 1996;153:11858.

20. Dassori AM, Mezzich JH, Keshavan M. Suicidal indicators in schizophrenia.

Acta Psychiatr Scand 1990;81:40913.

21. Fenton WS, Mc Glashan TH, Victor BJ, Blyler CR. Symptoms, subtype and

suicidality in patients with schizophrenia spectrum disorders. Am J Psychiatry

1997;154:19992004.

22. Grawe RW, Pedersen PB, Widen JH. Changes in prevalence and comorbidity in

a total population of patients with psychotic disorders in Norwegian psychiatric

hospitals. Nord J Psychiatry 1997;51:12732.

23. Havaki-Kontaxaki BJ, Kontaxakis VP, Protopappa VA, Christodoulou GN.

Suicides in a large psychiatric hospital: risk factors for schizophrenic patients.

Bibl Psychiatr 1994;165:6371.

24. Drake RE, Gates C, Whitaker A, Cotton PG. Suicide among schizophrenics: a

review. Compr Psychiatry 1985;26:90100.

25. Rossau CD, Mortensen PB. Risk factors for suicide in patients with

schizophrenia: Nated case-control study. Br J Psychiatry 1997;171:3559.

26. Roy A, Schreiber J, Mazonson A, Pickar D. Suicidal behavior in chronic

schizophrenic patients: a follow-up study. Can J Psychiatry 1986;31:73740.

27. De Hert M, Peuskens J. Suicide in schizophrenia. Acta Psychiatr Belg

1998;(Suppl 1):3745.

28. Haas GL. Suicidal behavior in schizophrenia. In: Marris RW and others, editors.

Review of suicidology. New York: Guilford Press; 1997.

29. Funahashi T, Ibuki Y, Domon Y, Nishimura T, Akehashi D, Sugiura H. A

clinical study of suicide among schizophrenics. Psychiatr Clin Neurosci

2000:54:1739.

30. Young AS, Nuechterlein KH, Mintz J, Ventura J, Gitlin VM, Liberman RP.

Suicidal ideation and suicide attempts in recent-onset schizophrenia. Schizophr

Bull 1998;24:62934.

Manuscript received January 2003, revised, and accepted May 2003.1Associate Professor of Psychiatry, University of Athens, EginitionHospital, Athens, Greece.2Lecturer in Psychiatry, University of Athens, Eginition Hospital, Athens,Greece.3Professor of Psychiatry, University of Athens, Eginition Hospital, Athens,Greece.Address for correspondence: Dr VP Kontaxakis, Department ofPsychiatry, University of Athens, Eginition Hospital, 74, Vas. SophiasAvenue, 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 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.