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Briefing Paper
Updated April 2007

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SUICIDE: ONE OF THE CONSEQUENCES OF FAILING TO TREAT SEVERE PSYCHIATRIC DISORDERS

What percentage of individuals with schizophrenia and 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 et al. Family perspectives on meeting the needs for care of severely mentally ill relatives: a national survey. 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 and 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 and Gottesman I. Schizophrenics kill themselves too: a review of risk factors for suicide. Schizophrenia Bulletin 16:571-589, 1990.

• This rate is at least four times higher than similar studies from the period from 1913 to 1960, suggesting that the suicide rate has risen markedly since massive deinstitutionalization began.

Stephens J et al. Suicide in patients hospitalized for schizophrenia: 1913-1940. Journal of Nervous and Mental Disease 187:10-14, 1999.

• 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 and Jamison KR. Manic-Depressive Illness. New York: Oxford University Press, 1990, p. 230.

• A recent 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 et al. Comprehensive Textbook of Suicidology. New York: Guilford Press, 2000, pp. 311-341.

• 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.

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 in 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 21:665-672, 1986.

• 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 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 154:1235-1242, 1997.

• 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 et al. Suicide attempts of high medical seriousness in schizophrenic patients. Comprehensive Psychiatry 33:384-387, 1992.

• 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 et al. Symptoms, subtype, and suicidality in patients with schizophrenia spectrum disorders. American Journal of Psychiatry 154:199-204, 1997.

• 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 39:1089-1095, 1982.

• 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 to 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 et al. Aftercare and clinical characteristics of people with mental illness who commit suicide: a case-control study. Lancet 353:1397-1400, 1999.

• 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 et al. Risk factors for suicide in young people suffering from schizophrenia: a long-term follow-up study. Schizophrenia Research 47:127-134, 2001.

• Studies have suggested that some antipsychotic medications, and especially lithium, may decrease the incidence of suicide among individuals with severe psychiatric disorders.

Tondo L et al. Lithium and suicide risk in bipolar disorder. Primary Psychiatry 6:51-56, 1999.

Müller-Oerlinghausen B. Arguments for the specificity of the antisuicidal effect of lithium. European Archives of Psychiatry and Clinical Neuroscience 251 Suppl:1172-1175, 2001.

• 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 to 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 to 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 et al. A case control study on psychopharmacotherapy before suicide committed by 61 psychiatric inpatients. Pharmacopsychiatry 35: 37-43, 2002.

• 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 to 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 68:167-181, 2002.

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