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Schizophrenia is a common mental disorder treated by many counseling professionals, and it is associated with a high rate of early mortality. The most common reason for early mortality in schizophrenia is suicide. To date, the most recent comprehensive study on correlates of suicidality among clients with schizophrenia is titled "Suicidal Behavior in Schizophrenia: Characteristics of Individuals Who Had and Had Not Attempted Suicide" (J. M. Harkavy-Friedman et al., 1999). It is the purpose of this Trends article to review this study and discuss its implications for counselors.
In their study, Harkavy-Friedman et al. (1999) compared demographic and clinical characteristics of psychotic clients who recently attempted to commit suicide with those who had no intent to physically harm themselves. Personal characteristics (e.g., age, sex, race, marital status, level of education), retrospective quantitative clinical information (e.g., number of prior hospitalizations, number of past major depressive episodes, substance abuse history), and current emotional state (e.g., depressive symptoms) were all included as independent variables. Therefore, the investigators' goals were to identify a specific group of clients with schizophrenia who had recently attempted suicide and then to compare those individuals with matched peers who had not made such an attempt. This is the first study found to date that tried to determine suicide potential among schizophrenic clients using both quantitative and qualitative data.
One hundred fifty-six clients with either schizophrenia or schizoaffective disorder participated in this study. Schizophrenia is characterized by specific diagnostic criteria including such symptoms as hallucinations, delusions, disorganized speech or behavior, and "negative symptoms" (e.g., blunted affect, lack of motivation, social withdrawal). Schizoaffective disorder must meet diagnostic criteria similar to those for schizophrenia; however, a diagnosable mood disorder must also be present for most of the time that the psychotic symptoms are affecting the individual (American Psychiatric Association [APA], 1994). Clients were volunteers who were either recruited from the New York State Psychiatric Institute (n = 75) or were members of families participating in the Diagnostic Center for Linkage Studies in Schizophrenia (n = 81). Participants were an average age of 37 years, most were men (60%), a large minority were Caucasian (43%), and most were never married (72%). Mean age at first psychotic symptom was 20 years, mean age at first hospitalization was 22 years, average duration of illness was 17 years, and mean number of lifetime hospitalizations was 8. A thorough literature review revealed that these demographic characteristics are consistent with the general population of clients having chronic schizophrenia (APA, 1997). Therefore, this sample population should generalize to other clients with long-term psychosis.
Once participants gave written informed consent, the investigators obtained demographic data, clinical information, and data regarding recent suicidal behaviors using the Diagnostic Interview for Genetic Studies (Nurnberger et al., 1994). This instrument reportedly demonstrates good reliability. A review of medical records confirmed much of the data obtained using this instrument. Results revealed that a large minority of participants (33%) had at least one recent suicide attempt, and 60% of those who recently attempted suicide had a history of multiple attempts. Over 80% of clients engaged in their first suicide attempt either shortly after the onset of psychotic symptoms or after their first hospitalization. Most participants (52%) who attempted suicide engaged in behaviors that were moderately to extremely lethal. The most common means of attempting suicide were overdosing (42%), slitting one's wrists (16%), jumping to one's death (8%), and hanging (6%). Most clients (76%) reported strong suicidal ideation and intent before their attempt.
Results indicated that none of the demographic characteristics assessed differentiated those clients who attempted suicide from those who did not. Age, sex, race, years of education, marital status, or living environment did not correlate with risk of suicidal behaviors. Results also showed that retrospective quantitative clinical characteristics did not predict which clients would attempt to physically harm themselves; that is, the two groups were comparable regarding age at first onset of symptoms, total duration of illness, age at first contact with mental health professionals, age at first psychiatric inpatient admission, total inpatient hospitalizations, history of major depressive disorder, history of manic episodes, and history of either alcohol or drug abuse.
However, a qualitative inquiry did uncover significant psychological differences between the two groups of clients. Clients who had attempted suicide did differ from those who had not attempted it regarding their emotional state before the act, the number of recent life Stressors, or both. This is the first study found to date that has documented reasons why clients with schizophrenia attempted suicide. Among those clients who attempted suicide, the most common reason for the action was current depression. Although Harkavy-Friedman et al. (1999) explained that they did not know how many of the participants met the diagnostic criteria for major depressive disorder (APA, 1994) at the time of the suicide attempt, it was clear that depressive symptoms had enough emotional impact to disrupt clients' judgment and problem-solving ability. Loss of a significant other (i.e., either a spouse, a boyfriend, or girlfriend) was the next most common reason given for suicidality. Although most of the participants were not married, the majority were involved in a romantic relationship. These types of relationships and the emotional impact of their disintegration have not been adequately studied by previous researchers. The other three most common reasons for attempting suicide were disturbance from psychotic symptoms, response to command hallucinations, and an effort "to escape."
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