Fenton WS, McGlashan TH, Victor BJ, et al: Am J Psychiatry 154:199-204, 1997

Abstract: Suicide is the single largest cause of premature death among individuals with schizophrenia. This report examines the relationship between positive or negative symptoms, illness subtype, and suicidal behavior among patients with schizophrenia and schizophrenia spectrum disorders in a long-term follow-up cohort. Based on index admission records, patients from the Chestnut Lodge Follow-Up Study with schizophrenia (n = 187), schizoaffective disorder (n = 87), schizophreniform disorder (n = 15), and schizotypal personality disorder (n = 33) were retrospectively assessed with the Positive and Negative Syndrome Scale, classic subtype criteria, and criteria for the deficit syndrome. Completed suicides, suicide attempts, and suicidal ideation during the follow-up period (average, 19 years) were ascertained by means of interviews with patients and/or surviving relatives. Over the follow-up period, 40% of the patients reported suicidal ideation, 23% reported suicide attempts, and 6.4% died from suicide. Patients who died from suicide had significantly lower negative symptom severity at index admission than patients without suicidal behaviors. Two positive symptoms (suspiciousness and delusions), however, were more severe among successful suicides. The paranoid schizophrenia subtype was associated with an elevated risk of suicide (12%), and the deficit subtype was associated with a reduced risk (1.5%). These findings suggest that prominent negative symptoms, such as diminished drive, blunted affect, and social and emotional withdrawal, counter the emergence of suicidality in patients with schizophrenia spectrum disorders, and that the deficit syndrome defines a group at relatively low risk for suicide. Prominent suspiciousness in the absence of negative symptoms defines a relatively high-risk group.

Editorial Comment

The authors are interested in the relationship between symptoms and suicide risk in schizophrenia. The database was the Chestnut Lodge Follow-Up Study, which included all patients discharged from that facility between 1950 and 1975. Patients were retrospectively evaluated using modern diagnostic and symptoms scales documented on medical records. Prominent negative symptoms characterized a population with a relatively low risk for suicide. On the other hand, patients with suspiciousness and delusions were more likely to commit suicide. These results may be helpful to clinicians who are concerned with identifying populations at greater risk for suicide.

Stephen R. Marder, MD West Los Angeles VA Medical Center