The risk of suicide and early death is higher among people with schizophrenia and related conditions, and appears to be growing, according to recent research.
It is already known that people with schizophrenia have increased risks for suicide, early death, and committing violent crime. But little is known about the risk factors for these outcomes, and whether they are modifiable, said Dr. Seena Fazel, at Oxford University, U.K., and colleagues.
They used information from Sweden on 24,297 patients with schizophrenia and related disorders. They were compared against 485,940 similar people without those conditions and 26,357 unaffected siblings. Siblings were used in order to take into account family risk factors such as parental criminality or violence.
Rates of suicide, early death, and conviction of a violent offense were all increased following diagnosis. These outcomes were 7.5 times more likely than in the general population for men and 11 times more likely for women.
The team found three risk factors, present before diagnosis, which predicted an adverse outcome: drug use disorders, criminality, and long-term self-harm. Siblings with these risk factors, but no mental health diagnosis, also had an increased risk of the outcomes.
Over the study period (1973 to 2009), the odds of these outcomes in patients with schizophrenia and related disorders rose compared with the risk for both the general population and unaffected siblings.
The increased risk may be linked with decreasing levels of inpatient care for these patients, the team suggests, based on their observations on the number of nights spent in the hospital during the study period.
They also believe that improved strategies to address the risk factors for violence and premature death (drug use, criminality, and self-harm before diagnosis) have the potential to reduce violence and premature deaths across the population, and not just in those with schizophrenia.
“A combination of population-based and targeted strategies might be necessary to reduce the substantial rates of adverse outcomes in patients with schizophrenia and related disorders,” says the team in The Lancet Psychiatry.
Said Fazel, “In recent years, there has been a lot of focus on primary prevention of schizophrenia, preventing people from getting ill. While primary prevention is clearly essential and may be some decades away, our study highlights the crucial importance of secondary prevention, treating, and managing the risks of adverse outcomes, such as self-harm or violent behavior, in patients.
“Risks of these adverse outcomes relative to others in society appear to be increasing in recent decades, suggesting that there is still much work to be done in developing new treatments and mitigating risks of adverse outcomes in people with schizophrenia.”
Commenting on the study in the same journal, Dr. Eric Elbogen and Sally Johnson, of the University of North Carolina-Chapel Hill School of Medicine, NC, point out that, “One of the unique aspects of this study, that violence and suicide were analyzed simultaneously, has an important implication for how we as a society perceive people with mental illness.
“News coverage of schizophrenia and other psychiatric disorders often focuses on violence and crime. Much less attention is paid to suicide and self-harm in people with severe mental illnesses.”
But they raise the important point that most people with schizophrenia and related disorders are neither violent nor suicidal. Fewer than 10 percent of all crimes are directly related to symptoms of mental illness, despite more than 1.2 million people with mental illness are incarcerated in jails or prisons in the US, according to the federal Bureau of Justice Statistics.
We should remember this when reporting about “the intricate links between schizophrenia and these adverse outcomes,” they write.
They add, “Despite the need to ensure people with schizophrenia are provided help to reduce their risks of suicide, violence, or premature death, researchers reporting findings also bear the burden of ensuring that most people with schizophrenia and related disorders, who are not violent, are not left to contend with stigma and discrimination.
“Policy makers, researchers, and clinicians need to remember the importance of appropriately weighing up the issue of schizophrenia relative to the myriad of other factors that contribute to increased risk of violence and suicide.”
A 2009 study by Fazel and colleagues analyzed 20 studies that compared the risk of violence in people with schizophrenia and other psychoses and the risk of violence in the general population. The findings indicated that these conditions are associated with violence but that “the association is strongest in people with substance abuse and most of the excess risk is mediated by substance abuse.”
“A potential implication of this finding is that violence reduction strategies that focus on preventing substance abuse among both the general population and among people with psychoses might be more successful than strategies that solely target people with mental illnesses,” they conclude.
Fazel, S. et al. Violent crime, suicide, and premature mortality in patients with schizophrenia and related disorders: a 38-year total population study in Sweden. The Lancet Psychiatry, 4 June 2014
Fazel, S. et al. Schizophrenia and violence: systematic review and meta-analysis. PLoS Medicine, 11 August 2009 doi: 10.1371/journal.pmed.1000120