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Anhedonia and suicide in chronic schizophrenia: a follow-up study
Schizophrenia Research 47 (2001) 105–106 www.elsevier.com/locate/schres
Letter to the Editors Anhedonia and suicide in chronic schizophrenia: a follow-up study Dear Editors, Anhedonia, the lowered ability to experience pleasure, constitutes a risk factor of suicide within one year in major affective disorders ( Fawcett et al., 1990). Moreover, in acute relapse of schizophrenia, Addington and Addington (1992) have shown that suicidal ideations were associated with anhedonia. Watson and Kucala (1978) have explored the relationships between anhedonia, suicide and premature natural deaths in psychiatric subjects. The results were equivocal, but suggested that suicides were characterized by low anhedonia. To our knowledge, the relationships between anhedonia and suicide in chronic schizophrenia have not been explored using a prospective follow-up study and the aim of the present study was to explore these relationships. Subjects were 150 in- or outpatients (82.66% and 17.34% respectively) meeting the research diagnosis criteria (RDC ) for chronic schizophrenia. The mean age was 38.88 years (SD= 10.23); 58% were men; 74% had never been married. The mean duration of illness was 14.80 years (SD=9.66). The subjects were recruited from two French psychiatric hospitals. All subjects gave written informed content to participate in the study. The RDC diagnoses based on structured interview and medical record data were determined by a consensus of two psychiatrists (GL and CN ). The inclusions were carried out from April 1991 to July 1995 and in May 1999 the patients were assessed concerning their status (alive or dead). The mean (SD) follow-up period for the patients was 63.31 months (15.45, range: 7–96 months). At the inclusion stage, the patients filled out
the revised Physical Anhedonia Scale (PAS) of Chapman and Chapman (1978) and the physical pleasure subscale of the Fawcett Clark Pleasure Capacity Scale (FCPCS-PP) (Loas et al., 1994). According to Chapman, the subjects were anhedonics if they scored at least 1.96 standard deviations above the mean of that scale calculated in the French reference group (Loas, 1995); 32 schizophrenics were anhedonic and 118 were not. The sex-ratio, the age and the mean duration of the illness were not significantly different between the hedonic and anhedonic schizophrenics. In May 1999 all the patients were assessed; most of them were always followed by the different departments of the two psychiatric hospitals. For each patient their status (alive or dead ) and (if necessary) causes of death were obtained from their psychiatrists, general practitioners, patient’s clinical files or death certificates. Thirteen of the subjects were deceased. The causes of death were: three suicides (drowning, shooting, jumping from high places); three cardiac problems; two cancers; one car crash; one suffocation; one respiratory arrest; one victim of homicide; and one infectious disease. The suicide mortality rates per 1000 person-years were 2.32‰ and 4.08‰ for hedonic and anhedonic schizophrenics, respectively. Anhedonics had a non significant 1.70-fold higher risk of suicide than hedonic schizophrenics (95% confidence interval; 0.16–18.18, Fisher exact test; P=0.54). The mean PAS and FCPCS-PP scores were not significantly different between the suicides and the survivors. The mean PAS scores (SD) were 23.66 (8.50) and 22.41 (8.89), respectively; Mann– Whitney U=184.5, P=0.76. The mean FCPCS-PP scores (SD) were 80.33 (10.60) and 79.58 (14.71), respectively; Mann–Whitney U=199.5, P=0.93.
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Letter to the Editor / Schizophrenia Research 47 (2001) 105–106
Moreover, the mean PAS and FCPCS-PP scores were not significantly different between the suicides and the subjects who died of natural causes; the Mann–Whitney U were 10.5, P=0.44 and 12.5, P=0.67, respectively. Our study presented several limitations. First, it is possible that the duration of the follow-up study be insufficient to indicate an increase of mortality in anhedonic schizophrenics. Moreover, the small size of the anhedonic group could explain the negative results. Second, the number of suicides could be underrepresented, as certain natural or accidental deaths (e.g., car crash) could be ‘hidden’ suicides. The main result of the study is that anhedonia is not a risk factor of suicide in chronic schizophrenic patients. Only two follow-up studies have explored the relationships between anhedonia and suicide in different psychiatric groups. Fawcett et al (1990) have conducted a 10-year follow-up study on 954 patients with major affective disorders. The results have shown that anhedonia, rated by items of the Schedule for Affective Disorders and Schizophrenia, was associated with suicide within one year. Watson and Kucala (1978) have compared 39 psychiatric patients deceased of suicide or natural causes with 39 survivors. The Watson anhedonia scale ( WAS) was filled out by the groups several years before they died. The deceased subjects were former psychiatric patients but the authors did not mention their diagnoses. The mean score of the WAS was not significantly different between the suicides and the survivors. Moreover,
the mean score for the WAS in the suicide group was significantly lower than that in the natural causes group. The Watson and Kucala study presented several limitations: first, the size of the groups was small; second, the reliability of the Watson scale was low; third, the patient group was heterogeneous.
References Addington, D.E, Addington, J.M., 1992. Attempted suicide and depression in schizophrenia. Acta Psychiatr. Scand. 85, 288–291. Chapman L.J., Chapman J.P., 1978. Revised Physical Anhedonia Scale, unpublished. Fawcett, J., Scheftner, W.A., Fogg, L., et al., 1990. Time-related predictors of suicide in major affective disorder. Am. J. Psychiatry 147 (9), 1189–1194. Loas, G., Salinas, E., Pierson, A., Salinas, E., Pierson, A., Guelfi, J.D., Samuel-Lajeunesse, B., 1990. Anhedonia and blunted affect in major depressive disorder. Comp. Psychiatry 35 (5), 366–372. Loas, G., 1995. L’e´valuation de l’anhe´donie en psychopathologie. In: Guelfi, J.D., Gaillac, V., Dardennes, R. ( Eds.), Psychopathologie quantitative. Masson, Paris, pp. 230–239. Watson, C.G., Kucala, T., 1978. Anhedonia and death. Psychol. Rep. 43, 1120–1122.
G. Loas* V. Yon M.C. Bralet C. Noisette Service Hospitalo-Universitaire, Hopital Pinel, 80044 Amiens cedex 01, France * E-mail address: [email protected] (G. Loas)
Letter to the Editors Anhedonia and suicide in chronic schizophrenia: a follow-up study Dear Editors, Anhedonia, the lowered ability to experience pleasure, constitutes a risk factor of suicide within one year in major affective disorders ( Fawcett et al., 1990). Moreover, in acute relapse of schizophrenia, Addington and Addington (1992) have shown that suicidal ideations were associated with anhedonia. Watson and Kucala (1978) have explored the relationships between anhedonia, suicide and premature natural deaths in psychiatric subjects. The results were equivocal, but suggested that suicides were characterized by low anhedonia. To our knowledge, the relationships between anhedonia and suicide in chronic schizophrenia have not been explored using a prospective follow-up study and the aim of the present study was to explore these relationships. Subjects were 150 in- or outpatients (82.66% and 17.34% respectively) meeting the research diagnosis criteria (RDC ) for chronic schizophrenia. The mean age was 38.88 years (SD= 10.23); 58% were men; 74% had never been married. The mean duration of illness was 14.80 years (SD=9.66). The subjects were recruited from two French psychiatric hospitals. All subjects gave written informed content to participate in the study. The RDC diagnoses based on structured interview and medical record data were determined by a consensus of two psychiatrists (GL and CN ). The inclusions were carried out from April 1991 to July 1995 and in May 1999 the patients were assessed concerning their status (alive or dead). The mean (SD) follow-up period for the patients was 63.31 months (15.45, range: 7–96 months). At the inclusion stage, the patients filled out
the revised Physical Anhedonia Scale (PAS) of Chapman and Chapman (1978) and the physical pleasure subscale of the Fawcett Clark Pleasure Capacity Scale (FCPCS-PP) (Loas et al., 1994). According to Chapman, the subjects were anhedonics if they scored at least 1.96 standard deviations above the mean of that scale calculated in the French reference group (Loas, 1995); 32 schizophrenics were anhedonic and 118 were not. The sex-ratio, the age and the mean duration of the illness were not significantly different between the hedonic and anhedonic schizophrenics. In May 1999 all the patients were assessed; most of them were always followed by the different departments of the two psychiatric hospitals. For each patient their status (alive or dead ) and (if necessary) causes of death were obtained from their psychiatrists, general practitioners, patient’s clinical files or death certificates. Thirteen of the subjects were deceased. The causes of death were: three suicides (drowning, shooting, jumping from high places); three cardiac problems; two cancers; one car crash; one suffocation; one respiratory arrest; one victim of homicide; and one infectious disease. The suicide mortality rates per 1000 person-years were 2.32‰ and 4.08‰ for hedonic and anhedonic schizophrenics, respectively. Anhedonics had a non significant 1.70-fold higher risk of suicide than hedonic schizophrenics (95% confidence interval; 0.16–18.18, Fisher exact test; P=0.54). The mean PAS and FCPCS-PP scores were not significantly different between the suicides and the survivors. The mean PAS scores (SD) were 23.66 (8.50) and 22.41 (8.89), respectively; Mann– Whitney U=184.5, P=0.76. The mean FCPCS-PP scores (SD) were 80.33 (10.60) and 79.58 (14.71), respectively; Mann–Whitney U=199.5, P=0.93.
0920-9964/01/$ - see front matter © 2001 Elsevier Science B.V. All rights reserved. PII: S0 9 2 0 -9 9 6 4 ( 0 0 ) 0 0 03 7 - 2
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Letter to the Editor / Schizophrenia Research 47 (2001) 105–106
Moreover, the mean PAS and FCPCS-PP scores were not significantly different between the suicides and the subjects who died of natural causes; the Mann–Whitney U were 10.5, P=0.44 and 12.5, P=0.67, respectively. Our study presented several limitations. First, it is possible that the duration of the follow-up study be insufficient to indicate an increase of mortality in anhedonic schizophrenics. Moreover, the small size of the anhedonic group could explain the negative results. Second, the number of suicides could be underrepresented, as certain natural or accidental deaths (e.g., car crash) could be ‘hidden’ suicides. The main result of the study is that anhedonia is not a risk factor of suicide in chronic schizophrenic patients. Only two follow-up studies have explored the relationships between anhedonia and suicide in different psychiatric groups. Fawcett et al (1990) have conducted a 10-year follow-up study on 954 patients with major affective disorders. The results have shown that anhedonia, rated by items of the Schedule for Affective Disorders and Schizophrenia, was associated with suicide within one year. Watson and Kucala (1978) have compared 39 psychiatric patients deceased of suicide or natural causes with 39 survivors. The Watson anhedonia scale ( WAS) was filled out by the groups several years before they died. The deceased subjects were former psychiatric patients but the authors did not mention their diagnoses. The mean score of the WAS was not significantly different between the suicides and the survivors. Moreover,
the mean score for the WAS in the suicide group was significantly lower than that in the natural causes group. The Watson and Kucala study presented several limitations: first, the size of the groups was small; second, the reliability of the Watson scale was low; third, the patient group was heterogeneous.
References Addington, D.E, Addington, J.M., 1992. Attempted suicide and depression in schizophrenia. Acta Psychiatr. Scand. 85, 288–291. Chapman L.J., Chapman J.P., 1978. Revised Physical Anhedonia Scale, unpublished. Fawcett, J., Scheftner, W.A., Fogg, L., et al., 1990. Time-related predictors of suicide in major affective disorder. Am. J. Psychiatry 147 (9), 1189–1194. Loas, G., Salinas, E., Pierson, A., Salinas, E., Pierson, A., Guelfi, J.D., Samuel-Lajeunesse, B., 1990. Anhedonia and blunted affect in major depressive disorder. Comp. Psychiatry 35 (5), 366–372. Loas, G., 1995. L’e´valuation de l’anhe´donie en psychopathologie. In: Guelfi, J.D., Gaillac, V., Dardennes, R. ( Eds.), Psychopathologie quantitative. Masson, Paris, pp. 230–239. Watson, C.G., Kucala, T., 1978. Anhedonia and death. Psychol. Rep. 43, 1120–1122.
G. Loas* V. Yon M.C. Bralet C. Noisette Service Hospitalo-Universitaire, Hopital Pinel, 80044 Amiens cedex 01, France * E-mail address: [email protected] (G. Loas)