Depression and Suicide in Schizophrenia

Patients with schizophrenia frequently suffer from more than one psychiatric disorder. More than half will experience some form of depression during their lifetime. This combination is often associated with impaired social adjustment, treatment non-compliance, multiple hospitalizations and relapse for psychosis. The rate of suicide among individuals with schizophrenia is about 10 percent, highlighting the importance of recognizing and treating depression associated with schizophrenia.

Is it Depression?

The incidence of depression during or immediately following an acute psychotic episode is very high, occuring in about 25% of patients with schizophrenia. Depressive symptoms may also appear just before a psychotic relapse. Negative symptoms of schizophrenia (inability to experience pleasure, lack of energy and motivation, social withdrawal, and impaired abstract thinking) can have a significant overlap with symptoms of depression making it difficult to recognize. Also, some depressive symptoms may be confused with side effects of antipsychotic medications such as akinesia, (apathy and diminished spontaneous movement and speech) or akathisia, (motor restlessness) which can produce dysphoria (negative moods). Additionally, a depressed mood is often seen in persons who are abusing or withdrawing from drugs or alcohol as well as in medical conditions, such as thyroid disorders. Deficits in perception, cognition, and communication skills in patients with schizophrenia often interfere with the detection of depression and risk for suicide.

Paul, a 33 year old male veteran with schizophrenia was able to function in social relationships but unable to work. Divorced with a young daughter, Paul was doing quite well on antipsychotic medication until his ex-wife moved to another state, taking his daughter, who he saw on weekends. At first, Paul spent his weekends with his mother, helping her with yard work. Gradually, he began to spend less and less time with his mother and more and more time at his own home watching television. Whenever his mother suggested that he telephone or write to his daughter, Paul would reply, "What's the use?" Paul began to neglect his grooming and began to hear voices again. At his mother's urging, Paul sought professional help and was diagnosed with depression. He was placed on an older, often called "typical" antipsychotic medication. Although the medication controlled the voices he heard it left Paul feeling tired and lethargic most of the time. Paul was sleeping or watching television large amounts of the day. Paul's mother noticed the changes in his activities and wondered if Paul was depressed. Paul’s psychiatrist determined that Paul’s behavior was a result of the side effects from the anti-psychotic medication, not depression because Paul did not feel particularly sad or hopeless. He prescribed one of the newer, atypical antipsychotic medications and Paul began to feel more like himself again.

One symptom that can differentiate a depressive episode from negative symptoms of schizophrenia is sadness. People with clinical depression frequently experience sadness, whereas people with negative symptoms of schizophrenia do not. Those who develop persistent depressive symptoms not related to psychotic episodes are more likely to have clinical depression. Clinical depression is a psychiatric disorder in which a person has a persistent (greater than 2 weeks) sad mood and/or an inability to derive pleasure from previously enjoyable activities. Changes in appetite, energy levels, and sleeping patterns are common, as are feelings of guilt, worthlessness, and hopelessness. People with clinical depression may have thoughts about death and suicide. Whether it is depression concomitant to a psychotic episode or a more persistent clinical depression, it is important to obtain a thorough evaluation by a mental health professional to determine the causative factors of these symptoms and how best to treat them.

Suicide

Untreated depression is a major risk factor for suicide, the eighth leading cause of death in the US. Suicide claims the lives of 30,000 Americans per year, outnumbering the murder rate by 3:2. Suicide impacts more than 180,000 persons in the US each year taking into account the effect a suicide has on the surviving family members.

Paul’s ex-wife returned with their daughter, they were getting along well and discussing reconciliation. Suddenly, Paul's ex-wife changed her mind and decided to move out of state once again. This second loss sent Paul spiraling into depression. He lost 10 pounds in one month, spent most of his days sleeping, and most of his nights crying or pacing. Paul felt hopeless, worthless and began to wonder if life was worth living. He quit taking his antipsychotic medication and began to hear voices again. One morning, after drinking a few beers in front of the television, Paul ingested a lethal dose of medication. Fortunately, his mother found him, unconscious but still alive, and he was successfully treated for the overdose of medication. During his hospital stay Paul was stabilized on anitpsychotic and antidepressant medication and began participating in a psychotherapy group where he learned how to cope with feelings of sadness, worthlessness, and hopelessness. The group helped him to change his thinking patterns. Paul has not heard voices or felt depressed for several months now and is currently also participating in a vocational rehabilitation program.where he is learning how to cope with feelings of sadness, worthlessness, and hopelessness. The group helped him to change his thinking patterns. Paul has not heard voices or felt depressed for several months now and is currently also participating in a vocational rehabilitation program.

The highest risk of suicide occurs in the presence of multiple co-existing conditions, particularly combinations of mood or psychotic disorders with alcohol or drugs. Substance and alcohol abuse alone or in combination with psychiatric disorders are found in 25% of suicides. Major depressive disorder and bipolar disorder are associated with about half of all suicides. Patients with depression and schizophrenia are nearly three times more likely to attempt suicide than people with clinical depression alone and may be less likely to communicate suicidal intent to health care professionals. They are also more likely to use highly lethal methods in their suicide attempts. To date, there are no definitive measures to predict suicide. Researchers have identified factors that place individuals at higher risk for suicide, but as with suicide in general, the progression to suicide among people with schizophrenia is complex.

In general, the risk of suicide rises with advanced age, especially after the age of 60. By the age of 75, the risk for suicide doubles. This increase may be related to factors such as retirement, widowhood, social isolation, declining vigor and health, and other losses.

Suicide Prevention

Researchers believe that both depression and suicidal behavior can be linked to decreases in the neurotransmitter serotonin in the brain. Low levels of this brain chemical have been found in patients with depression, impulsive disorders, a history of violent suicide attempts, and also in postmortem brains of suicide victims. This has led to the use of a group of antidepressants called SSRIs (selective serotonin reuptake inhibitors) to treat depression in people with and without schizophrenia. The newer antipsychotic medications may also relieve some depressive symptoms in people with depression and schizophrenia. Psychotherapy, such as cognitive-behavioral therapy, in conjunction with medication, has also been found to be an effective treatment for depression. MIRECC researchers are currently conducting studies to test the effectiveness of medications and psychotherapies for depression in people with schizophrenia.

Risk and Protective Factors for Suicide
Protective Factors	General Risk Factors	Schizophrenia-Related Risk Factors
Intact social supports, marriage Active religious affiliation or faith Presence of dependent young children Ongoing supportive relationship with a caregiver Absence of depression or substance abuse Living close to medical and mental health resources Awareness that suicide is a product of illness Proven problem-solving and coping skills	Young and elderly men Native American or Caucasian Self-reported hopelessness Deteriorating health Significant loss (emotional, social, physical, or financial security) Current or past substance abuse Family History of suicide Easy access to a firearm	Long-term illness with many relapses Symptoms and poor functioning upon discharge Awareness of illness, fear of deterioration Excessive dependence or loss of faith in treatment Depressed mood, hopelessness, hostility Prominent positive symptoms

MIRECC Funds Pilot Health Services Study of Veterans Released From Los Angeles County Jail

by Jim McGuire

Veterans in jail have received increasing attention by the VA. In 1996, veterans were estimated to be 12%, or 69,300 of the U.S. jail population, and 83% of these veterans were eligible for VA services. While it is VA policy not to offer treatment services in jail or prison unless covered by special agreement, jail release outreach services providing linkage to VA and community treatment have grown.

Locally, about 7,500 veterans pass through the Los Angeles County Jail annually. The VA Greater Los Angeles Health Care System Comprehensive Homeless Program has taken leadership in linking veterans to VA medical, psychiatric and substance abuse services for many years.

Raul Espinosa (inset) of the Community Transition Unit at the LA County Jail Twin Towers

In the past year, LA County Sheriff Lee Baca has created a Community Transition Unit (CTU). The mission of the CTU is to "enhance (inmate) participation in educational, vocational, and other life skills training programs, and to assist (inmates) with successful reintegration into the community", accomplishing this through partnership with community and other public agencies, such as the VA. The existence of the CTU has led to expanded access to incarcerated veterans and a need to develop effective programs based on data about this population.

Health services research studies health care accessibility, use, costs, quality, and outcomes, in order to improve health care services. An essential first step in health services research is to establish the nature and extent of the problems experienced by health care consumers. There is virtually no information currently available about the needs or use of services of incarcerated veterans. Accordingly, a two-phase study has recently been launched by Dr. Jim McGuire, Director of VA's CHALENG Program Evaluation for the Northeast Program Evaluation Center (NEPEC). This study examines data collected through outreach assessments over a three-year period from 1997-1999.

Dr. McGuire and Dr. Robert Rosenheck, Director of the NEPEC, collaborated on the first phase of the research which compared 1,676 veterans contacted and assessed by jail outreach workers to 6,560 homeless veterans contacted in the community. Some initial findings are:

Three in four veterans in jail had a long-term (3 year) pattern of unemployment compared to one-half the community homeless.
Rates of alcohol (48% vs. 42%), drug abuse (62% vs. 39%), serious mental illness (35% vs. 23%), and dual diagnosis (23% vs. 13%) were all much higher for those contacted in the jails.
Current alcohol and drug use was lower for the inmate group.
Serious medical problems were lower (33% vs. 37%) for those in jail.
38% of the jail veterans (vs. 84% of the community homeless) made it to the VA for follow-up services in year after outreach.

While it was not clear how many of the incarcerated veterans were subsequently released from jail, this profile suggests high social and clinical need for the incarcerated veterans, particularly in employment and psychiatric and substance abuse treatment. That current use of drugs and alcohol was lower for the inmate group suggests that the time of outreach may present a window of opportunity for linkage to and engagement with post-release community treatment.

An upcoming MIRECC-funded study will complete the second phase of the research. It will obtain data from the criminal justice system 1) to determine the needs of "released veterans", 2) to draw a much clearer picture of specific clinical problems and the extent to which veterans released from jail with these problems receive appropriate VA treatment and, 3) to determine if there is any association between receiving VA services and remaining out of jail. Dr. Jim Mintz (VISN22 MIRECC Director, Data Evaluation Unit) will provide statistical and data support and, along with Dr. Alex Young (VISN22 MIRECC Director of Health Services Research), consultation with analysis of study results.

While cause-effect relationships cannot be established by this type of study, data from this research will be needed to inform development and testing of various interventions currently under consideration by the VA West Los Angeles Healthcare Center and the Los Angeles County Sheriff's Department. These initiatives range from development of scheduled releases allowing for systematic linkage to community program for employment and mental health services to intensive community re-entry residential care programs.

Fall 2001

Table of Contents

Is it Depression?

Suicide

Suicide Prevention

MIRECC Funds Pilot Health Services Study of Veterans Released From Los Angeles County Jail

by Jim McGuire