Suicidal ideation in schizophrenia: A cross-sectional study in a tertiary mental hospital in North-East India.

INTRODUCTION: Suicide is a leading cause of mortality in schizophrenia. The study attempts to find an association of suicidal ideation, a less studied entity than suicide attempt, with various sociodemographic and clinical profiles in patients with schizophrenia.
MATERIALS AND METHODS: It is a cross-sectional study involving 140 patients diagnosed as schizophrenia. Sociodemographic and clinical profiles were collected using a semi-structured proforma. Positive and Negative Syndrome Scale, Calgary Depression Scale for Schizophrenia, InterSePT Scale for Suicidal Thinking, and Drug Attitude Inventory-10 were applied to assess psychopathology, depressive symptoms, suicidal ideas, and attitude toward psychotropics, respectively. The analysis was done using appropriate statistics.
RESULTS: Majority of the study sample were Hindus, male, unmarried, literate, unemployed, and belonging from lower socioeconomic class. About 25.7% attempted suicide earlier and 29.3% currently have suicidal ideation. A previous suicide attempt, family history of psychiatric illness and that of suicide and comorbid substance use, significantly predicted (p < 0.05) a current suicidal ideation. Ideation has also been found to be significantly correlated to comorbid depression and the positive, negative, emotional, and excitement domains of schizophrenic psychopathology.
CONCLUSION: The current study shows suicidal ideations in schizophrenia patients to be significantly related to schizophrenic psychopathology and comorbid depression, thus calling for a holistic management in preventing a fatal outcome. Copyright:

INTRODUCTION

Schizophrenia is a debilitating mental disorder characterized by distorted thinking and perception that runs a chronic course. It is associated with a truncated life expectancy of 10–25 years; suicide being a major contributor, having a lifetime risk of 9%–13%.[1] The rate of suicide attempts in schizophrenia ranges from 20% to 40% with around 11% to 50% of patients having ideations at some point of their life.[234]

Suicide in schizophrenia is of multifactorial origin. Sixty percent of individuals with schizophrenia who die by suicide do so within the initial 4–10 years of being diagnosed.[56] A longer duration of untreated psychosis (DUP), multiple hospitalizations, immediate postdischarge period, a family history of psychiatric illness and suicide, a previous attempt, presence of positive symptoms, and depressive symptoms all are significant contributors to suicidal behavior in schizophrenia.[34567891011]

Although many researchers have studied relationship of suicide attempts and schizophrenia, there is relatively less work on suicidal ideation in schizophrenia. Moreover, India is a country with sociocultural diversity and North-Eastern India is even more diverse. There is hardly any study looking into this area published from this part of India. We, thus, felt the need to study this area on patients seeking treatment in a tertiary care mental hospital established by the British in 1876.

MATERIALS AND METHODS

This cross-sectional study recruited patients between age groups of 18 years and 65 years with the International Classification of Diseases-10 (World Health Organization, 1992)[12] diagnosis of schizophrenia (F20) attending a tertiary mental hospital in North-East India after obtaining informed consent. It was approved by the institution ethics committee. Those having comorbid intellectual disability were excluded beforehand. They were assessed on the 7th day of admission with a semi-structured proforma for collecting their sociodemographic and clinical parameters. Psychopathology was assessed using the Positive and Negative Syndrome Scale[13] whose scores were calculated based on the five-factor model (“positive,” “negative,” “emotional,” “excitement,” and “disorganized” domains) of Van der Gaag.[14] The Calgary Depression Scale for Schizophrenia (CDSS) was used to assess depression.[15] Suicidal ideation was assessed using the International Suicide Prevention Trial (InterSePT) Scale for Suicidal Thinking (ISST).[16] The Drug Attitude Inventory-10 items (DAI-10) assessed attitude toward psychotropics.[17] The ISST and DAI-10 are self-reported scales which were translated into the local language following the translation and back translation protocol for its application.

Data were analyzed using SPSS version 20.0 (SPSS South Asia Pvt Ltd., Bengaluru, Karnataka, India).[18] Descriptive and frequency analysis was carried out using mean, standard deviation, frequency, and percentages. Pearson's Correlation statistics was applied to study the correlation between variables. Comparisons were studied using appropriate statistics such as Chi-square test and Fisher's exact test.

RESULTS

Sociodemographic and clinical profile

The study included 140 patients (males 54.3% and females 45.7%). Their mean age was 31.17 (standard deviation - 8.5) years and they were mostly Hindu (72.91%), unmarried (45.7%), and belonging from a lower socioeconomic status (44.3%) [Table 1]. About 42.1% of the sample had 6–10 years of formal education, while 12.9% were illiterate. About 55% of the sample were from joint family background and they mostly hailed from rural areas (66.4%).

Table 1

Comparison of sociodemographic and clinical parameters with suicidal ideations in schizophrenia

Variables	Frequency distribution (having suicidal ideation)	Percentage of the total sample (percentage having suicidal ideation)	Chi-square test
Gender
Male	76 (23)	54.3 (30.26)	0.77
Female	64 (18)	45.7 (28.12)
Religion
Hindu	101 (32)	72.11 (31.68)	1.821
Muslim	25 (7)	17.9 (28.0)
Christians	14 (2)	10.0 (16.66)
Years of education
None	18 (7)	12.9 (38.88)	2.962#
1-5	23 (6)	16.4 (26.08)
6-10	59 (19)	42.1 (32.2)
11-15	25 (7)	17.9 (28.0)
>15	15 (2)	10.7 (13.33)
Marital status
Married	49 (15)	35.0 (30.61)	0.085
Unmarried	64 (18)	45.7 (28.1)
Divorced/separated	27 (8)	19.3 (29.6)
Socioeconomic status
Upper	6 (0)	4.3 (0)	6.290#
Upper middle	5 (3)	3.6 (60.0)
Middle	30 (11)	21.4 (36.67)
Lower middle	37 (8)	26.4 (21.62)
Lower	62 (19)	44.3 (30.64)
Domicile
Rural	93 (24)	66.4 (25.8)	1.619
Urban	47 (17)	33.6 (36.17)
Family type
Nuclear	63 (21)	45.0 (33.33)	0.906
Joint	77 (20)	55.0 (25.97)
DUP (months)
<12	81 (22)	57.86 (27.16)	0.4192
>12	59 (19)	42.14 (32.20)
Previous admission(s)
No	93	66.40	0.090
Yes	47	33.60
Previous suicidal attempt
No	104 (20)	74.3 (19.23)	19.7449***
Yes	36 (21)	25.7 (58.33)
F/H/O psychiatric illness
None	85 (18)	60.7 (21.17)	8.250#,*
Schizophrenia	41 (17)	29.3 (41.46)
Mood disorder	7 (4)	5.0 (57.14)
Substance	7 (2)	5.0 (28.57)
F/H/O suicide
Yes	25 (16)	17.9 (64.0)	17.710***
No	115 (25)	82.1 (21.74)
Comorbid substance use
None	90 (19)	64.3 (21.11)	8.1315**
Present	50 (22)	35.7 (44.0)
Attitude toward psychotropic medications
Positive	44 (2)	31.43 (4.54)	18.965***
Negative	96 (39)	68.57 (40.62)

*P<0.05, **P<0.01, ***P<0.001, #Fisher’s exact test. F/H/O=Family history of, DUP=Duration of untreated psychosis

About 48.5% had more than 5 years of illness. Majority of them had DUP of less than a year (57.85%). About 33.6% had past history of admission(s) in a psychiatric facility for nonsuicidal reasons. About 39.3% of the sample had a family history of psychiatric illness, mostly schizophrenia (29.3%), while 17.9% had a family history of suicide. About 35.7% of the sample had a concurrent substance use disorder. About 25.7% attempted suicide earlier among which 21.4% made planned attempts. About 18.6% of attempts were made before hospital admission, while 7.1% were done after discharge. In our sample, 29.3% had a current suicidal ideation.

Association of sociodemographic profile and clinical parameters with suicidal ideation

Both parametric and nonparametric tests were used wherever applicable to find an association between the variables [Table 1]. None of the sociodemographic parameters were found to be significantly associated with current suicidal ideation. Among the clinical factors, family history of psychiatric illness (P = 0.029), of suicide (P < 0.001), comorbid substance use (P =0.0043), previous attempts (P < 0.001), and a negative attitude toward psychotropics (P < 0.001) are found to be significant predictors of a current ideation. Interestingly, both total illness duration (P = 0.229) and DUP (P = 0.517) were not significantly associated with a current suicidal ideation.

Association of schizophrenic psychopathology and depression with suicidal ideation

The scores of ISST (suicidal ideation) was found to be significantly correlated to the positive (P < 0.01), negative (P < 0.05), excitement (P < 0.01), and emotional (P < 0.01) scores of schizophrenic psychopathology and not with the disorganized score (P = 0.323). ISST score is also found to be significantly correlated positively with CDSS score (depression) (P < 0.01) [Table 2].

Table 2

Correlational analysis between age, family income, total duration of illness, psychopathology, and depression with suicidal ideation (InterSePT Scale for suicidal thinking) in schizophrenia

Illness variables	ISST score (r)	P
Age	−0.019	0.825
Monthly income	−0.088	0.302
Total duration of illness	−0.102	0.229
PANSS: Positive score	0.425	0.000***
PANSS: Negative score	0.185	0.029*
PANSS: Disorganized score	0.084	0.323
PANSS: Excitement score	0.270	0.001**
PANSS: Emotional score	0.607	0.000***
Depression (CDSS score)	0.853	0.000***

*P<0.05, **P<0.01, ***P<0.001. PANSS=Positive and Negative Syndrome Scale, CDSS=Calgary Depression Scale for schizophrenia, ISST=InterSePT Scale for suicidal thinking

DISCUSSION

No significant correlation was found in the present study between age, gender, and religion with the presence of suicidal ideations. While a similar finding was also reported in some studies, an over-representation of young age and female gender to have committed more suicide is also found.[2349] The design of the studies may be responsible for the difference. Although higher education has been found to be intimately related to suicidal behavior irrespective of the cause, studies involving schizophrenic suicidal behavior both in India and abroad failed to find any significant association between them, and this has also been reflected in the current study.[41119] Marital status of the sample was also found to have no significant association with suicidal ideation and this was also found in an earlier study while refuted in another where a protective role of being married is found.[411] The present study recorded sufferers more from urban location to harbor a death wish, but the family type and domicile of our patients were not found to be significantly associated with suicidal ideation. These sociodemographic parameters have conflicting relationship with suicidality in available literature which can be explained by the study design, the population enrolled, and effect of other factors such as availability of social support and economy.[811]

About 29.3% of schizophrenia patients in this study have current suicidal ideation. This goes in line with earlier findings which have noted 29% to as high as 79% of sufferers to harbor suicidal thinking.[234] Suicidal ideation is a construct which depends on multitude of factors including the ability and wish of the subject to verbalize, the communication style of both examiner and subject, mutual trust, personality factors, and other contextual factor and is bound to vary.

The present study failed to find any significant correlation between illness duration and DUP with suicidal thinking. There are studies that are in line with this finding, but some go against.[719] Suicidal ideation in schizophrenia is multifactorial. Symptoms, recovery, reaction to illness, support systems, employment, and disability being responsible. In India, the support systems, reaction to the illness, and religious and cultural beliefs are different from the rest of the world. Hence, the cross-cultural difference may be explained.

The current study finds suicidal thinking to be significantly associated with past suicide attempt, a family history of psychiatric illness (especially schizophrenia), and suicide. Various studies have found these parameters to be important predictors of a future attempt and ideation.[8] Substance use has also been found to be a contributor to suicidality and it finds support from research done in India and abroad.[31020] About 68.57% of our sample were found to have an unfavorable attitude toward psychotropic medications in our study and this has been found to be significantly associated with current suicidal ideation. A meta-analysis also finds the same.[1] Negative attitude toward psychiatric treatment leads to poor adherence and a worse outcome with increased suicidal behavior in psychosis. Support for this has been bounteous from the western studies.[20]

Among the five-factor model of schizophrenic psychopathology, apart from “disorganization” domain, others namely “positive,” “negative,” “emotional,” and “excitement” domains were significantly correlated with suicidal ideation in the study. While positive symptoms were found to be prominent predictors in some studies, negative symptoms were reported to play both a contributory and a protective role on suicidal behavior in others.[4820] The role of “emotional”, “excitement,” and “disorganization” domains of psychopathology with suicidal thinking is scant in the existing literature.[1] Thus, more research is needed to find whether suicidality is a core symptom of schizophrenia in some cases and also for its value in public health.

Depression can set in at any time over the course of schizophrenia. It can occur as a result of the positive symptoms or can be misconstrued as a negative symptom. Regaining of insight has also been found to trigger depression and suicidality. Whatever the cause may be, depression in schizophrenia needs close observation and a holistic management. In the present sample, depression has been found to be significantly correlated to suicidal ideation [Table 2]. Regression analysis shows that among all the variables, scores of depression are the single most significant predictor of current suicidal ideations. Our finding matches a host of others. A systematic review of 29 international case–control and cohort studies in schizophrenia has concluded depressive symptoms to be significantly associated with patients having suicidal ideation.[11] Other studies that are in line with the present finding are majorly from western countries as literature from this part of the world is relatively scarce.[48]

The limitations of the current study are worth mentioning. A small sample size, the possibility of not verbalizing suicidal ideations by subjects, the chance of recall bias, and a cross-sectional model of this study (where a life span approach to suicidal behavior could have been more informative) are some limitations to mention a few. Furthermore, the level of psychosis in the patients can question the validity of their responses. Nevertheless, studying only suicidal ideation is a new construct which needs to be much more researched.

CONCLUSION

It must be noted that suicidality in schizophrenia is an important issue. An ideation to die leads to planning and then an attempt. Knowing the possible factors that can lead to suicidal thinking is an important way to further assess this behavior in schizophrenia patients that may be helpful in preventing premature loss of lives.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.