Suicidal ideation in postpsychotic depression

Suicidal

Ideation Mitchell

in Postpsychotic Shuwall

Although approximately 10% of schizophrenics commit suicide, little is known about the clinical correlates of this behavior. This study investigated the relationships between suicidal ideation, anxiety, and psychosis in a group of schizophrenic and schizoaffective patients with operationally defined cases of postpsy-

A

PPROXIMATELY 10% of schizophrenic lives end in suicide.’ However, relatively little is known about the clinical correlates of this tragic behavior, aside from an expectable relationship to depressed mood2,3 and associations with certain demographic variables.3-6 We therefore undertook to examine the relationships between suicidal ideation and other relevant psychopathologic stigmata, in this case the symptomatology of psychosis and anxiety, in a cohort of schizophrenic and schizoaffective patients with operationally defined postpsychotic depressions. Our aim was to determine whether these additional variables could add meaningfully to our understanding of proneness to suicide in this vulnerable population. METHOD

We interviewed patients who met Research Diagnostic Criteria (RDC)7 for schizophrenia or schizoaffective disorder for their most recent psychotic episode, who were currently either nonpsychotic or only residually psychotic (RDC definition), and who also met operationalized criteria for postpsychotic depression. 8.9These criteria included (1) meeting RDC criteria A and B for depression, (2) having a Hamilton Depression Rating Scale scorei of 12 or more, not counting items for derealization or paranoia, and (3) maintaining (1) and (2) for three consecutive weekly evaluations, with the Hamilton score on the third week not being the lowest of the three. All patients were being treated with their best-adjusted weekly dose of fluphenazine decanoate and benztropine 2 mg orally three times daily at the time of the evaluation.

From the Hillside Hospital Division of the Long Island Jewish Medical Center and the Albert Einstein College of Medicine, Glen Oaks, NY. Supported in part by National Institute of Mental Health Grant No. MH-34309 and National Institute of Drug Abuse Grant No. DA-05039. Presented at the Annual Meeting of the American Psychopathological Association, March 5, 1992. Address reprint requests to Mitchell Shuwall, Ph.D., Hillside Hospital, PO Box 38, Glen Oaks, NY 11004. Copyright 0 1994 by W.B. Saunders Company 0010-440X/94/3502-0011$03.00/0 132

and Samuel

Depression

G. Siris

chotic depression. Psychosis contributed to the variance in suicidal ideation over and above the effects of depression and anxiety. Treatment and research implications of this finding are discussed. Copyright 0 1994 by W. B. Saunders Company

After obtaining informed consent, we interviewed patients with the Schedule for Affective Disorders and Schizophrenia (SADS),” and compared the SADS suicide ideation measure with other depression, psychosis, and anxietyrelated items using multiple regression techniques appropriate for highly correlated independent variables. RESULTS

Sixty-eight patients (37 men, 31 women, mean age 33.9 2 10.5 years) had been hospitalized an average of 4.7 + 3.7 times and were maintained on an average fluphenazine decanoate dose of 0.55 + 0.42 mL per week. Their SADSextracted Hamilton Depression Rating Scale scores12 averaged 22.5 + 6.9. Figure 1 is a histogram that depicts the distribution of scores for suicidal ideation in this group and suggests a bimodal distribution. Thirty-four had either no or equivocal suicidal ideation. The remaining 34 patients had definite suicidal ideation of at least a mild degree. The average SADS suicidal ideation item score was 2.44 + 1.29. Table 1 shows correlations between the suicidal ideation item and the depression, psychosis, and anxiety scales of the SADS, along with their component items. The correlations between each of these scales and suicidal ideation were quite strong, and these relationships were in the anticipated direction. Not surprisingly, the amount of overall variance in suicidal ideation contributed to by these three items was also significant (Z?2= .23, F = 6.22, P = .0009). However, the intercorrelations between each of these items were also considerable (depression with anxiety, r = .68, P < .OOl; depression with psychosis, r = .23, P = .06; and anxiety with psychosis, r = .21, P = .09). The results of a hierarchical multiple regression procedure assessing the unique contributions of the individual items are therefore presented in Table 2. Given the three factors of anxiety, depression, and psychosis, only psychosis (with statistical significance) and anxiety (at a trend level)

ComprehensivePsychiatry,

Vol. 35, No. 2 (March/April),

1994: pp 132-134

SOCIAL IDEATION IN POSTPSYCHOTIC

133

DEPRESSION

Table 1. Cross-Sectional

Analysis of 68 Patients With

Syndromally Defined Postpsychotic Depression CorrelationCoefficientof SADS SuicidalIdeationItem With: SADS-extracted

r

P

.33

,006

Hamilton Depression Rating

Scale score* Component items Blue mood

.2J

.02

Self-reproach

.33

,006

Insomnia

.I6

.20

Functional impairment

.21

.os

.06

.61

Psychomotor retardation

-.02

Agitation

t

.23

.06

Somatic anxiety

.34

,004

-.02

Depersonalization

(I

Fig 1. Cross-sectional analysis of 66 patients with syndromally defined postpsychotic depression. Histogram of SADS suicide ideation item ratings.

contributed to the variance in suicidal ideation over and above the other two factors. DISCUSSION

Currently available research associates suicide among schizophrenic patients with being young, male, having initially high functioning or expectations, being in the early years of chronic illness, having experienced multiple exacerbations” or hospitalizations,4,13 and suffering depression or hopelessness.14 Less is known about the influence of psychosis or anxiety, which are so frequently part of the experience of patients with this disorder. Although some studies suggest that severe delusions and hallucinations are associated with suicide,15 others dispute this.4 Even less is known about the contribution of anxiety. Whereas Johnson et a1.16stressed the importance of panic disorder combined with depression as a suicide risk factor in a nonschizophrenic population, and Fawcett” has noted such an association in a broader population of affective disorder patients that included some patients with schizoaffective disorder, this issue has not been addressed specifically with regard to patients with schizophrenia or schizoaffective disorder suffering from a postpsychotic depression.

.a4

Psychic anxiety

.a7

Poor appetite

.Ol

.91

Weight loss

.12

.31

Obsessions

.26

.03

Concern with bodily functioning

.25

.04

Distrustfulness

.30

.Ol

Diurnal-AM

.06

.5a

Diurnal-PM

.05

.67

.34

,004

SADS psychosis scale Component items Severity of hallucinations

.26

.03

Severity of delusions

.31

.Ol

Thought disordert

.I2

.34

.39

,001

Phobia

.25

,037

Psychic anxiety

.23

,061

Somatic anxiety

.34

,004

SADS-derived anxiety scale Component items

*Excluding suicidal ideation items. tAverage of impaired understandability, loosening of associations, and illogical thinking items.

Appreciating that anxiety, depression, and psychosis are often found together among schizophrenic patients, we sought to tease apart these factors using a hierarchical multiple regression analysis. Although, as expected, depression, anxiety, and psychosis were each associated with suicidal ideation, as well as with each other, closer inspection revealed that both psychosis and to a lesser extent anxiety contributed to suicidal ideation over and above the contributions of the other factors. However, three points Table 2. Tests of Unique Contribution of Each Variable Using Tests of Rz Change Associated With Multiple Regression Variable

df

R*

Change*

F

P

3.42

,068

Anxiety

1

,041

Depression

1

,003

.30

,585

Psychosis

1

,065

5.42

,023

*Refers to change in R2 when variable is added to equation already containing other

two variables.

134

SHUWALL AND SIRIS

should be clarified. First, the populations of schizophrenic patients studied were all depressed to some extent, and thus these findings may not generalize to patients without postpsychotic depression as defined in this study. Second, the multiple regression procedure used in this case cannot be interpreted to mean that psychosis and anxiety are more important than depression in predicting suicidal ideation. Rather, the findings suggest that, given a population of schizophrenic patients with some depressive affect, the presence of psychosis and/or anxiety is associated with higher levels of suicidal ideation independent of the level of depression. Thus, in depressed schizophrenic patients, the presence of active psychosis or strong anxiety should alert the clinician to the potential for suicidal ideation and indicate a more in-depth assessment of suicidal potential. This is important to note because the nature of psychosis (notwithstanding the presence of command hallucinations) may often obscure the less salient,

self-destructive feelings that may accompany such symptoms. Finally, suicidal ideation rather than completed suicide was studied, and therefore interpretations and generalizations must be made in this context. Further study is needed to explore factors mediating the above findings (i.e., Is the relationship between the experience of psychosis or anxiety and suicidal ideation causal in these patients, and if so, what is the direction of that causality? Also, if a causal relationship exists, what is there specifically about the experience of psychosis or anxiety that increases the likelihood or severity of suicidal ideation, or vice versa? Alternately, what common mechanisms might underlie psychosis, anxiety, and suicidal ideation?). Additionally, it would be important to understand the relative contributions that psychosis and anxiety each have on suicidal behavior per se, rather than on suicidal ideation alone.

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10. Hamilton M. A rating scale for depression. J Neurol Neurosurg Psychiatry 1960;23:56-62. 11. Endicott J, Spitzer RL. A diagnostic interview: the schedule for Affective Disorders and Schizophrenia. Arch Gen Psychiatry 1978;35:837-844. 12. Endicott J, Cohen J, Nee J, Fleiss J, Sarantakos S. Hamilton Depression Rating Scale: extracted from regular and changed versions of the Schedule for Affective Disorders and Schizophrenia. Arch Gen Psychiatry 1981;38:98103. 13. Roy A, Mazonson A, Pickar D. Attempted suicide in chronic schizophrenia. Br J Psychiatry 1984;144:303-306. 14. Cohen LJ, Test MA, Brown RL. Suicide and schizophrenia: data from a prospective community treatment study. Am J Psychiatry 1990;147:602-607. 15. Johns CA, Stanley M, Stanley B. Suicide in schizophrenia. In: Mann JJ, Stanley M (eds): Psychobiology of Suicidal Behavior. New York, NY: New York Academy of Sciences, 1986:294-300. 16. Johnson J, Weissman MM, Klerman GL. Panic disorder, comorbidity, and suicide attempts. Arch Gen Psychiatry 1990;47:805-808. 17. Fawcett J. Suicide risk factors in depressive disorders and in panic disorder. J Clin Psychiatry 1992;53:9-13.