Suicidal behavior in patients with schizophrenia and other psychotic disorders.

OBJECTIVE: Patients with schizophrenia are known to be at high risk for suicide attempts and dying by suicide. However, little research has been conducted to determine whether the risk for suicidal behavior is elevated among patients with psychosis in general. METHOD: This study evaluated 1-month and lifetime rates of suicidal behavior among 1,048 consecutively admitted psychiatric inpatients (ages 18 to 55 years) with DSM-III-R psychotic disorders. Demographic, clinical, and diagnostic correlates of suicidal behavior were examined. RESULTS: A high rate of suicidal behavior was found in the group: 30.2% reported a lifetime history of suicide attempts, and 7.2% reported a suicide attempt in the month before admission. The highest 1-month and lifetime rates were found in patients with schizoaffective disorder and major depression with psychotic features. Ratings of the medical dangerousness of the most recent suicide attempt on the basis of the extent of physical injury were higher in patients with schizophrenia spectrum psychoses. Agreement was high between emergency room assessments and semistructured interview assessments of suicidal behavior. CONCLUSIONS: Rates of suicidal behavior were high across a broad spectrum of patients with psychotic disorders; patients with a history of a current or past major depressive episode (as a part of major depressive disorder or schizoaffective disorder) were at a greater risk for suicide attempts, but patients with schizophrenia, on average, made more medically dangerous attempts. Risk factors for suicidal behavior in patients with psychosis appear to vary compared to those for the general population.     

Suicidal behavior in schizophrenia: characteristics of individuals who had and had not attempted suicide.

OBJECTIVE: This study compares demographic and clinical characteristics of 52 individuals with schizophrenia or schizoaffective disorder who had attempted suicide with those of 104 individuals with schizophrenia or schizoaffective disorder who had not made a suicide attempt. METHOD: Participants were interviewed with the Diagnostic Interview for Genetic Studies. RESULTS: Most suicide attempts were of moderate to severe lethality, required medical attention, and involved significant suicidal intent. Individuals who had and had not attempted suicide did not differ with respect to demographic variables, duration of illness, rate of depression, or substance abuse. The two groups are affected differentially when depressed. CONCLUSIONS: Biopsychosocial assessments and interventions are essential for reducing the risk for suicidal behavior in individuals with schizophrenia.     

Suicide attempts in schizophrenia: the role of command auditory hallucinations for suicide

BACKGROUND: We examined the presence of command auditory hallucinations for suicide (CAHS) in a sample of individuals with schizophrenia or schizoaffective disorder. We examined the relationship between CAHS and demographic and clinical variables. We also investigated the relationship between CAHS and suicide attempts. METHOD: 100 individuals with DSM-IV schizophrenia or schizoaffective disorder hospitalized on an inpatient research unit participated. Information was gathered using the Diagnostic Interview for Genetic Studies and the Harkavy Asnis Suicide Scale. Data were gathered from 1995 to 2001. RESULTS: CAHS were frequent in this sample (22%), as were suicide attempts (33%). Eight percent of the entire sample (36% of those who experienced CAHS) made at least 1 suicide attempt in response to the hallucinations. The presence of CAHS was not related to demographic or clinical measures assessed. The frequency of CAHS was not statistically different for suicide attempters (30%) and nonattempters (18%). However, 80% (8/10) of attempters with CAHS reported at least 1 attempt in response to CAHS. Three of 6 repeat attempters who made at least 1 suicide attempt in response to CAHS also made other attempts that were not in response to CAHS. The presence of CAHS was not associated with a history of depression or substance abuse/dependence. CONCLUSION: The presence of CAHS does not directly predict suicide attempts. However, individuals who are already at risk for suicidal behavior (e.g., past attempters) may be at increased risk for a suicide attempt when experiencing CAHS.     

Risk factors for completed suicide in schizophrenia and other chronic psychotic disorders: a case-control study

OBJECTIVE: Despite an increased risk for suicide among individuals diagnosed with psychotic disorders, risk factors for completed suicide remain largely unexamined in this population. Using a case-control design, this study aimed to investigate clinical and behavioural risk factors for suicide completion in schizophrenia and other chronic psychotic disorders. METHOD: A total of 81 psychotic subjects were examined; of these, 45 died by suicide. Proxy-based interviews with, on average, 2 informants were conducted using the SCID I and II interviews and a series of personality trait assessments. RESULTS: Psychotic individuals at risk for suicide are most readily identified by the presence of depressive disorders NOS, moderate to severe psychotic symptoms and a family history of suicidal behaviour. They also exhibited fewer negative symptoms, had more comorbid diagnoses and, contrary to findings in other populations, we found that cluster A and C personality trait symptoms seem to have protective effects against suicide in schizophrenics and other chronic psychotic suicides. CONCLUSIONS: Our study suggests that behavioural mediators of suicide risk, such as impulsive-aggressive behaviours, do not play a role in schizophrenic and chronic psychotic suicide. This is contrary to findings in other diagnostic groups, thus implying heterogeneity in predisposing mechanisms involved in suicide.     

Cross-sectional similarities and differences between schizophrenia, schizoaffective disorder and mania or mixed mania with mood-incongruent psychotic features.

BACKGROUND: The cross-sectional clinical differentiation of schizophrenia or schizoaffective disorder from mood-incongruent psychotic mania or mixed mania is difficult, since pathognomonic symptoms are lacking in these conditions. AIMS OF THE STUDY: To compare a series of clinical variables related to mood and cognition in patient groups with DSM-III-R diagnosis of schizophrenia, schizoaffective disorder, mood-incongruent psychotic mania and mood-incongruent psychotic mixed mania. METHODS: One hundred and fifty-one consecutive patients were evaluated in the week prior to discharge by using the structured clinical interview for DSM-III-R-patient edition (SCID-P). Severity of psychopathology was assessed by the 18-item version of the brief psychiatric rating scale (BPRS) and negative symptoms by the scale for assessment of negative symptoms (SANS). Level of insight was assessed with the scale to assess unawareness of mental disorders (SUMD). RESULTS: There were no differences in rates of specific types of delusions and hallucinations between subjects with schizophrenia, schizoaffective disorder, psychotic mania and psychotic mixed mania. SANS factors scores were significantly higher in patients with schizophrenia than in the bipolar groups. Patients with mixed state scored significantly higher on depression and excitement compared to schizophrenia group and, to a lesser extent, to schizoaffective group. Subjects with schizophrenia showed highest scores on the SUMD indicating that they were much more compromised on the insight dimension than subjects with psychotic mania or mixed mania. CONCLUSION: Negative rather than affective symptomatology may be a useful construct to differentiate between schizophrenia or schizoaffective disorders from mood-incongruent psychotic mania or mixed mania.     

Differing correlates for suicide attempts among patients with schizophrenia or schizoaffective disorder in India and USA

BACKGROUND: Suicide is one of the most common causes of death among persons with schizophrenia. Differing risk factors have been identified in published studies. The differences may have arisen because a uniform set of variables was not analyzed. Alternatively, the nature and effect of risk factors may vary in different settings. To test these possibilities, we investigated the same set of variables in two independent cross-national samples ascertained using identical protocols. METHODS: Patients with schizophrenia or schizoaffective disorder (DSM IV criteria) were recruited in India (n=460) and the USA (n=424). RESULTS: Consistent with earlier publications, a diagnosis of schizoaffective disorder, history of depression, pattern of symptoms and educational status were significantly associated with suicide attempts in the US sample. None of these variables were significantly associated in the Indian sample. CONCLUSIONS: The impact of known risk factors for suicide attempts among patients with schizophrenia differs across ethnic groups.     

Clozapine treatment for suicidality in schizophrenia: International Suicide Prevention Trial (InterSePT)

BACKGROUND: Approximately 50% of patients with schizophrenia or schizoaffective disorder attempt suicide, and approximately 10% die of suicide. Study results suggest that clozapine therapy significantly reduces suicidal behavior in these patients. METHODS: A multicenter, randomized, international, 2-year study comparing the risk for suicidal behavior in patients treated with clozapine vs olanzapine was conducted in 980 patients with schizophrenia or schizoaffective disorder, 26.8% of whom were refractory to previous treatment, who were considered at high risk for suicide because of previous suicide attempts or current suicidal ideation. To equalize clinical contact across treatments, all patients were seen weekly for 6 months and then biweekly for 18 months. Subsequent to randomization, unmasked clinicians at each site could make any interventions necessary to prevent the occurrence of suicide attempts. Suicidal behavior was assessed at each visit. Primary end points included suicide attempts (including those that led to death), hospitalizations to prevent suicide, and a rating of "much worsening of suicidality" from baseline. Masked raters, including an independent suicide monitoring board, determined when end point criteria were achieved. RESULTS: Suicidal behavior was significantly less in patients treated with clozapine vs olanzapine (hazard ratio, 0.76; 95% confidence interval, 0.58-0.97; P =.03). Fewer clozapine-treated patients attempted suicide (34 vs 55; P =.03), required hospitalizations (82 vs 107; P =.05) or rescue interventions (118 vs 155; P =.01) to prevent suicide, or required concomitant treatment with antidepressants (221 vs 258; P =.01) or anxiolytics or soporifics (301 vs 331; P =.03). Overall, few of these high-risk patients died of suicide during the study (5 clozapine vs 3 olanzapine-treated patients; P =.73). CONCLUSIONS: Clozapine therapy demonstrated superiority to olanzapine therapy in preventing suicide attempts in patients with schizophrenia and schizoaffective disorder at high risk for suicide. Use of clozapine in this population should lead to a significant reduction in suicidal behavior.     

Suicide in schizophrenia: a retrospective case-control study of 51 suicides

The aim of this study was to identify factors associated with suicide in patients with schizophrenia who required inpatient admission and to compare these factors with the risk profile of patients with other diagnoses also requiring inpatient care. A retrospective, matched case-control study of 51 patients with schizophrenia requiring psychiatric inpatient care was undertaken. A priori specified risk factors were investigated within the schizophrenia group and compared with those of patients with other psychiatric diagnoses. The results show that previous suicide attempts are associated with an increased risk of suicide across all diagnoses. The presence of depressive symptoms and involvement of police with the index admission become more significant factors in patients with schizophrenia, compared to those with other diagnoses. Supportive mental health accommodation is associated with a reduced risk of suicide. Suicide of individuals is difficult to predict in patients with schizophrenia. Young men appear particularly vulnerable at times of inpatient care. Depressive symptoms and previous suicide attempts are significant risk factors.     

Schizoaffective disorder merges schizophrenia and bipolar disorders as one disease--there is no schizoaffective disorder

PURPOSE OF REVIEW: Schizoaffective disorder was named as a compromise diagnosis in 1933, and remains popular as judged by its place in the International Classification of Diseases and the Diagnostic and Statistical Manual of Mental Disorders, its frequent use in clinical practice, and its extensive discussion in the literature. Some, however, have questioned the validity of schizoaffective disorder as separate from psychotic mood disorder. We examined the literature to assess the rationale for the continuation of schizoaffective disorder as a legitimate diagnostic category. RECENT FINDINGS: The diagnosis of schizoaffective disorder depends on the disease specificity of the diagnostic criteria for schizophrenia; however, the psychotic symptoms for schizophrenia, traditionally held as specific, can be accounted for by psychotic bipolar. Further, the interrater reliability for diagnosing schizoaffective disorder is very low. A recent and expanding body of comparative evidence from a wide range of clinical and basic science studies, especially genetic, reveals multiple similarities between schizoaffective disorder, schizophrenia and psychotic bipolar. SUMMARY: Schizoaffective disorder unifies schizophrenia and bipolar, blurring the zones of rarity between them and suggesting that schizoaffective disorder is not a separate, 'bona-fide' disease. Patients diagnosed with schizoaffective disorder likely suffer from a psychotic mood disorder. The diagnosis of schizoaffective disorder, which can result in substandard treatment, should be eliminated from the diagnostic nomenclature.     

Suicidality in schizophrenia: a review of the evidence for risk factors and treatment options

Suicide is a major contributor to the morbidity and mortality of schizophrenia, accounting for approximately 10% of deaths in these patients. The known risk factors for suicide in schizophrenia include prior suicide attempts, substance abuse, male sex, onset during first decade of illness, social isolation, depression, and feelings of hopelessness. There is significant evidence suggesting that clozapine reduces the suicide rate in patients with schizophrenia and schizoaffective disorder. Possible factors that lead to a decrease in suicidality with clozapine include the following: a direct antidepressant action, improved cognitive function and insight, diminished negative symptoms, reduced substance abuse, and improved compliance. These effects may converge or lessen feelings of hopelessness and more of its converse optimism. The International Suicide Prevention Trial (InterSePT) is a large prospective, 2-year randomized trial of the comparative effects of clozapine and olanzapine involving 980 patients at high risk for suicide in 11 countries in 56 sites. The study included complete freedom to augment these treatments if needed, blinded ratings, a blinded Suicide Monitoring Board, and equivalent clinical contact. The results support the superiority of clozapine over olanzapine to reduce the risk of suicidality and suggest its use should be considered for all patients with schizophrenia with high risk for suicide.     

What is specific to suicide in schizophrenia disorder? Demographic, clinical and behavioural dimensions

BACKGROUND: Schizophrenia and schizoaffective disorder are diagnostic categories that are particularly at risk for suicide. A number of risk factors have been proposed to play a role in vulnerability to suicide, but it is unclear whether these are specific to certain diagnostic groups at risk for suicide or generalizable across disorders. It remains to be better understood what differentiates schizophrenic from non-schizophrenic suicides and whether or not these two groups share a common suicide liability. METHODS: Five hundred and twenty seven consecutive suicides, 43 of whom met criteria for schizophrenia and schizoaffective disorder, were investigated by means of proxy-based interviews using structured diagnostic instruments and personality trait assessments. RESULTS: Compared to other suicides, we found that schizophrenic and schizoaffective suicides presented comparably elevated levels of impulsive aggressive traits. They also had comparable levels of family history of suicidal behaviour among first degree relatives. Overall, schizophrenics and schizoaffective suicides met criteria for fewer psychiatric disorders, and were less likely to meet criteria for more than one disorder. Compared to suicides without schizophrenia or schizoaffective disorders, lower levels depressive disorders, of current and lifetime comorbid alcohol abuse, and personality disorders were found within those suicides who met criteria schizophrenia and schizoaffective disorders. CONCLUSIONS: Elevated levels of impulsive-aggressive personality traits, considered as indicative of an elevated risk for suicide in other diagnostic categories, are also found among schizophrenic and schizoaffective suicide completers. Elevated levels of impulsive aggressive behaviours may serve as a common liability to suicide across major psychopathological categories, including schizophrenia and schizoaffective disorder.     

Obsessive-compulsive and panic symptoms in patients with first-admission psychosis

OBJECTIVE: The occurrence, persistence and specificity of the association between comorbid obsessive-compulsive and panic symptoms and three psychotic disorders--schizophrenia/schizoaffective disorder, bipolar disorder with psychosis, and major depression with psychosis--were examined in a first-admission, epidemiologically defined group of patients with psychotic symptoms. METHOD: The Structured Clinical Interview for DSM-III-R obsessive-compulsive and panic modules were administered at baseline and 24-month follow-up to patients with schizophrenia/schizoaffective disorder (N=225), bipolar disorder with psychosis (N=138), and major depression with psychosis (N=87) participating in the Suffolk County (N.Y.) Mental Health Project. The rates of subsyndromal symptoms and disorder criteria met were compared across the three psychosis groups. Recognition and treatment of anxiety symptoms at initial discharge and impact of the baseline presence of anxiety symptoms on 24-month clinical status were also examined. RESULTS: Obsessive-compulsive and panic symptoms were present at baseline in 10%-20% of all three groups. There was no specific association between obsessive-compulsive symptoms and any specific psychosis diagnosis; however, women with major depression with psychosis had a significantly higher rate of panic symptoms than the other two groups, and schizophrenia/schizoaffective disorder patients with baseline panic symptoms were significantly more likely to exhibit positive symptoms of psychosis after 24 months. CONCLUSIONS: The authors found no specific association between obsessive-compulsive symptoms and diagnosis early in the illness course, but the finding of an association between panic symptoms and psychotic depression among female patients and between baseline panic and positive psychotic symptoms in schizophrenia/schizoaffective disorder patients at 24 months suggests the need for further study.     

Prospective study of adolescents with subsyndromal psychosis: characteristics and outcome

OBJECTIVE: The aim of this study was to examine the characteristics and outcome of adolescents with psychotic disorder not otherwise specified (PsyNOS) and brief psychotic disorder (BrPsy), two neglected subsyndromal diagnostic entities. METHODS: As part of an ongoing, naturalistic study investigating adolescents considered to be prodromal for schizophrenia, 29 youngsters (mean age, 16.2 +/- 2.7 years) with PsyNOS or BrPsy were identified as theoretically at highest risk for schizophrenia and followed for over 6 (mean, 22.8 +/- 19.4) months. RESULTS: Contrary to our expectations, only 7 of the 26 individuals (27.0%) with follow-up data developed schizophrenia or schizoaffective disorder, and only 2 subjects (7.7%) retained their diagnosis of BrPsy/PsyNOS. The most frequent other diagnoses at follow-up were mood disorders (34.6%), personality disorders (11.5%), and obsessive-compulsive disorder (7.7%). Regarding severity of outcome, 38.5% of the patients progressed to a syndromal psychotic disorder, 23.1% continued to have attenuated positive symptoms, and 38.4% improved to having attenuated negative symptoms only, or no positive or negative symptoms. BrPsy was associated with lower maximum levels of negative symptoms (p = 0.02) and higher likelihood of symptom remission (p = 0.02). CONCLUSIONS: This study indicates that psychotic symptoms not fulfilling criteria for schizophrenia or a psychotic mood disorder are unreliable predictors of a syndromal psychotic disorder outcome at 2 years. Long-term studies of PsyNOS and BrPsy are needed to clarify where these disorders fall in the developmental course of schizophrenia.     

Depressive symptoms in schizophrenia: comprehensive differential diagnosis

Depression is a common complication of schizophrenia and is associated with increased morbidity and mortality. Contrary to traditional clinical wisdom, depressive symptoms occur during all phases of schizophrenia and are not restricted to the postpsychotic period. In this review, the authors summarize current empirical research and offer a practical approach to the identification of depressive subtypes in schizophrenia. The following subtypes are considered: (1) depressive symptoms occurring secondary to organic factors (caused by medications, substance abuse, or underlying medical problems); (2) nonorganic depressive symptoms occurring with acute psychotic symptoms (intrinsic to the acute psychotic episode or schizoaffective disorder); and (3) nonorganic depressive symptoms occurring without acute psychotic symptoms (prodromal symptoms, negative symptoms, acute dysphoria, secondary depressive syndrome, or chronic demoralization). The authors discuss each of these entities and offer guidelines for diagnosis.     

Obsessive-Compulsive Disorder,Psychosis, and Bipolarity: A Longitudinal Cohort and Multigenerational Family Study

Obsessive-compulsive disorder (OCD) often co-occurs with psychotic and bipolar disorders; this comorbidity complicates the clinical management of these conditions. In this population-based longitudinal and multigenerational family study, we examined the patterns of comorbidity, longitudinal risks, and shared familial risks between these disorders. Participants were individuals with a diagnosis of OCD (n = 19814), schizophrenia (n = 58336), bipolar disorder (n = 48180), and schizoaffective disorder (n = 14904) included in the Swedish Patient Register between January 1969 and December 2009; their first-, second-, and third-degree relatives; and population-matched (1:10 ratio) unaffected comparison individuals and their relatives. The Swedish Prescribed Drug Register was used to control for the potential effect of medication in the longitudinal analyses. Individuals with OCD had a 12-fold increased risk of having a comorbid diagnosis of schizophrenia and a 13-fold increased risk of bipolar disorder and schizoaffective disorder. Longitudinal analyses showed that individuals first diagnosed with OCD had an increased risk for later diagnosis of all other disorders, and vice versa. The risk of bipolar disorder was reduced, but not eliminated, when the use of selective serotonin reuptake inhibitors was adjusted for. OCD-unaffected first-, second-, and third-degree relatives of probands with OCD had a significantly increased risk for all 3 disorders; the magnitude of this risk decreased as the genetic distance increased. We conclude that OCD is etiologically related to both schizophrenia spectrum and bipolar disorders. The results have implications for current gene-searching efforts and for clinical practice.Key words: OCD, schizophrenia, schizoaffective disorder, bipolar disorder, genetic epidemiology     

Early onset psychotic disorders: Diagnostic stability and clinical characteristics

To examine the clinical features and diagnostic stability of early-onset psychotic disorders. These data are from a two-year longitudinal prospective study of youth with psychotic disorders. Standardized diagnostic assessments are administered at baseline and at one and two-year’s follow-up. Fifty-one subjects have been recruited to date; 18 with schizophrenia, 14 with bipolar disorder, 7 with schizoaffective disorder, 1 with an organic psychosis, and 11 subjects whose symptoms where either questionable and/or did not meet diagnostic criteria for another disorder (classified as psychosis nos). Thirty-nine subjects were reassessed at year one, twenty-four at year two. Three subjects have been lost to follow-up. The study diagnosis was the same as the first onset diagnosis (prior to entering the study) in 50% of subjects. Over the two-year period of the study, the diagnosis remained unchanged in over 90% of subjects. Subjects with schizophrenia had higher ratings of premorbid impairment, including social withdrawal and dysfunctional peer relationships, than those with bipolar disorder. At the one-year follow-up, subjects with schizophrenia and schizoaffective disorder had significantly higher rates of delusions, bizarre behavior, and negative symptoms than those with bipolar disorder. Subjects with bipolar disorder tended to have cyclical courses, whereas those with schizophrenia and schizoaffective disorder were often chronically impaired. Subjects with psychosis nos had higher rates of dissociative symptoms and histories of child maltreatment Early-onset psychotic disorders can be reliably diagnosed using standardized assessments and are stable over a two-year period. Compared to bipolar disorder, schizophrenia is associated with a poorer premorbid history, and persistent positive and negative symptoms.     

The Twenty-Year Trajectory of Suicidal Activity Among Post-Hospital Psychiatric Men and Women with Mood Disorders and Schizophrenia

The Chicago Follow-up Study has followed the course of severe mental illness among psychiatric patients for more than 20 years after their index hospitalization. Among these patients are 97 schizophrenia patients, 45 patients with schizoaffective disorders, 102 patients with unipolar nonpsychotic depression, and 53 patients with a bipolar disorder. Maximum suicidal activity (suicidal ideation, suicidal attempts and suicide completions) generally declines over the 3 time periods (early, middle, and late follow-ups) following discharge from the acute psychiatric hospitalization for both males and females across diagnostic categories with two exceptions: female schizophrenia patients and female bipolar patients. A weighted mean suicidal activity score tended to decrease across follow-ups for male patients in the schizophrenia, schizoaffective, and depressive diagnostic groups with an uneven trend in this direction for the male bipolars. No such pattern emerges for our female patients except for female depressives. Males’ suicidal activity seems more triggered by psychotic symptoms and potential chronic disability while females’ suicidal activity seems more triggered by affective symptoms.     

The international suicide prevention trial (interSePT): rationale and design of a trial comparing the relative ability of clozapine and olanzapine to reduce suicidal behavior in schizophrenia and schizoaffective patients

Suicidal behavior in patients with psychotic disorders represents a seriously undertreated life-threatening condition. The International Suicide Prevention Trial (InterSePT) is the first large-scale, prospective study designed to evaluate the potential of antipsychotic medications to reduce suicidal behaviors in patients with schizophrenia or schizoaffective disorder who are known to be at high risk for suicide. The unique challenges to study design and the solutions identified for the InterSePT study are described. These challenges included defining suicidal behavior in patients with psychosis, endpoint selection, determination of analytic strategy, and development of scales to assess suicidal behavior. Given the life-threatening nature of suicidal behavior, ethical considerations required that the design minimize suicide attempts and deaths. While the study focused primarily on treatment of suicide, opportunities were used to collect data in related areas of interest, including suicide risk factors, other efficacy measures (e.g., Positive and Negative Syndrome Scale, Covi Anxiety Scale, Calgary Depression Scale), adverse events, pharmacoeconomics, and pharmacogenetics. Because of the complexity of the design issues, a steering committee, suicide monitoring board, and publication committee were established to assist with their management.     

Substance use, suicidality, and adolescent-onset schizophrenia: an Israeli 10-year retrospective study

OBJECTIVE: The aim of this study was to investigate the link between the use of specific types of substances and suicidality in adolescent inpatients with schizophrenia and schizoaffective disorder. METHODS: We performed a 10-year naturalistic retrospective study of 178 adolescent inpatients diagnosed as suffering from either schizophrenia or schizoaffective disorder. A comparison was made between the suicide-attempting adolescent inpatients and the non-attempting subjects, by the use of specific types of substances, measurements of psychotic, depressive, and aggressive symptoms, and clinical data reported during their hospitalization. RESULTS: The suicide attempters reported considerably greater usage of inhalants and lysergic acid diethylamide (LSD). Alcohol and methylene-dioxy-methylamphetamine (MDMA) were also used significantly more by this group. However, no differences were found in the usage of cannabis, amphetamines, cocaine, and opiates. The suicide-attempting patients were found to have had more previous psychiatric admissions, a greater level of deliberate self-harm behavior, and a higher level of suicide ideation, but a decreased severity of psychotic symptoms. CONCLUSIONS: This study is the first report of the association between specific types of substances and suicidality in the high-risk population of adolescent psychotic inpatients. The strong association between inhalants, LSD, alcohol, and MDMA with suicidality is relevant to suicide prevention and intervention programs in adolescent-onset schizophrenia.     

Rates and clinical correlates of treatment non-adherence in schizoaffective bipolar patients

Murru A, Pacchiarotti I, Nivoli AMA, Bonnin CM, Patrizi B, Amann B, Vieta E, Colom F. Rates and clinical correlates of treatment non‐adherence in schizoaffective bipolar patients. Objective: To analyze demographical, clinical, and therapeutic variables that may be associated with pharmacological non‐adherence in a sample of schizoaffective patients, bipolar type. Method: Adherence to treatment and its clinical correlates were assessed at the end of a 10‐year follow‐up in 76 patients meeting DSM‐IV‐TR diagnosis of schizoaffective disorder, bipolar type. Adherent and poorly adherent patients were compared regarding clinical and therapeutic variables. Results: The rate of poorly adherent patients was 32/76 (41.2%) of the sample. Adherent patients were more likely to have presented an affective episode at illness onset and to have fewer purely – non‐affective – psychotic episodes. Demographic or other clinical variables were not found to be associated to treatment adherence. Family history for psychiatric disorders or suicide did not correlate either, and neither did any specific pharmacological agent. Conclusion: Rates of non‐adherence in schizoaffective disorder are high. Adherence seems to be associated to a more affective course of illness (affective first episode and fewer purely psychotic episodes). Patients with more prominent schizophrenia‐like characteristics could be at higher risk for poor adherence and need to be closely followed and monitored. Even when properly treated, schizoaffective disorder is a disabling and severe disorder with high risk for recurrences.