Change in suicide rates for patients with schizophrenia in Denmark, 1981-97: nested case-control study
BMJ 2004; 329 doi: https://doi.org/10.1136/bmj.38133.622488.63 (Published 29 July 2004) Cite this as: BMJ 2004;329:261All rapid responses
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Sir:
Atlhough misdiagnoses of schizophrenia were more widespread in the USA,
this is not a problem that Europe was immune from. I have come accross
many patients in my practice, as I am sure have my colleagues, who either
have clear bipolar disorder or personlity disorder but who have attracted
a long term diagnosis of schizophrenia. This issue does not seem to be
addressed in this paper and could account, to some extent, for the
observed fall in suicide rates possibly coinciding with improved treatment
of and for affective disorder.
Competing interests:
None declared
Competing interests: No competing interests
Sir:
Notably, suicide is more commonly reported among patients with mood
disorders as compared to patients with schizophrenia and related spectrum
disorders. Unlike suicide, homicide is more common among patients with
schizophrenia. Both suicide and homicide are more common among psychiatric
population with severe mental illnesses than in general population.
Core depressive features-either reactive/psychogenic or endogenous-
are known to occur in patients with schizophrenia and these symptoms
tremendously enhance the suicidality. The constellation of depressive
symptoms usually manifest either during prodromal phase of psychotic
breakdown or following resolution of psychotic symptoms, as post-psychotic
depression. Episodes of suicide well correlate temporally with these
periods of psychosocial devastation and personal disintegration, which are
coupled with tremendous stigma.
Early recognition of psychotic breakdown, prompt access to
psychiatric services, proper treatment of early or late breakthrough
depression, overall effective management of schizophrenic psychosis by
atypical antipsychotics with better clinical and adverse effect profiles
and continuing antistigmatization campaigns worldwide are some of the
other determinants of suicide reduction among patients with schizophrenia
and related disorders.
Finally, suicide is a preventable phenomenon and hence effective
preventive programs should be continued in order to further reduce the
still high rate of suicide among vulnerable patients with severe
psychoses.
Reference:
Merete Nordentoft, Thomas Munk Laursen, Esben Agerbo, Ping Qin, Eyd
Hansen Høyer, and Preben Bo Mortensen. Change in suicide rates for
patients with schizophrenia in Denmark, 1981-97: nested case-control
study. BMJ 2004; 329: 261-0
Competing interests:
None declared
Competing interests: No competing interests
Dear Editor,
The analysis of suicidal rate among Schizophrenia patients by Merete
Nordentoft et al(1) is certainly one of the very important piece of work
in this subject.
Though at the end of the study we are left with no strong reasons for
this significant decline, there is much room for educated speculations
that can drive further research into this crucial topic. The authors feel
that factors that patients share with the general population, such as less
access to means to commit suicide and better treatment after attempted
suicide may be the main influences. But before concluding so we have to
address some concerns:
1. There is a better reduction of suicide rate in female population
in both subjects and controls. Based on this we cannot say that same
factors operate for both controls and subjects and that is why we have
same pattern of change (i.e. female better than male suicide rates). The
logic says that causal relations cannot be ascertained by just observing
sameness in content and pattern of outcome in two groups under study.
2. If we assume that the same factors operated to reduce suicidal rate in
both groups we have to believe that the additional operating factors in
subject population such as antipsychotic treatment, antidepressant cover
and improvement in Quality of Life (of mentally ill patients in
particular) did nothing or insignificant if anything to reduce suicide
rate. This is very difficult to accept given the recent studies in this
direction (2,3,4).
Apart from this issue, as now it is generally well known that the
risk of suicide is highest during the first year after first contact with
the health care, the pattern of variation in incidence of schizophrenia
itself correlated to suicide rates (say in every next 12 – 18 months time)
should be looked into in future studies of similar nature.
1.Merete Nordentoft, Thomas Munk Laursen, Esben Agerbo, Ping Qin, Eyd
Hansen Hoyer, and Preben Bo Mortensen. Change in suicide rates for
patients with schizophrenia in Denmark, 1981-97: nested case-control study
BMJ 2004; 329: 261-0.
2.Harkavy-Friedman JM, Nelson EA, Venarde DF, Mann JJ. Suicidal
behaviour in schizophrenia and schizoaffective disorder: examining the
role of depression. Suicide Life Threat Behav. 2004 spring; 34(1): 66-76.
3.Potkin SG, Alphs L, Hsu C, Krishnan KR, Anand R, Young FK, Meltzer
H, Green A; InterSePT Study Group. Predicting suicidal risk in
schizophrenic and schizoaffective patients in a prospective two-year
trial. Biol Psychiatry. 2003 Aug 15; 54(4): 444-52
4.Ponizovsky AM, Grinshpoon A, Levav I, Ritsner MS. Life satisfaction
and suicidal attempts among persons with schizophrenia. Compr Psychiatry.
2003 Nov-Dec; 44(6): 442-7
Competing interests:
None declared
Competing interests: No competing interests
The factors that lead to suicide among the persons afflicted with
schizophrenia are different from those among the general population.
However, the very clear parallel nature of the incidence of suicide in the
Danish schizophrenics and their total population begs for further studies
in diverse socio-cultural mileu.
Competing interests:
None declared
Competing interests: No competing interests
Based on World Health Statistics from the 1990s, the gloomy
prediction was that societies with increasing gross national product would
report increasing suicides among both men and women (1). On a World
scale, Denmark is a very prosperous society, that has now reported
substantially reduced suicide rates over a generation (2). What a cause
for hope in the UK!
Since the same decline took place for the general population, for all
ages, for both sexes, as for intensively treated psychiatric "cases",
inspite of major changes in the provision and staffing of psychiatric
services in the later period of this study (2), it is unlikely that
suicide reduction had anything to do with psychiatry. The authors
helpfully identify a key risk period and population that has never been
effectively addressed: the month after discharge from first inpatient
admission for young male patients with schizophrenic psychosis. In the
UK (in Lambeth) this was addressed ten years ago (3) in an inter-
professional demonstration project called Bridging Therapy funded by the
Kings Fund. However, it is not clear that the learning from this and
similar innovative but short-term projects has any impact on the wider
British system of care.
One lesson we could learn from the Danes is that an increasingly
diverse society can simultaneously become more tolerant and inclusive.
Feelings of shame, failure, rejection and disconnectedness in young men
could all predipose to suicide during or after hospital admission. In
relation to lethal shame and isolation, could a growing culture of
forebearance, hope and integration in Denmark have contributed to their
overall reductions in suicide? To reduce social stigma and helplessness
around mental health in young men, Britain now has a national opportunity
for action to "include" psychiatric patients. The Government has invited
suggestions for a Framework for Vocational Rehabilitation for better
employment prospects (4). Let's work on it.
1 Moniruzzaman S, Andersson R. Relationship between economic
development and suicide mortality: a global cross-sectional analysis in an
epidemiological transition perspective. Public Health 2004; 118: 346-348.
2 Nordentoft M, Laursen TM, Agerbo E, Qin P, Høyer EH, Mortensen PB.
Change in suicide rates for patients with schizophrenia in Denmark, 1981-
97: nested case-control study
BMJ 2004; 0: bmj.38133.622488.63v1-0
3 Rainsford E, Caan W. Experience of supervising discharges.
J Clin Nurs 1994;3(3):133-4.
4 Department for Work and Pensions. Developing a Framework for
Vocational Rehabilitation. London: DWP, 2004.
Competing interests:
None declared
Competing interests: No competing interests
Dear sir,
I cannot completely agree with your conclusions.Especially the
availability of means to commit suicide.I think there is definitely
increased availability of means to commit suicide.Over the period, we had
more access to drugs(over dosage), and other means.Inspite the decreased
mortality from suicide could be due to better treatment options and
support.
Competing interests:
None declared
Competing interests: No competing interests
Suicide in psychiatric patients
Nordentoft et al(1) report the correspondence of changes in suicide
rates among those with schizophrenia and the general population in
Denmark. Here in Ireland Corcoran and I reported the same confluence and
remarked that suicide in psychiatric inpatients over a century from the
1880s moved " in tandem with that in the general population" (2). In
recent years with more refined diagnostic classifiactions the changes in
suicide numbers were uniform across diagnostic categories, including
schizophrenia, and more common off than on site, whether leave was
authorised or not. Sadly, unlike in Denmark, our rates in both groups,
have increased substantially. Obviously the factors credited with the
Danish decline do not operate here and the similarity of change over so
long a period and before modern treatments invites speculation as to
generic cultural and social influences - wharever they may be!
1 Nordentoft M,Laursen TM,Agerbo E,Qin P, Hoyer EH, Mortensen
PB.Change in suicide rates for patients with schizophrenia in Denmark,1981
-97: nested case-control study.BMJ 2004; 329: 261-264
2 Corcoran E, Walsh D. Suicide in psychiatric inpatients in Ireland.
Ir J Psych Med 1999; 16(4): 127 - 131.
Competing interests:
None declared
Competing interests: No competing interests