5000 suicides a year are likely caused by schizophrenia and bipolar disorder.

SUMMARY: Suicide accounts for approximately 29,000 deaths each year in the United States. Two different methods of analysis both suggest that at least 5,000 of the individuals who commit suicide have schizophrenia or bipolar disorder at the time of their suicide. Other studies indicate that most of these individuals were not receiving adequate psychiatric treatment at the time of their death. It is concluded that adequate psychiatric treatment could save up to 5,000 lives per year. Robins E. Psychosis and suicide. Biological Psychiatry 1986;21:665–672.

10-13% of individuals with schizophrenia and 15% of individuals with bipolar disorder kill themselves.

•A 1992 survey of individuals with schizophrenia and bipolar disorder reported that 19 percent had threatened or attempted suicide within the previous year.
Steinwachs DM, Kasper J, Skinner E. Family Perspectives on Meeting the Needs Ffor Care of Severely Mentally Ill Relatives: A National Survey (Baltimore: School of Public Hygiene and Public Health, Johns Hopkins University, 1992).

•The Epidemiologic Catchment Area (ECA) study reported that 28 percent of individuals with schizophrenia had attempted suicide.
Robins LN, Regier DA. Psychiatric Disorders in America (New York: Free Press, 1991), p. 50.

•Estimates of the completed suicide rate for individuals with schizophrenia range from 10 to 13 percent.
Caldwell C, Gottesman I. Schizophrenics kill themselves too: a review of risk factors for suicide. Schizophrenia Bulletin 1990;16:571–-589.

•This rate is at least four times higher than similar studies from the period from 1913 to 1940, suggesting that the suicide rate has risen markedly since massive deinstitutionalization began.
Stephens J, Richard P, McHugh PR. Suicide in patients hospitalized for schizophrenia: 1913-1940. Journal of Nervous and Mental Disease 1999;187:10–14.

•Estimates of the completed suicide rate for individuals with bipolar disorder are approximately 15 percent. Between 25 and 50 percent attempt suicide at least once.
Goodwin FK, Jamison KR. Manic-Depressive Illness (New York: Oxford University Press, 1990), p. 230.

•A reevaluation of studies of suicide and mental disorders concluded that many of the previous studies were methodologically flawed. It estimated that approximately 5 percent of individuals with schizophrenia and bipolar disorder commit suicide, and that the suicide rate for individuals with severe psychiatric disorders is 7 to 10 times the rate in the general population.
Tanney BL. Psychiatric diagnoses and suicidal acts, in Maris RW, Berman AL, Silverman MM (eds), Comprehensive Textbook of Suicidology (New York: Guilford Press, 2000), pp. 311–341.

•In France 3,470 individuals with schizophrenia were followed for 10 years. There were 141 suicides, or 4 percent of the patients, during the 10-year period. The authors calculated that the risk of suicide “was approximately 16 times higher than that of the general population.”
Limosin F, Loze J-Y, Philippe A et al. Ten-year prospective follow-up study of the mortality by suicide in schizophrenic patients. Schizophrenia Research 2007;94:23–28.

•Incidence studies of schizophrenia and bipolar disorder suggest that there are approximately 110,000 new cases of these diseases (combined) each year in the United States. If the completed suicide rate for individuals with these diseases is approximately 5 percent, that would mean that approximately 5,000 individuals with schizophrenia and bipolar disorder commit suicide each year in the United States.

What percentage of individuals who commit suicide had schizophrenia or bipolar disorder at the time they committed suicide?
This asks the same question as #1 above but asks it in a different way.

•The total number of suicide deaths in the United States in 1999 was 29,199. There were also 16,899 homicides in the United States, so suicides outnumbered homicides 5 to 3.

•The only major study of psychosis and suicide was done in St. Louis, 1956–1957. During one year, 134 individuals committed suicide, and 19 percent of them had symptoms of psychosis (mostly delusions) in the month preceding their suicide. This percentage should be considered to be conservative, since the study was carried out prior to massive deinstitutionalization, when most of the most seriously mentally ill individuals were still hospitalized and thus less able to commit suicide.
Robins E. Psychosis and suicide. Biological Psychiatry 1986;21:665–672.

•If that percentage, admittedly conservative, was true in 1999, then 19 percent of the 29,199 completed suicides, or 5,548 individuals who committed suicide in 1999, were psychotic at the time they committed suicide.

•The conclusions reached by both sets of analysis are thus consistent:

At least 5,000 individuals who commit suicide each year are psychotic at the time of their suicide.

Is there a relationship between suicide in individuals with severe psychiatric disorders and their failure to receive treatment?

There are suggestions in several research studies that suicide is much more likely to occur in those individuals with schizophrenia and bipolar disorder who are not being adequately treated or not being treated at all:

•A study of 92 individuals with schizophrenia who committed suicide reported that 78 percent of them “were in the active phase” of their illness, with many symptoms, at the time of the suicide.
Heilä H, Isometsä ET, Henriksson MM et al. Suicide and schizophrenia: a nationwide psychological autopsy study on age- and sex-specific clinical characteristics of 92 suicide victims with schizophrenia. American Journal of Psychiatry 1997;154:1235–1242.

•A study of individuals with schizophrenia who made serious suicide attempts reported that 81 percent of them had “positive psychotic symptoms at the time of attempting suicide.”
Nieto E, Vieta E, Gastó C et al. Suicide attempts of high medical seriousness in schizophrenic patients. Comprehensive Psychiatry 1992; 33:384–387.

•A study of 187 individuals with schizophrenia who attempted or committed suicide reported that “two positive symptoms (suspiciousness and delusions) were more severe among successful suicides.”
Fenton W, McGlashan TH, Victor BJ et al. Symptoms, subtype, and suicidality in patients with schizophrenia spectrum disorders. American Journal of Psychiatry 1997;154:199–204.

•In a study of suicide among psychiatric patients, it was reported that “42 of the 59 patients (71.1%) who were depressed in their last episode [of hospitalization] were not receiving adequate antidepressant or lithium carbonate medication at the time of suicide.”
Roy A. Risk factors for suicide in psychiatric patients. Archives of General Psychiatry 1982;39:1089–1095.

* A study in Kentucky found that only 2 of 28 individuals with schizophrenia who committed suicide had evidence in their blood of having taken antipsychotic medication. Thus, 93 percent of them were not being treated. Shields LBE, Hunsaker DM, Hunsaker JC III. Schizophrenia and suicide: a 10-year review of Kentucky Medical Examiner cases. Journal of Forensic Sciences 2007;52:930–937.

•A case control study of 149 individuals (70 percent diagnosed with schizophrenia or major affective disorder) who committed suicide within five years of psychiatric hospitalization compared with 149 individuals who did not reported that “the main finding . . . is that suicides in people with mental illness were associated with reductions in care at the final service contact before death.” The reductions included lowering the dose of medication, less supervision, and reduced frequency of appointments.
Appleby L, Dennehy JA, Thomas CS et al. Aftercare and clinical characteristics of people with mental illness who commit suicide: a case-control study. Lancet 1999;353:1397–1400.

•A case control study of 63 individuals with schizophrenia who committed suicide and 63 individuals with schizophrenia who did not reported that “there were seven times as many patients who did not comply with treatment in the suicide group as there were in the control group.”
De Hert M, McKenzie K, Peuskens J. Risk factors for suicide in young people suffering from schizophrenia: a long-term follow-up study. Schizophrenia Research 2001;47:127–134.

•Studies have suggested that some medications, especially clozapine and lithium, may decrease the incidence of suicide among individuals with severe psychiatric disorders.
Tondo L, Baldessarini RJ, Hennen J. Lithium and suicide risk in bipolar disorder. Primary Psychiatry 1999;6:51–56.
Müller-Oerlinghausen B. Arguments for the specificity of the antisuicidal effect of lithium. European Archives of Psychiatry and Clinical Neuroscience 2001;251(suppl):1172–1175.

•A study from Germany using a case-control methodology compared 27 inpatients with schizophrenia and 24 inpatients with affective psychoses, all of whom suicided, with their matched inpatient case controls who did not suicide. Among those with schizophrenia, 4 of the individuals who suicided were not taking antipsychotic medication compared with none of the case controls (p = 0.055). Among those with affective psychoses, 7 of the individuals who suicided were not taking mood stabilizers or antidepressants compared with 2 of the case controls (p = 0.06). The authors concluded that there is “a significantly increased risk” of suicide when medications are not used.
Gaertner I, Gilot C, Heidrich P et al. A case control study on psychopharmacotherapy before suicide committed by 61 psychiatric inpatients. Pharmacopsychiatry 2002;35: 37–43.

•A Swiss 34-year follow-up study of 158 individuals with bipolar disorder reported that 18 of them (11 percent) had committed suicide. The suicide rate was more than twice as high among patients who had not been treated compared with those who had been treated (p = 0.04), a difference the authors called “spectacular.”
Angst F, Stassen HH, Clayton PJ et al. Mortality of patients with mood disorders: follow-up over 34-38 years. Journal of Affective Disorders 2002;68:167–181.

Science News December 6, 2010

People with severe mental illness 12 times more likely to commit suicide

People with psychotic disorders, such as schizophrenia or bipolar disorder, are 12 times more likely to commit suicide than average, according to research released today by King’s Health Partners.

The research found that the rate of suicide was highest in the first year following diagnosis (12 times national average) and that high risk persisted ? remaining four times greater than the general population ten years after diagnosis, a time when there may be less intense clinical monitoring of risk. Neither the risk of suicide nor the long-term risk of suicide, as compared to the general population, have been studied and measured in this way before. And the findings show that doctors must always remain vigilant when assessing a patient’s risk of suicide regardless of time since first diagnosis.

A key aim of the study was to challenge the widely held view that “10-15% of people suffering psychotic disorders are likely to commit suicide”¹. This study shows that these figures, largely derived from research in the 1970s, are misleading as they use crude measurement techniques² and do not accurately measure risk over a lifetime. Today’s findings indicate a lower overall risk, but more persistent danger of suicide among this patient group over a lifetime.

Dr Rina Dutta, MRC Research Fellow and Honorary Consultant Psychiatrist, King’s Health Partners, said: “It’s well known that people who commit suicide often suffer serious mental health problems, but it’s surprising that the risk they face remains so high ten years or more after first diagnosis. Putting a figure on it like this helps doctors to understand the extent of risk some of their patients face.”

The research studied a group of almost 3,000 patients in the UK (London, Nottingham and Dumfries and Galloway) who suffered their first psychotic illness between 1965 and 2004. The patients were traced after an average follow-up time of 11.5 years and their death certificates were analysed. People with psychotic disorders experience disturbed thoughts, feelings, mood and behaviours. Psychotic conditions tend to strike when people are young and affect one in 50 of the UK population.

King’s Health Partners (KHP) is a major collaboration between three of the country’s most successful NHS Foundation Trusts – Guy’s and St Thomas’, King’s College Hospital and South London and Maudsley, and one of the world’s leading research universities, King’s College London. KHP is one of only five Academic Health Science Centres (AHSC) in the UK. The objective of AHSCs is to break down barriers so that world-class research finds its way more swiftly, effectively and systematically to improve healthcare services for patients. Currently, research findings tend to take a long time to trickle down to benefit patients.
Reassessing the Long-term Risk of Suicide after a First Episode of Psychosis is published in the US journal Archives of General Psychiatry on Monday 6 December 2010.
This study was funded by the Medical Research Council, London, UK, as well as by grants from the British Medical Association, Psychiatry Research Trust, London, UK and the Chief Scientist Office, Scottish Government.