Characteristics of the schizophrenia suicide attempts in comparison with the suicide attempts with other diagnosed psychiatric disorders: An Egyptian study

Abstract

Background:

There has been much literature on schizophrenia, but little is known about the characteristic features of suicide attempts with schizophrenia in comparison with the suicide attempts with other diagnosed psychiatric disorders.

Aims:

The objective of this study was to clarify the specific characteristics and risk factors among suicide attempters with schizophrenia that differentiate them from other psychiatric disorders.

Methods:

Thirty-three suicide attempters diagnosed with schizophrenia and 87 suicide attempters with other psychiatric disorders were included. Suicide attempts seriousness were appraised by the Beck’s Suicide Intent Scale (BSIS). Standardized scales were applied: Suicide Probability Scale (SPS) and Barratt Impulsiveness Scale, Version 11 (BIS-11). The Structured Clinical Interview for DSM-IV Axis I Disorders (SCID-I) and The Structured Clinical Interview for DSM-IV Axis II Disorders (SCID-II) based on the Diagnostic and Statistical Manual of Mental Disorders-IV (DSM-IV) was applied to assess the psychiatric status of individuals. Demographic and clinical characteristics, method of suicide and suicide probability scores and impulsivity were compared among both groups (schizophrenia group and other psychiatric disorders group).

Results:

In total, 27.5% of suicide attempts suffered from schizophrenia. The current study found that having more past history of medical diseases, longer duration of illness, using more violent suicidal methods, and having less significant suicidal ideations were the significant factors that differentiated schizophrenia suicide attempts from those diagnosed with other psychiatric disorders. The schizophrenia group did not show more impulsivity or hostility than other psychiatric disorders group.

Conclusion:

These results indicated that each group shows its unique characteristics. They give us new perspectives to prevent suicides in schizophrenia according to their different characteristics.

Keywords

Schizophrenia attempted suicide suicide intent mental disorders impulsivity Egypt

Introduction

Suicide is a leading cause of death and disease burden worldwide, with approximately one million annual deaths globally (World Health Organization (WHO), 2012). More than 90% of subjects who commit suicide have a psychiatric illness (Mann et al., 2005; Yoo et al., 2016). The absolute risk of suicide in different psychiatric disorders varies from 2% to 8% (Nordentoft, Mortensen, & Pedersen, 2011; Skip, Harris, & Barraclough, 1998).

Schizophrenia, the focus of the current research, is associated with higher rates of morbidity and mortality than the general population (Fuller & Hollister, 2016; Hammoudeh et al., 2016). Between 40% and 80% of schizophrenia patients develop suicide ideation (Barrett et al., 2010; Melle & Barrett, 2012; Stip, Caron, Tousignant, & Lecomte, 2017), 20%–40% attempt suicide during the course of their illness (Lyu & Zhang, 2014; Suokas et al., 2010; Yildiz, Yazici, & Böke, 2010), and with a lifetime risk of suicide estimated to be 3.23% (Dutta et al., 2010; Palmer, Pankratz, & Bostwick, 2005).

Although rates of completed and attempted suicides in schizophrenia are lower than in other psychiatric conditions (Ventriglio et al., 2016), yet, these figures are still unacceptably high, suggesting the need to identify the characteristics and risk factors of attempted suicide in schizophrenia, as a first step to prevent suicide in this vulnerable group (Hammoudeh et al., 2016; Hor & Taylor, 2010).

Risk factors for suicide in schizophrenia include delusions, auditory hallucinations and poor treatment adherence. Other studies point toward other risk factors in determining future suicide attempts: drug use disorders, affective symptoms, past suicidal ideation, previous suicide attempt, high number of psychiatric hospitalizations, social isolation and drug-induced parkinsonism (Bertelsen et al., 2007; Hammoudeh et al., 2016; Haw, Hawton, Sutton, Sinclair, & Deeks, 2005; Nock et al., 2009). A recent prospective study confirmed history of suicide attempt as a main risk factor for suicide (Fleischhacker et al., 2014), with the highest risk being within a year following the attempt. This association declined over time (Clapham et al., 2018).

So far, suicide with schizophrenia has been studied by previous researchers. For example, there are many retrospective studies of the rates and risk factors of suicide and schizophrenia, and studies comparing the characteristics of schizophrenia suicide attempters and non-attempters (Altamura, Bassetti, Bignotti, Pioli, & Mundo, 2003; Hor & Taylor, 2010; Isjanovski, Vukovic, Hadjihamza, Pejoska-Gerazova, & Raleva, 2010; Lui, 2009; Lyu & Zhang, 2014; Mauri, Paletta, Maffini, Moliterno, & Altamura, 2013; Ran et al., 2005; Rogers & Fahy, 2008). But little research studied the characteristics of suicide attempts with schizophrenia in comparison with other diagnosed psychiatric disorders. This is an unmet need in research, given the fact that a previous suicidal attempt is the most robust risk factor for completed suicides (Lyu & Zhang, 2014), and that attempts among patients with schizophrenia seem to be more serious and with more lethal methods compared with those without schizophrenia (Pompili et al., 2007; Skeem, Silver, Aippelbaum, & Tiemann, 2006).

In addition, there are few studies on suicidal behaviors in schizophrenia in the Arab countries. A study on overall suicidality in the Arab countries reported a lifetime suicide attempt rate of 0.72%–6.3% and a suicide ideation rate of 2.09%–13.9% (Karam, Hajjar, & Salamoun, 2007).

The current study aimed to compare the demographic, clinical characteristics and psychological variables of attempted suicides with schizophrenia (schizophrenia group), with other diagnosed psychiatric disorders (other psychiatric disorders group), so as to find what differentiates this vulnerable group from other psychiatric disorders and find the disease-specific risk factors, which would help develop a unique prevention strategy to decrease the death rate for individuals with schizophrenia.

Materials and methods

Study design, site and duration

This cross-sectional comparative study was carried out in Ain Shams Hospital’s psychiatry department, in the period from January 2016 until the end of April 2017. The institute of psychiatry is located in Eastern Cairo and serves a catchment area of about the third of Greater Cairo with a population of 17.681 million. It serves both urban and rural areas.

Sampling

Recognizing the need for clearly defined criteria for a serious suicide attempt, cases of accidental or low intent attempts were excluded. In addition, the sample was recruited from in-patients admitted in a tertiary psychiatry center.

The clinical sample of this study consisted of a consecutive sample of ALL patients admitted to Ain Shams Hospital’s psychiatry department because of attempted suicide – regardless of their diagnosis – in the period of the study. Male and female patients were included, with an age older than 18 years, who were admitted following serious suicide attempt (as indicated by Suicide Intent Scale of medium or high intent) and who agreed to participate. Suicide attempters with Suicide Intent Scale score of low intent and who refused to sign the consent were excluded.

Measures

A full history was taken from cases using the standard Ain Shams University psychiatric sheet including demographic data, past history of psychiatric and medical disorders, and suicide attempt assessment (methods used, previous attempts).

Beck’s Suicide Intent Scale (BSIS) (Beck, Schuyler, & Herman, 1974) was used to assess the intent and seriousness to end one’s life. The BSIS consists of 15 items that quantify an attempter’s verbal and nonverbal behavior prior to and during the most recent suicide attempt. Each item is scored from ‘0’ to ‘2’ with the total score ranging from 0 to 30. The range (15–19) indicates low intent, (20–28) indicates medium intent and (29+) indicates high intent. At the beginning of the study, the scale was translated into Arabic and then translated back into English. It showed good reliability with an inter-rater agreement of the Arabic version was found to be high as well (Kappa coefficient = .88).

The Structured Clinical Interview for DSM-IV Axis I Disorders (SCID I) (First, Spitzer, Williams, & Gibbon, 1995) was used to generate current axis I diagnoses for the suicide attempters. Arabic version was used (Missiry et al., 2004).

Axis II personality diagnoses were assessed by the Structured Clinical Interview for DSM-IV Axis II Disorders (SCID II) (First, Gibbon, Williams, & Benjamine, 1997). Arabic version was used (Hatata, Khalil, Asaad, Abo Zeid, & Okasha, 2004).

Subjects were assessed using Suicide Probability Scale (SPS) (Cull & Gill, 1988). Arabic version was used (Al beheiry, 2003). This scale gives empirically validated measure of suicide risk in adults and adolescents over 14 years of age. It is a 36-item self-report measure of current suicide ideation, hopelessness, negative self-evaluation and hostility.

Impulsivity rating was measured using the self-administered 30-item Barratt Impulsiveness Scale, Version 11 (BIS-11) (Patton, Stanford, & Barratt, 1995). The English version showed high reliability and validity. Arabic version was used (Ghanem et al., 2013).

Procedures

The database of the psychiatric institute showed that 145 patients were admitted to the inpatient department with an attempted suicide during the period of the study. Of these patients, 18 were excluded from the study due to having low intent by BSIS and there were seven dropout patients (i.e. dropout rate = 5.83%). Therefore, data of only 120 cases were included.

Interviews with the subjects were scheduled when their general condition improved (however, within the first week after the suicide attempt). Patients were interviewed in privacy and confidentiality was ensured. Approval of the ethical committee of Faculty of medicine Ain Shams University was obtained. An informed written consent was signed from all participants in the study.

In current study, the attempted suicides were divided into two groups based on the subjects’ psychiatric diagnosis: the group of the attempted suicides with schizophrenia (schizophrenia group) and the group of attempted suicides with other psychiatric disorders (other psychiatric disorders group).

Statistics

The collected data were analyzed to obtain results by using the computerized version of the Statistical Package for Social Sciences, 14th version (SPSS 14). Quantitative variables were described in mean–standard deviation (SD) and numbers and percentages if qualitative. Pearson chi-square test (χ²) was used to detect presence or absence of significant association between two categorical variables. Correlations (two-tailed) were calculated using Pearson coefficient. For quantitative variables, group means were compared using Student’s t test (two-tailed). Binary logistic regression: was used to predict the outcome of categorical variable based on one or more predictor variables. The value of p was used to indicate the level of significance (p = .05 is considered significant, p = .01 is highly significant and p = .001 is very highly significant).

Results

During the study period, 120 subjects met the eligibility criteria for the study. Psychiatric morbidity diagnosed by SCID-I and SCID-II scales showed that 99.8% of cases had at least one axis I psychiatric disorder, 40.8% had comorbid axis I and axis II disorders and 0.2% had only axis II disorders.

The most commonly encountered psychiatric disorders in suicide attempters were depression (58.3%). The second most common disorder was schizophrenia (27.5%) (Figures 1 and 2).

Figure 1.

SCID I distribution of the study group.

Figure 2.

SCID II distribution of the study group.

Demographic characteristics

In the current study, there were 33 (27.5%) attempted suicides with schizophrenia and 87 (72.5%) attempted suicides with other psychiatric disorders. There was no significant difference among both groups based on the demographic characteristics as described in Table 1. However, there was significant difference between both groups regarding the age, with the schizophrenics being older with a mean age of (31.7 ± 4.5) years.

Table 1.

Demographic characteristics of the study group.

Demographic characteristics	Totaln = 120 (%)	Schizophrenia groupn = 33 (27.5%)	Other psychiatric disorders groupn = 87 (72.5%)	p value
Age (category), years
<30	76 (63.3%)	15 (45.5%)	61 (70.1%)	.012*
>30	44 (36.6%)	18 (54.5%)	26 (29.9%)
Gender
Males	60 (50%)	20 (60.6%)	40 (46%)	.15
Females	60 (50%)	13 (39.4%)	47 (54%)
Marital
Married/engaged	48 (39.9%)	11 (33.3%)	37 (42.5%)	.24
Single	65 (54.1%)	19 (57.6%)	46 (52.9%)
Divorced/widower	7 (5.7%)	3 (9.1%)	4 (4.6%)
Occupation
Employed	43 (35.8%)	15 (45.5%)	28 (32.2%)	.35
Student	30 (25%)	6 (18.2%)	24 (27.6%)
Unemployed	47 (39.1%)	12 (36.4%)	35 (40.2%)

Statistically significant <.05.

Significant values were marked in bold.

Clinical characteristics

Table 2 shows that the schizophrenia group was more likely to have comorbid chronic medical illnesses including diabetes mellitus, bronchial asthma, anemia, favism, G6PD (glucose-6-phosphate dehydrogenase) deficiency, hypertension and renal stones, compared with those with other psychiatric disorders. In addition, the schizophrenia group had a significantly longer duration of psychiatric illness.

Table 2.

Clinical characteristics of the study group.

Clinical characteristics	Totaln = 120 (%)	Schizophrenia groupn = 33 (27.5%)	Other psychiatric disorders groupn = 87 (72.5%)	p value
PH of medical diseases
No	105 (87.5%)	27 (81.8%)	78 (89.7%)	.042*
Yes	15 (12.5%)	6 (18.2%)	9 (10.3%)
FH of suicide
No	111 (92.5%)	31 (93.9%)	80 (92%)	.71
Yes	9 (7.5%)	2 (6.1%)	7 (8%)
FH of psychiatric diseases
No	93 (77.5%)	22 (66.7%)	71 (81.6%)	.08
Yes	27 (22.5%)	11 (33.3%)	16 (18.4%)
Age of onset of psychiatric (years), M ± SD	24.1 ± 10	25.5 ± 11.2	23.5 ± 9.6	.34
Duration of illness (years), M ± SD	5.6 ± 6.6	7.5 ± 8.2	4.9 ± 5.8	.051*

PH: past history; FH: family history; M: mean; SD: standard deviation.

Statistically significant <.05.

Significant values were marked in bold.

Suicide attempt variables

Table 3 shows that 15.2% of the schizophrenia group were previously engaged in suicide attempts in past 6 months compared to 25.3% of attempters with other psychiatric disorders (p = .035). With respect to the method of attempted suicide used, there were significant difference among both groups (p ⩽ .001).

Table 3.

Suicidal history of the study group.

Suicidal history	Totaln = 120 (%)	Schizophrenia groupn = 33 (27.5%)	Other psychiatric disorders groupn = 87 (72.5%)	p value
Attempts in past 6 months
Yes	27 (22.4%)	5 (15.2%)	22 (25.3%)	.035*
No	93 (77.5%)	28 (84.8%)	65 (74.7%)
Psychiatric help in past 6 months
Admission	5 (4.1%)	1 (3%)	4 (4.6%)	.06
OPC	39 (32.5%)	15 (45.5%)	24 (27.6%)
No	76 (63.3%)	17 (51.5%)	59 (67.8%)
Method
Burn	4 (3.3%)	4 (12.1 %)	0 (0%)	<.001**
Cutting	7 (5.8%)	4 (12.1%)	3 (3.4%)
Jumping	19 (15.8%)	6 (18.2%)	13 (14.9%)
Poisoning	70 (58.3%)	7 (21.2%)	63 (72.4%)
Stabbing	17 (14.1%)	12 (36.4%)	5 (5.7%)
Other	3 (2.5%)	0 (0%)	3 (3.4%)

OPC: outpatient clinic.

Statistically significant <.05.

Statistically highly significant <.001.

Significant values were marked in bold.

SPS and personality characteristics

Table 4 shows that there were no significant differences between both groups on degree of suicide probability, hopelessness, negative self-image and hostility subscales. However, as to suicidal ideation subscale, schizophrenia group was less inclined to have suicidal ideations than other psychiatric disorders group (p = .004).

Table 4.

Suicide probability scale (SPS) scores of the study group.

SPS data	Totaln = 120 (%)	Schizophrenia groupn = 33 (27.5%)	Other psychiatric disorders groupn = 87 (72.5%)	p value
Hopelessness
Non-significant	95 (79.1%)	28 (84.8%)	67 (77%)	.35
Significant	25 (20.8%)	5 (15.2%)	20 (23%)
Suicidal ideation
Non-significant	35 (29.1%)	16 (48.5%)	19 (21.8%)	.004*
Significant	85 (70.8%)	17 (51.5%)	68 (78.2%)
Negative self-image
Non-significant	82 (68.3%)	24 (72.7%)	58 (66.7%)	.52
Significant	38 (31.6%)	9 (27.3%)	29 (33.3%)
Hostility
Non-significant	66 (55%)	17 (51.5%)	49 (56.3%)	.64
Significant	54 (45%)	16 (48.5%)	38 (43.7%)
SPS degree
Mild	5 (4.1%)	3 (9.1%)	2 (2.3%)	.18
Moderate	21 (17.5%)	7 (21.2%)	14 (16.1%)
Severe	94 (78.3%)	23 (69.7%)	71 (81.6%)

Statistically significant <.05.

Significant values were marked in bold.

Impulsivity as a trait measured by BIS-11 Scale showed no significant difference in the degree of impulsivity between both groups (Table 5).

Table 5.

Barratt Impulsiveness Scale (BIS) scores of the study group.

BIS	Totaln = 120 (%)	Schizophrenia groupn = 33 (27.5%)	Other psychiatric disorders groupn = 87 (72.5%)	p value
Attentional impulsivity (M ± SD)	19.1 ± 2.9	19.0 ± 2.8	19.1 ± 3	.79
Motor impulsivity (M ± SD)	27.1 ± 4.2	27.1 ± 5.2	27.1 ± 3.8	.99
Non-planning (M ± SD)	30.8 ± 4.5	31.5 ± 4.1	30.5 ± 4.6	.29
BIS degree
Mild	23 (19.1%)	8 (24.2%)	15 (17.2%)	.51
Moderate	57 (47.5%)	13 (39.4%)	44 (50.6%)
Severe	40 (33.3%)	12 (36.4%)	28 (32.2%)
BIS score (M ± SD)	76.9 ± 9.2	77.5 ± 10	76.7 ± 8.9	.66

SD: standard deviation.

A logistic regression analysis, in which significant factors were included, showed that past history of comorbid medical diseases, longer duration of illness, the use of more violent suicidal methods and less suicidal ideations remained significant (Table 6).

Table 6.

Logistic regression analysis of variables differentiating schizophrenia suicide attempters from non-schizophrenics.

	R	Sign.	Odds ratio	95% CI
	R	Sign.	Odds ratio	Lower	Upper
Age (years)	−0.202	0.216	0.536	0.187	0.697
Education	0.339	0.728	0.821	0.288	1.068
PH of medical diseases	1.117	0.029*	1.423	0.498	2.850
Duration of illness (years)	−1.007	0.022*	0.652	0.228	2.846
Attempts in past 6 months	−0.609	0.180	3.709	0.423	3.071
Method	1.045	0.012*	1.079	0.377	1.403
Suicidal ideation significance	1.327	0.033*	1.034	0.362	2.343

PH: past history; CI: confidence interval.

Statistically significant <.05.

Discussion

Schizophrenia is a serious mental disorder, and previous literature has reported suicide to be one of the main causes of premature death for sufferers with schizophrenia (Lyu & Zhang, 2014; Miles, 1977; Ventriglio et al., 2016). This study was set to investigate the characteristics and potential risk factors for attempted suicides in schizophrenia through comparing the characteristics of attempted suicides with schizophrenia (33 patients), with other diagnosed psychiatric disorders (87 patients) in Egypt.

This study indicates that about 27.5% of all serious attempted suicides admitted to the hospital in the study period suffered from schizophrenia, and that depression was the most common psychiatric disorder in all suicide attempts. These results agree with all previous studies indicating depression to be the most common pathology in suicide attempters (e.g. Bryan et al., 2014; Hawton, Houston, Haw, Townsend, & Harriss, 2003; Ibiloglu et al., 2016).

However, many studies showed much less rates of the frequency of presence of schizophrenia in suicide attempts ranging from 2% to 5.5% compared to 27.5% in the present study (Bassim et al., 2005; Hawton et al., 2003; Kim et al., 2015; Lin et al., 2014; Okasha, Lotaief, & El Mahallawy, 1986).

Schizophrenia presented in higher rates than most studies due to the fact that the majority of those studies were community or general hospital based. On the other hand, the subjects in the current study were recruited from the inpatient department of a tertiary care psychiatric hospital. This may represent a more severe spectrum of psychiatric disorders either with a more chronic course of illness or higher recurrence rates that necessitated their admission to a mental health hospital.

Supporting that, Bertolote, Fleischmann, De Leo and Wasserman (2003) reported that in studies of psychiatric hospital population, severe disorders (e.g. schizophrenia) reached 45.3% of all diagnoses, whereas less severe disorders (e.g. anxiety and adjustment disorders) were found mostly in the general population–based studies. In the same context, in a study that was undergone in a psychiatric facility, their results were similar to ours, where most common psychopathologies in suicide attempters were depression followed by drug dependence and schizophrenia (Hussain, Ansari, Raza-ur-Rahman Nighat, Shoro, & Shaikh, 2009).

Demographic characteristics of schizophrenia suicide attempters

The current study showed male preponderance in the schizophrenia group. Yet, it failed to reach a statistical significance. There is contradictory gender patterns in suicidal behaviors in schizophrenia, with some sources stating male gender to be a risk factor for suicidality in schizophrenia (Clapham et al., 2018; Gallego et al., 2015), while others indicating that women with schizophrenia are more likely to attempt suicide as compared to men with schizophrenia (Austad, Joa, Johannessen, & Larsen, 2015; Canuso & Pandina, 2007; Fuller & Hollister, 2016; Ko, Tsai, Chi, & SuC LeeH ChenPS Yang, 2018).

The mean age of schizophrenic group was significantly older than the other psychiatric disorders group. In agreement with the present results, some studies documented schizophrenia attempters to be older compared to controls, mood disorders and non-attempter schizophrenia patients, respectively (Clapham et al., 2018; Gallego et al., 2015; Isjanovski et al., 2010)

However, this came in contrast to many studies which report a significantly younger age in schizophrenia suicide attempters compared to those diagnosed with depression or other psychiatric disorders (Fuller & Hollister, 2016; Ishii et al., 2014; Limosin, Loze, Philippe, Casadebaig, & Rouillon, 2007). The inconsistent conclusions may have resulted from different research samples, different cultures, and that only serious attempts were included.

Clinical characteristics of schizophrenia suicide attempters

We found no significant difference on almost all clinical characteristics variables between the schizophrenia group and other psychiatric disorders group, in relation to family history of suicide, psychiatric disorder or in the age of onset of the disease. This came in contrast with studies reporting a significant association between suicide attempts in schizophrenia and a family history of psychiatric disorders or suicidal behaviors (Mauri et al., 2013). This could be underestimated in the present sample due to small sample size. This association needs further exploration.

Compared with other psychiatric disorders, schizophrenia group scored higher on physical illness, with 18.2% of schizophrenia suicide attempters had a comorbid medical disease. This came in contrast to studies, in which schizophrenia attempters reported less health issues than affective disorders group (Gallego et al., 2015; Ishii et al., 2014).

Meanwhile, in contrast to several studies, reporting a high risk of suicide during the first episode of schizophrenia, which declines over years (Dutta et al., 2010; Nordentoft, Madsen, Fedyszyn, 2015; Ventriglio et al., 2016), the schizophrenia group had a longer duration of illness than in the other group, and only one patient was in acute psychotic episode. A close observation was found in Isjanovski et al. (2010) and Mauri et al. (2013). The delay in accessing the mental healthcare system and starting treatment in Egypt may greatly contribute to this inconsistency. This also highlights the fact that the early detection of schizophrenia symptoms and early intervention are important not only in improving the overall outcomes but also in preventing suicides.

Suicidal history in schizophrenia attempters

Schizophrenia group scored significantly lower on number of previous suicide behaviors in past 6 months relative to the other psychiatric disorders. This was consistent with Clapham et al.’s (2018) study, reporting many suicides with schizophrenia to occur without recorded past suicidal behavior. This does not agree with a previous finding, that a history of suicide attempts was common in schizophrenia attempters (Isjanovski et al., 2010). Spontaneous suicidal communication by the patient to the clinician may therefore be insufficient to identify most of risky suicidal patients with schizophrenia (Clapham et al., 2018). This unpredictable nature of suicidality among patients with schizophrenia suggests routine screening of suicide ideation even in stable patients.

In agreement with previous literature, the schizophrenia group was more inclined to use violent suicide methods than other psychiatric disorders group (Ishii et al., 2014; Lyu & Zhang, 2014). The main suicide method of the schizophrenic group was stabbing (36.4%) followed by self-poisoning (21.2%) then jumping from heights (18.2 %). This difference was highly significant.

Psychological characteristics and the SPS data of schizophrenia suicide attempters

There were similarities on psychological variables – hopelessness, negative self-image and hostility – between the schizophrenia group and the other psychiatric disorders. However, the suicide attempters with schizophrenia had significantly less suicidal ideation in reference to other psychiatric disorders. There was no significant difference regarding the overall degree of probability of suicide.

In contrast to these results, studies comparing patients with schizophrenia and mood disorders found that attempters in schizophrenia spectrum had higher rates of suicidal ideation (Chapman et al., 2014; Gallego et al. (2015). However, this contrast could be attributed to the use of different methodology.

The comparison between both groups regarding impulsivity – as a trait – was noteworthy. In agreement with Reddy et al. (2014), who reported no difference between schizophrenia attempters and healthy controls on the impulsivity variable, the present study reported the schizophrenia group not to be more impulsive than other psychiatric disorders.

In contrast, other studies reported impulsivity to be higher in non-abusing schizophrenia patients than in healthy controls and other psychiatric disorders, respectively (Doihara et al., 2012; Zhornitsky et al., 2012).

In the end, multiple logistic regression analysis showed that independent significant associations emerged only for having more comorbid medical diseases, longer duration of illness and less suicidal ideations, and using more violent suicidal methods. These findings support that presence of comorbid medical diseases and longer duration of illness without early detection and intervention may play an independent role in increasing the risk of attempting suicide. In addition, having less suicidal ideation and the use of lethal methods of suicide indicate the seriousness of such attempts and its higher lethality. All these factors could interact together.

Limitation of study

One limitation of the study was the narrow range of sampling. The data were obtained from a single tertiary referral psychiatric hospital; this may limit the generalizability of the results. In addition, this is not a randomly selected sample. However, we did resort to a consecutive sample design, due to the low flow of serious suicide attempts. The cross-sectional nature of the study limits our ability to draw causal inferences. Future studies on this research topic may be conducted in larger and more diverse samples.

Despite these limitations, the results of this study have important implications for scientific, clinical and policy efforts aimed at suicide prevention.

Conclusion

The suicide attempters with schizophrenia had significantly longer duration of illness and more medical comorbidities. The schizophrenia group was more likely to make suicide attempts using violent methods with more serious outcomes. They scored significantly less on suicidal ideation and did not show more hostility or impulsivity than the other psychiatric disorders group. This study may help improve prediction and prevention of suicidal behaviors and suicide deaths in schizophrenia disorders.

Footnotes

Funding

The author(s) received no financial support for the research, authorship and/or publication of this article.

ORCID iD

Mai SeifElDin Abdeen

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