Compared with suicide attempts among persons without schizophrenia, attempts among those with schizophrenia are serious and typically require medical attention. Suicidal intent is generally strong, and the majority of those who attempt suicide have made multiple attempts. In addition, the methods used to attempt suicide are considered more lethal than those used by suicidal persons in the general population. Gupta and colleagues 42 reported that, in their sample of patients with schizophrenia, suicide attempts were associated with the number of lifetime depressive episodes, and depression has been recognized as a major risk factor among persons with schizophrenia who have attempted suicide. Roy and associates 43 found that significantly more of their sample of patients with schizophrenia who had attempted suicide had suffered from a major depressive episode at some time during their illness.

In contrast, Drake et al. 44 found, in their sample of schizophrenic patients, that those who had attempted suicide were trying to manipulate others, consolidate support or gain entrance to the hospital. Attempts frequently occurred in the context of interpersonal conflict, such as arguments with family or housemates. These authors suggested that impulsive attempts were associated with the dysphoric side-effects of the medication, such as akathisia. Nevertheless, in a recent study, akathisia was not linked to suicidality or depression among patients with treatment-resistant schizophrenia 45.

In a study 46 comprising 500 patients affected with schizophrenia and/or affective disorders, a history of suicide attempts was associated with comorbidity, low scores on the Global Assessment Scale (GAS), low age at onset and poor premorbid adjustment. This study showed that men affected with schizophrenia were less likely to attempt suicide when compared to men with diagnoses other than schizophrenia. Among women, suicide attempts were more common in those with lower age at onset and who had no children. Kelly et al. 29 found that, among their sample of schizophrenia patients who had committed suicide, some 93% had engaged in previous suicidal behaviors versus only 23% of the patients who died by other means of death.

Suicide attempts are a significant risk factor for suicide and are associated with significant medical costs and, for this reason, an examination of risk factors for attempted suicide in schizophrenia is important. A recent systematic review of the risk factors for attempted suicide in schizophrenia identified only 14 studies that met selection criteria 47. These authors examined 29 variables that were studied in at least two or more studies and found only five significant variables: past suicidal ideation, previous deliberate self harm, previous depressive episodes, drug abuse or dependence, and a higher mean number of psychiatric admissions

Great caution is required during the period after hospital discharge because patients with schizophrenia usually experience hopelessness and demoralization during this time. For these patients, discharge often means losing the hospital environment and the people who in some way have become central in their life. The number of psychiatric admissions, which are usually higher among patients who have attempted suicide, may be indicative of a severe relapsing illness.

The concept of insight has always been an important part of clinical psychiatry and neuropsychiatry nomenclature but, until recently, the term had been used to describe a disparate and wide range of phenomena 48. During the last fifteen years, most researchers have defined insight as being comprised of at least three domains: awareness of the illness, awareness of the need for treatment, and awareness of the consequences of the disorder 49. Increased agreement on terminology and phenomenology and the development of reliable and valid measures of insight has led to an explosion of research in this area. The relationship between insight and suicide has been an area of study that has benefited.

Many scholars and clinicians have proposed a relationship between insight and suicidal behavior in patients with psychotic disorders. Early empirical studies on the predictors of suicidal behavior in patients with psychotic disorders often noted the consequences of a fuller understanding of the implications of having a psychotic disorder, and the sense of resignation and hopelessness that was often associated with this awareness. Studies by Farberow, Shneidman and Leonard 50, Warnes 51, and a series of studies by Drake and colleagues in the 1980's 52535455 all reported very similar findings and cited a hopeless awareness of the severity of their psychopathology as one of the most important predictors of completed suicide in patients with psychotic disorders. While these studies suggested increased awareness of one's illness was associated with suicidal behavior in these patients, it was not possible to determine whether insight was directly related to suicide or only indirectly related via its influence on hopelessness. In addition, because these studies predated advances in research methodology, poor reliability for the measurement of insight contributed to the ambiguity of the results. With the development of reliable and valid measures for the assessment of insight 565758, more recent research has been able to clarify these relationships.

Two recent studies studied the relationship between insight and suicide while taking hopelessness into account. In the first study, Kim et al. 59 compared two groups of patients with schizophrenia: 200 with a lifetime history of suicidal ideation and/or attempts and 133 without any history of suicidality. The group with a history of suicidality had significantly higher levels of both general awareness of illness and hopelessness. However, when hopelessness and insight were entered into a multiple regression model, along with several other variables, only hopelessness was statistically significant. In the second study, Bourgeois and colleagues 60 analyzed data from 980 patients from the International Suicide Prevention Trial (InterSePT) 61. The results were similar to those of Kim et al. 59. Greater awareness of illness significantly predicted suicide risk when entered independently into the model (with better insight associated with increased suicide risk), but was no longer significant once hopelessness was entered into the equation. Interestingly, the baseline level of awareness was associated with increased risk for suicidal behavior, but improvement in awareness over the follow-up period was associated with reduced risk for suicidal behavior. In summary, research to date suggests that awareness of illness is indeed associated with increased suicide risk in this population, but only if that awareness leads to hopelessness. This conclusion is consistent with the literature demonstrating the relationship between hopelessness and suicide 626364 and helps to reconcile those research findings with the positive prognostic implications of improvement in awareness of the illness 65. The severity of the hopelessness that a person with schizophrenia experiences seems contingent, at least in part, on the level of premorbid functioning and the magnitude of the decline in functioning relative to that premorbid capacity.

Several points can be made about the clinical implications of these findings. Patients with schizophrenia need to be carefully assessed for hopelessness and suicidal ideation throughout the course of their illness, particularly if there is marked improvement their in awareness of any facet of the illness syndrome. In addition, although improvements in insight are often strongly related to improvements on many clinical dimensions, we must work judiciously when we strive to increase insight in patients with other risk factors, such as young age and a substantial decline from the premorbid level of functioning. There is often a mourning process that individuals diagnosed with schizophrenia must pass through as they come to terms with what was lost with the onset of their illness, with the magnitude of the loss being determined by many factors 66. By being attentive to this process, we can better assess the relative risk for our patients on an individual on a case-by-case basis.

Depression, as a mood or a syndrome, is frequently present in people with schizophrenia, and yet depression is also frequently under-diagnosed and under-treated. Depression is considered to be a major risk factor for suicidal behavior across populations. Researchers have suggested that depression can serve as a stressor or trigger for suicidal behavior among individuals who are at risk for suicidal behavior 67, and this has been demonstrated among individuals with schizophrenia 68. For example, Harkavy-Friedman and colleagues 6869 demonstrated that major depression serves as a trigger for suicide attempts, and depressed mood and hopelessness are correlated with current suicidal ideation.

Many researchers have found high rates of major depressive disorder among individuals with schizophrenia 545569707172, and it is a requirement for the diagnosis of schizoaffective disorder in the DSM-IV 73. In addition, many researchers have identified depressed mood and hopelessness as an important component of suicidal behavior 53747576. Despite this knowledge, depression is often ignored and untreated among individuals with schizophrenia, leading to increased risk for suicidal behavior. It has been demonstrated that antidepressants can be used effectively for treating depression without increasing psychotic symptoms 7778, but they are still under-utilized in this at-risk population.

While depression can often be masked or confused with the negative symptoms or side-effects of medication 7980, an astute clinician can identify depression by asking targeted questions. While not all suicide attempts and completed suicides in schizophrenia are triggered by depression, psychological and psychopharmacological treatment of depression is likely to play an important role in preventing suicidal behavior in schizophrenia.

Adequate attention to depression, in the form of assessment and treatment, as well as consideration of other factors that may trigger suicidal behavior in schizophrenia, is important. Ongoing clinical assessment for the signs and symptoms of depression is essential. When identified, depression must be treated, and psychopharmacological, as well as cognitive-behavioral and psychosocial interventions, ought to be considered.

The depression-related aspects of schizophrenia are generally differentiated according to the time at which they occur during the psychotic episodes – contemporaneously with the psychosis or as a "post-psychotic depression" phenomenon. This latter syndrome has been reported as particularly relevant for suicide risk 8182.

In general, for a variety of populations, both normal and disturbed, the most powerful predictor of suicidality, both completed suicide and attempted suicide, is depression, both the psychiatric diagnosis (major depressive disorder or biopolar disorder) and the mood as assessed by clinical judgment or by self-report inventories 83. Beck et al. 84 found that the cognitive component of depression, which they first called pessimism and later hopelessness, was a more powerful predictor of subsequent suicide than the more general syndrome of depression. For example, in a follow-up study of psychiatric outpatients, Beck and his colleagues 85 found that hopelessness scores were significantly related to subsequent completed suicide.

Nordentoft et al. 86 studied patients with first-episode schizophrenia-spectrum disorders for one year, during which time 11% attempted suicide. Suicidal ideation and plans in the prior year were predicted by hopelessness scores, while actual suicide attempts in the prior year were predicted by both depression and hopelessness scores. Drake and Cotton 87 compared 15 schizophrenic inpatients who completed suicide subsequently with schizophrenics who did not do so during a 3 to 7 year follow-up. The suicides were judged to be more hopeless but not more depressed. Schizophrenics with depressed mood had a probability of 0.22 of subsequently completing suicide while schizophrenics with depressed mood and hopelessness had a 0.37 probability of doing so. A depressed mood alone resulted in a 0.07 probability of subsequent completed suicide and no depressed mood (with or without hopelessness) a 0.06 probability. It appears, then, that hopelessness was an important factor in predicting suicide.

Hopelessness plays a larger role in schizophrenia than its association with suicidality. For example, Aguilar et al. 88 observed that first-episode schizophrenic patients had higher levels of hopelessness (as measured by Beck's hopelessness scale) than other non-affective psychotics. Furthermore, higher hopelessness scores predicted a worse short-term outcome, in particular, worse global functioning at a one-year follow-up. (Depression scores did not predict outcome.)

Some investigators have drawn attention to the role of insight or awareness of their disorder (and its progression) as affecting the level of hopelessness and suicidality in schizophrenics. For example, Strauss 89 interviewed schizophrenics about the course of their disorder, and he noted that a relapse after gradual improvement can lead to extreme despair in patients. It appears also that insight into their disorder appears to increase the level of hopelessness in schizophrenics and increases their risk of suicide, whereas neurocognitive deficits that impede awareness reduce the risk of suicide.

Are there clinical symptoms or illness subtypes that are associated with suicide and that could serve as indicators of suicidal danger? Some symptoms are generally indicative of suicidal danger regardless of the diagnosis. Depressive symptoms have already been addressed, but they frequently coexist with anxiety symptoms 9091. Anxiety contributes to suicidality in post-psychotic depression 92, and comorbidity with panic attacks was associated with higher suicide rates in patients with schizophrenia 93. Suicide was correlated with psychomotor agitation and restlessness 3094 and a fear of mental disintegration, if present, predicts suicide with an odds ratio of 12.1 30. Akathisia is manifested subjectively in an unbearable feeling of inner tension and restlessness, and subjective awareness of akathisia is also associated with higher suicidality. Findings from a study devoted to this topic demonstrated that, among patients with akathisia, there was a greater likehood of suicidal behavior than among those without akathisia 95. These authors stressed that their findings imply that the suicidality may be related to internal feelings of distress that are concomitantly expressed both as subjective restlessness and as hopelessness and suicidal ideation. Akathisia is also associated with a constellation of symptoms with both affective and anxious features as well as motor components.

In addition to general risk factors, there may also be risk factors more or less characteristic for patients of a particular diagnostic group. Are there specific characteristics of the schizophrenic disorder associated with or predisposing to suicide? Separate sections of this review are devoted to the role of positive symptoms, negative symptoms, command hallucinations and insight. According to Zilboorg 96, clinical evidence for strong hostility can be found in every suicide, and aggressiveness, impulsivity and non-compliance are particularly frequent in schizophrenic illness. These characteristics help to differentiate between suicidal and non-suicidal schizophrenia patients 97. Hostility at admission was associated with long-term suicide risk 21, and involvement of the police at the time of admission seems to be a specific risk factor within the schizophrenia population not encountered elsewhere 98. However, it is perhaps impulsivity rather than aggressiveness that may be of importance. Suicidal subjects were found to exhibit acting-out behavior, to run away from hospital and to be more often discharged against medical advice 24. Many suicide victims experienced compulsory hospital treatment, and the majority of them had poor treatment adherence 2499.

The importance of psychopathology for suicidal behavior may change over time. Considering the condition of the patient immediately before suicide, no uniform picture could be identified. A withdrawal from relationships due to depression has been described, as has an increase in the patient's paranoid behavior, and both should be regarded as acute signals of suicidal danger 25. Farberow et al. 100 described presuicidal schizophrenic patients as extremely tense, restless and impulsive. Such patients can suddenly become quiet and calm at the time the decision to commit suicide is made. A comprehensive account of the psychopathological conditions preceding suicide has been provided by Wolfersdorf et al. 101. In comparison to schizophrenic controls, suicides had a higher degree of subjective suffering and ambivalence, and most of them were preoccupied by the feeling of having failed. According to Drake et al. 102, the patients' presuicidal condition is characterized by feelings of inadequacy, hopelessness and fears of mental disintegration. Also, the patients tend to develop a more negative or indifferent attitude towards the psychiatric personnel, and they often no longer request support or attention 103.

Schizophrenia is an illness of considerable heterogeneity, and several attempts have been made to differentiate subtypes. Regarding suicide, classical subtypes of paranoid, catatonic, hebephrenic, and undifferentiated schizophrenia do not seem to be of importance 94104. Andreasen and Olsen 105 proposed differentiation into positive, negative and mixed schizophrenia. There is some evidence for a weak negative correlation between positive symptoms, and thus positive schizophrenia, and suicide 30. Another typology has been devised by Crow 106 who differentiated the type I schizophrenia syndrome, equivalent to acute schizophrenia, and type II, equivalent to the defect state. Both an early onset of a defect state 24 and the deficit subtype of the illness 2021 were associated with a reduced risk of future suicide. Nevertheless, it is not the specific syndrome, but the course of the illness, frequent relapses 24101, a high severity of illness, a downward shift in social and vocational functioning 21107108, and a realistic awareness of the deteriorative effect of the illness that are the schizophrenia-specific suicide risk factors 3.

There are many ways to classify suicidal patients, and many of these typologies are also applicable to patients with schizophrenia. For instance, a differential typology has been proposed with respect to the "hard" and "soft" suicidal method 109, an ethical typology based on the role a clinician may play in the suicidal process 110, and a sociological typology reflecting the societal level of social integration and moral regulation 111. The clinical usefulness of all these typologies for predicting suicide seems to be limited, however, and the same applies to the differentiation between single suicides, extended suicides and suicidal pacts. Both latter types are extremely rare in patients with schizophrenia.

About one third of suicide victims are found to meet the criteria for a personality disorder 112, and a classification using the presence or absence of Axis II disorders would be feasible. Nevertheless, this variable seems to play a less important role in schizophrenia due to its less frequent comorbidity with schizophrenia. In contrast, comorbidity of schizophrenic and substance use disorders is very frequent 113, and a typology based on the additional presence or absence of an addictive disorder could be meaningful, the more so as drug misuse or dependence considerably increases the risk of suicide 30.

Some other suicide subtypes have been described in schizophrenic disorders, but they have been only clinically inferred and not empirically tested. Based on their study of psychotic inpatients and their behavior in the psychiatric hospital setting, Farberow et al. 100 proposed three subtypes of schizophrenic suicide: (1) the unaccepting, grossly disturbed patient resisting hospitalization; (2) the dependent, satisfied patient whose suicide outside the hospital appears to be a consequence of stressful conflict and ambivalence concerning the home environment; and (3) the dependent, dissatisfied, demanding patient who has no other place to go and yet seems to have lost faith in the therapeutic potential of hospitalization. In an investigation on suicide 114, the authors learned to differentiate two other clinical types of schizophrenic suicide: (1) Type I schizophrenia suicide, characterized by early illness onset along with early difficulties in psychosocial adaptation, and (2) Type II characterized by a later illness onset where the patients often show a high premorbid functional capacity. However, due to the seriousness of their illness, they experience a distinct psychosocial and professional downward mobility. Patients of both types have insight with regard to their condition and are capable of critical and realistic self-assessment of their reduced life perspectives 115. Their suicide occurs in a non-psychotic condition. Type I patients realize their failure in comparison with the achievements of their peers, while Type II patients are not able to live up to their high expectations and feel inadequate in relation to their own goals 102. In both types, suicide appears to be the result of a realistic appraisal of the patients' whole life situation including the incapacitating illness and its negative psychosocial consequences.

Substance use/abuse/dependence is often comorbid with schizophrenia, and psychosis and substance use are both found to increase suicide risk 150. Researchers, in studies of two American cohorts, found significantly more comorbid substance abuse among people with schizophrenia who were suicidal, particularly among the younger ones 151152153. They stated that it is important, in view of the changing patterns in the epidemiology of schizophrenia comorbid with substance use/abuse, that clinicians obtain accurate drug-use history in order to detect and promptly treat drug use/abuse. Youths who abuse drugs are at increased risk for committing suicide, and drug or alcohol abuse is found in about 70% of children and adolescents who commit suicide 154.

Harris and Barraclough's 10 meta-analysis on suicide as outcome in mental disorders reported on the standardized mortality ratio (SMR) for various psychoactive substance-use disorders. After combining the studies, they compared suicide risks of drug users and nonusers and found the SMRs for suicide of users to be higher than those of nonusers in all groups. In subjects with alcohol dependence and abuse it was 6-times higher, in opioid dependence and abuse 14-times, and in cannabis users 4-times. In this meta-analysis, suicide risk among schizophrenic patients was 8.5 times greater than among nonschizophrenics. Subsequently, Wilcox et al. 155 located twenty studies not included in the Harris and Barraclough 10 review and identified another 22 studies published after 1997. By combining data from all of these studies, they found more robust associations between suicide and overall opioid use disorder, mixed intravenous drug use, alcohol use disorders among women.

The increased suicide risk in substance-abusing schizophrenic patients 156157158159160161162 could be the result of a cumulative effect of many factors or events, such as the loss of remaining social control through the consumption of psychotropic substances, noncompliance with antipsychotic medication, and presence of paranoia and depression 163. In Allebeck and Allgulander's 164 sample of young male substance abusers, the diagnostic category associated with the highest suicide risk was schizophrenic psychosis. Abuse substances worsen both symptoms and prognosis of the illness and are related to higher relapse rates.

Suicide may become the ultimate solution for reducing suffering caused by hopelessness and social isolation. Various studies have recognized the importance of substance abuse in the suicides of patients with schizophrenia 165166167168169. Drug and alcohol abuse increase the risk of suicide in the general population 151170171172173 and, when this behavior is associated with a diagnosis of schizophrenia, the risk is much higher. It is also important to take into consideration the difficulties in reaching marginalized individuals. A comparison of patients who began drug abuse before their first admission with those who began abusing drugs after their first admission showed that the use of specific drugs was associated with significant differences in age, age at first hospitalization, premorbid functioning and subtype of schizophrenia. The differences were not uniform across the different drugs 174.

But, when comparing schizophrenics who attempt suicide with nonattempters, drug abuse is not found to differ between the two groups 69. However, schizophrenic patients who use substances do have more positive symptoms, especially hallucinations 175, and more suicide attempts than patients with the same diagnosis and no substance use 175176. Interestingly, hallucinations 142, but not delusions 177, were found to increase the incidence of suicide attempts in patients with schizophrenia, independently from alcohol/drug abuse/dependence 142.

The suicide risk for adolescents or young adults with schizophrenia is three times higher than that for adult schizophrenic patients. The first two years of the disease are especially dangerous. Suicidality in this group of young patients often goes along with the harmful use of psychotropic substances and affective syndromes 178. Among patients with psychotic symptoms, the risk of suicidal behavior is significant higher in cohorts that include adolescents and young adults as well as older paitents.

The situation of individuals with first-episode schizophrenia in life is often much more unstable since they are not used to the disorder and since, as adolescents, they are facing the typical problems and conflicts of young persons beginning a new phase in life. They are confronted with a painful psychological crisis with two aspects, and the symptoms of psychosis might be only a part of this crisis. In addition other syndromes, such as mood disorders and addictive behaviors, complicate the situation and increase the risks for the individual.

Though various approaches for first-episode schizophrenia have been developed in recent years, it is still difficult for a person suffering from symptoms of psychosis for the first time to find appropriate support. It usually takes several months until this person is diagnosed correctly and treated by a psychiatrist. The current health-care system still fails to meet the needs of this group of patients. Early detection and intervention programs are crucial, and suicide prevention must be an important component of these programs.

A recent Danish register-based study by Qin and Nordentoft 179 found that 37% of men and 57% of women who committed suicide had a history of admission to psychiatric hospitals. This suggests that men at risk for suicide are less likely to seek or receive psychiatric treatment, but the study confirms previous reports that suicide risk is highly associated with a history of admission to psychiatric hospital. It further showed that the risk peaked, not only shortly after discharge as reported in the literature 180181182183184, but also shortly after admission. For patients with schizophrenia and related disorders, there was, as in other conditions, two sharp peaks in suicide risk, the first immediately after admission (adjusted risk ratio around 80 compared with persons with no history of admission) and the second peak shortly after discharge (adjusted risk ratio around 110 compared with persons with no history of admission). Approximately one third of the suicides in schizophrenics occur during admission or during the first week after discharge. From a preventive perspective, this is actually good because it identifies important risk periods upon which preventive interventions should focus. For instance, suicide among patients with schizophrenia currently admitted or discharged within last week accounts for almost three percent of all suicides in Denmark.

It is possible that a very small proportion of the suicides registered as suicides after discharge were actually suicides committed while hospitalized if the person did not die immediately but was transferred to medical department where he or she died of the consequences of a suicide attempt carried out during psychiatric hospitalization. This concerns very few cases and does not influence the result of the analyses.

The situation of people immediately prior to their suicidal act is critical for its prevention. Schizophrenic patients who decide to commit suicide often contact health-care workers in the days or weeks before their act. However, many factors impair the ability of treatment professionals to recognize the acute risk of suicide in their patients. These factors are related to the suicide phenomenon itself, to problems associated with the treatment system and to the treatment practices adopted by professionals, but they are also related to the personal psychological issues of the workers 25191192.

Staff knowledge of suicidology and their psychological readiness to deal with the anxiety and despair of suicidal patients are important in the treatment process, and uncertainties may be fatal 193. Increased attention to interpersonal behaviour may provide a basis for more accurate recognition and more successful long-term treatment of high-risk suicidal patients. Withdrawal by a depressed schizophrenic patient and an increase in paranoid behavior should be regarded as signals of an acutely increased risk of suicide 25. In addition, awareness that psychological and somatic symptoms are connected could facilitate the identification of an acute risk of suicide 194.

Particular attention should be paid to the suicide risk in situations in which the treatment regimen is changed in some significant way 255253191195196197198199200201202. Difficulty in recognizing depression in schizophrenics is further complicated by the fact that depressive withdrawal from personal relationships may be misinterpreted as a negative symptom related to the primary illness 203204. Organizational factors and staff turnover are also obstacles to maintaining suicide-prevention activities and making them routine in psychiatric care 205.

There is little evidence that the typical neuroleptic drugs, with or without antidepressants, as well as the atypical antipsychotic drugs other than clozapine, have an effect on fatal or non-fatal suicidal behavior in patients with schizophrenia 222223. However, there is considerable data that indicates that clozapine does reduce the risk of suicide. Clozapine was first reported to reduce the rate of suicidality in 88 patients with schizophrenia in a mirror-image study 224. The percentage of patients with no suicidality increased from 53% at baseline to 88% during treatment with clozapine. There was an 86% decrease in suicide attempts. Nearly identical results were obtained in another mirror-image study in hospitalized patients 225.

An epidemiologic study of mortality and morbidity in current and former clozapine users based upon the US Clozaril^® National Registry reported that mortality from suicide was markedly decreased in current clozapine users in comparison with past users 226. American and English clozapine registry data revealed a reduced risk of suicide for patients treated with clozapine compared to the general population of patients with schizophrenia 227228.

However, there are limitations in these studies that limit the confidence that the findings reach the highest standards of evidence-based medicine, such as no randomization of the patients in the treatment groups and the use of retrospective, broad inclusion criteria. These issues were addressed in the International Suicide Prevention Trial (InterSePT), a randomized, two year, open-label trial with blind ratings, and determination of whether potential endpoints met criteria for a suicide attempt or a hospitalization to prevent suicide by a blind, independent, expert Suicide Monitoring Board (SMB; Meltzer et al. 61229. It included 980 patients with schizophrenia or schizoaffective disorder who were at high risk for a subsequent suicide attempt, based primarily on having made at least one suicide attempt in the three years prior to study entry or on being currently suicidal. The primary outcome measure was either time to a suicide attempt (including death by suicide) or hospitalization to prevent suicide. A significant 24% difference in the hazard ratio for this endpoint in favor of clozapine was found. The number of patients needed to be treated with clozapine in order to reduce the risk of one suicide event was 13. Clozapine was superior to olanzapine in patients with schizophrenia or schizoaffective disorder, in neuroleptic-resistant as well as neuroleptic responsive patients, and in both males and females. The two drugs did not differ in overall efficacy in reducing total psychopathology, positive and negative symptoms, or depression. Thus, the difference between the impact of the drugs on suicidality was not secondary to other efficacy differences, confirming the view of suicide as a separate dimension of the schizophrenia syndrome. As a result of this study, the Food and Drug Administration of the United States approved an indication for clozapine to reduce the risk of suicide in schizophrenia. Hennen and Baldessarini 230 recently completed a meta-analysis of available data on the issue and concluded there was a substantially lower overall risk of suicidal behavors and completed suicides for clozapine. Thus, there is strong evidence to suggest that, for patients with schizophrenia or schizoaffective disorder who have made and survived a serious suicide attempt, or who can be judged to be at very high risk for such an attempt based on careful assessment, clozapine treatment should be instituted and maintained.

Draket al. 201 noted that there is a need for empathic support in reducing suicide risk. These authors suggested that clinicians should acknowledge the patient's despair, discuss losses and daily difficulties, and help to establish new and accessible goals. Social isolation and work impairment have been reported as risk factors for suicide in individuals with schizophrenia 2753231. Individuals with good premorbid functioning are those more at risk of suicide. Interventions such as social skills training, vocational rehabilitation and supportive employment are therefore very important in the prevention of suicide in schizophrenic patients. Broadly speaking, these kinds of therapies focus on working out daily problems rather than achieving psychological insight. It has become increasingly clear that supportive, reality-orientated therapies are generally of great value in the treatment of patients with schizophrenia. In particular, supportive psychotherapy aims at offering the patient the opportunity to meet with the therapist and discuss the difficulties encountered in daily activities. Patients are encouraged to discuss concerns about medications and side-effects as well as issues such as social isolation, money and stigma. The therapist plays an active role as he gives suggestions and shares good and bad periods empathically. The nature of these treatments and their availability vary greatly from place to place. Psychosocial approaches have however limited value for acutely psychotic patients.

Mueser and Berenbaum 232 reviewed controlled trials of psychotherapy and concluded that reality-orientated psychotherapy is superior to a dynamic, insight-orientated approach. Nevertheless, exploratory psychotherapy may have some benefits as it gives patients who have achieved stable remission the opportunity to understand inner conflicts and discuss, within a solid therapeutic alliance, suicidal thoughts or suicidal behavior. Patients learn to dealuse symbolism and thought rather than action (suicide) 233234. However, any psychotherapy technique with schizophrenic patients requires certain alteration and modifications of the standard approach 235236237. An approach elaborated by Hogarty et al. 238239 is Personal Therapy, which includes three levels of treatment with defined criteria for progression from basic to more challenging levels. Treatment begins from early months after discharge, which aims at clinical stabilization and therapeutic joining, and moves in later phases to promoting introspection and an understanding of the relationship between stressors and maladaptive responses. An intermediate phase promotes skills remediation, relaxation training, role-playing and psychoeducation. There is evidence to suggest that the combination of psychosocial and pharmacological treatments increases compliance and helps to achieve a better outcome 240.

Cotton et al. 53 stressed the importance of psychotherapy with schizophrenic patients who are at risk of suicide and noted the need to appreciate their hopeless awareness of the chronic illness. According to Westermeyer et al 64, the surviving schizophrenic individual may be the type of patient who is able to adjust to life as a chronic schizophrenic or as a moderately and episodically impaired schizophrenic, and thus may be less likely to commit suicide.

Increased insight may parallel increased suicidality, but this is not per se a reason to try to decrease insight in patients with schizophrenia. In fact, insight is also positively related to compliance with treatment, both medication and psychotherapy, which both can help to reduce suicidality. Gradual increases in insight secondary to treatment were also related to decreased suicidality in one study. Dramatic increases in insight should, however, be avoided and should be managed within an appropriate therapeutic relationship. Structured psychotherapies might add to the benefits of successful drug treatment of schizophrenic patients. Thus, insight may have a bidirectional impact on suicidality. It might increase it through increased hopelessness and despair 241, and these feelings may arise because the patient realizes that he or she with have to depend on lifelong medication and/or understands the social consequences of having schizophrenia. On the other hand, gradual gains in insight brought about by successful drug treatment and/or psychotherapy may decrease suicidality and may further contribute to compliance, which is a factor that protects the patients from relapses and recurrences. In turn, the benefit from adhering to treatment may make the patient's outlook on his or her illness more positive, thereby reducing suicidality. The best way to achieve these goals may be to combine drug treatment with psychotherapy, a method that has proved to be superior to each type of treatment alone in other types of mental disorders. Controlled data in this respect, however, are lacking 82.

The suicide rate expresses a balance between protective and risk factors. During the last century, several measures might have influenced the suicide rate. The introduction of chlorpromazine in the 1950s made it possible to treat the psychotic symptoms of schizophrenia but, in the years after the introduction of chlorpromazine, the suicide rate actually increased. This might have resulted from increased patient insight into the illness. The patients were not racked with hallucinations or delusions, but they were still not capable of working or living without help from the community 242.

Deinstitutionalization began in the 1960s, and the number of hospital beds decreased during the following 40 years. However, the association between these changes and the suicide rate is not clear. The intent of deinstitutionalization was to improve the quality of life for patients, but it is a very difficult and demanding challenge for the society to treat patients with schizophrenia in their homes. It is not accomplished simply by closing beds. The influence of deinstitutionalization on the suicide rate is difficult to interpret because there were conflicting results 186243244. The number of beds also produced conflicting results because many patients were actually not discharged to their homes but to other institutions. Thus, a trans-institutionalization occurred in many cases.

In the 1990s, the atypical antipsychotics were introduced and it seems that these drugs might have some anti-suicidal properties, especially clozapine 230245. This might be to due their lesser propensity to cause extra pyramidal side-effects (EPS). (There is some evidence for a relationship between suicidality and EPS 95.

Another factor influencing the suicide rate could be the introduction of the selective serotonin reuptake inhibitors (SSRI) in the 1980s because they are less toxic in overdose and because it now became easier to treat depression in patients with schizophrenia. Depression in schizophrenia is very common and is associated with suicidality 8246.

According to the WHO, the general worldwide suicide rate has increased the last 50 years. The figures for suicide in schizophrenia are not present for many countries, but in Denmark and Norway the suicide rate in schizophrenia has been decreasing since 1990 (Gurli Perto, Danish Central Psychiatric Research Register, personal communication 2005 and Statistics Norway), paralleling canges in the general suicide rate.