Elsevier

Schizophrenia Research

Volume 202, December 2018, Pages 347-353
Schizophrenia Research

Service utilization and suicide among people with schizophrenia spectrum disorders

https://doi.org/10.1016/j.schres.2018.06.025Get rights and content

Abstract

Objective

To compare individuals with and without schizophrenia spectrum disorders (SSD) (schizophrenia, schizoaffective disorder, or psychotic disorder not otherwise specified) who die by suicide.

Method

This is a retrospective case control study which compared all individuals who died by suicide in Ontario, Canada with (cases) and without (controls) SSD between January 1, 2008 and December 31, 2012. Cases (individuals with SSD) were compared to controls on demographics, clinical characteristics, and health service utilization proximal to suicide. A secondary analysis compared the characteristics of those with SSD and those with severe mental illness (defined as those without SSD who have had a psychiatric hospitalization within the five-years before suicide (excluding the 30 days prior to death)).

Results

Among 5650 suicides, 663 (11.7%) were by individuals with SSD. Compared to other suicides, SSD suicides were significantly more likely to be between the ages of 25–34. SSD suicide victims were significantly more likely to reside in the lowest income neighbourhoods and to reside in urban areas. SSD victims were also significantly more likely to have comorbid mood and personality disorders and all types of health service utilization, including outpatient mental health service contact in the 30 days prior to death, even when compared only with those who had a history of mental health hospitalization.

Conclusions

Individuals with schizophrenia spectrum disorder account for over 1 in 10 suicide deaths, tend to be younger, poorer, urban, more clinically complex, and have higher rates of mental health service contact prior to death. The demographic and service utilization differences persist even when the SSD group is compared with a population with severe mental illness that is not SSD. Suicide prevention strategies for people with schizophrenia spectrum disorder should emphasize the importance of clinical suicide risk assessment during clinical encounters, particularly early in the course of illness.

Introduction

People with schizophrenia spectrum disorders (SSD) have significantly higher rates of death by suicide compared with the general population (Bjorkenstam et al., 2014; Brugnoli et al., 2012; Fazel et al., 2014; Nordentoft et al., 2011, Nordentoft et al., 2004). Studies report a lifetime risk of 4–5% with evidence that risk of suicide is highest early in the course of illness (Bakst et al., 2010; Dutta et al., 2012; Fleischhacker et al., 2014; Palmer et al., 2005). Suicide is the leading cause of premature death in SSD, and identifying individuals with SSD who are at high risk for death by suicide is an important clinical, research and public health priority (Fleischhacker et al., 2014).

Epidemiological studies have identified population-based risk factors that are routinely incorporated into clinical assessments to identify, and intervene with, individuals at high risk of suicide. However, individuals with SSD may differ from the general population with respect to suicide risk factors and may require different types of suicide interventions. There are few studies that systematically compare those who die by suicide in SSD vs. other psychiatric diagnoses. Furthermore, the generalizability of existing studies is limited by small sample sizes, the use of clinical samples, and diagnoses made retrospectively through psychological autopsy (Banwari et al., 2013; Cavanagh et al., 2003; Lopez-Morinigo et al., 2014). Suicide is a rare outcome and a retrospective, population-based study and validated algorithm for diagnosis ascertainment allows for a rigorous analysis of the percentage of suicide victims with SSD and the differences in demographics, clinical features and mental health service utilization in those with and without a diagnosis of SSD.

The objective of this study was to examine the characteristics of those who die by suicide with and without SSD. Our hypothesis was that individuals with SSD would have a much larger suicide prevalence relative to best estimate of a population-based one-year prevalence rate of 0.6 (95% CI 0.38–0.91) and will have uniquely different suicide risk factors compared to individuals who die by suicide without SSD (Goldner et al., 2002).

Section snippets

Data sources

Ontario is Canada's most populous province, with approximately 13 million people (Open Minds, Healthy Minds: Ontario's Comprehensive Mental Health and Addictions Strategy, 2011). The Ontario Ministry of Health and Long-Term Care provides coverage for all medically necessary services to residents and captures administrative data reflecting health care utilization. The Institute for Clinical Evaluative Sciences (ICES) holds these health administrative data sources which are linked via an

Cohort development

5697 suicides were identified from the ORG-D database and a further 219 were identified from other data sources in Ontario between January 1, 2008 and December 31, 2012 (Table 1). After excluding 1 case with a missing death date and 265 cases because they were not eligible for coverage under the OHIP in the 5 years prior to suicide death, there were 5650 suicide deaths included in this study, among whom 663 (11.7%) were associated with a diagnosis of schizophrenia, schizoaffective disorder or

Discussion

Over 1 in every 10 suicide deaths in Ontario over a five-year period are associated with a diagnosis of SSD. This estimate is likely the most accurate to date due to the large number of suicides over a large geographic area and duration, as well as the use of a validated algorithm designed to identify cases of SSD diagnosed both in hospital and in the community. SSD diagnoses are strongly overrepresented in those who die by suicide, as the prevalence of schizophrenia spectrum disorder in the

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