Effects of Patient-Initiated Brief Admissions on Psychiatric Care Consumption in Borderline Personality Disorder: ARegister-Based Study.

Previous studies have reported that patients with borderline personality disorder (BPD) often have negative experiences in psychiatric inpatient care. To address this issue, a novel intervention known as patient-initiated brief admission (PIBA) has been developed. PIBA offers a constructive approach to crisis management in situations of heightened anxiety, as well as during instances of self-harm and suicidal ideation. The intervention allows patients to directly contact the psychiatric ward to initiate a brief admission lasting 1-3 days. This easily accessible care option during a crisis has the potential to prevent harm to the patient and reduce the need for prolonged hospital stays. The aim of the present study is to investigate the effects of PIBA on psychiatric care consumption among patients diagnosed with BPD. This retrospective register-based study includes data from both inpatient and outpatient care registries for patients diagnosed with BPD. Data were extracted from the National Board of Health and Welfare in Sweden. The study period encompasses 2013-2020, with the PIBA intervention occurring between 2016 and 2019. The sample included 107 patients in the PIBA group and 5659 matched controls. Data were analysed using a difference-in-differences (DiD) approach through ordinary least squares (OLS) regression and ordinal logistic regression. Throughout the 3-year follow-up, both groups exhibited a reduction in the number of days of utilisation of psychiatric inpatient care services. The DiD analysis indicated an additional decrease of 1.5 days at the 6-month mark for the PIBA group (ß = -1.436, SE = 1.531), expanding to 3 days fewer at the 12-month follow-up (ß = -3.590, SE = 3.546), although not statistically significant. For outpatient care, the PIBA group displayed an increase in the number of visits, averaging to half a visit more every 6 months (ß = 0.503, SE = 0.263) compared with the controls. Statistically significant differences were observed for two out of six measurements at the 12-month (ß = 0.960, SE = 0.456) and 18-month follow-up period (ß = 0.436, SE = 0.219). The PIBA group had a statistically significant lower odds of experiencing extended lengths of inpatient care days after the index date than the controls (OR 0.56, 95% CI: 0.44-0.72). In conclusion, PIBA was associated with a significant reduction in the length of individual hospital stays, but not in the overall number of inpatient care days. PIBA may be linked to a shift from longer inpatient care utilisation to outpatient care utilisation. These findings suggest that PIBA may reduce the risk of prolonged hospitalisations for patients who have access to the intervention. Future research should explore the impact of PIBA on healthcare costs and cost-effectiveness, both in relation to health care for the individual and cost-effectiveness in relation to recovery and health.

Long-Term Effect of Maintenance Electroconvulsive Therapy in Patients With Depression-Data From a Small Randomized Controlled Trial.

OBJECTIVES: This study aimed to compare the long-term effects of maintenance electroconvulsive therapy (M-ECT) with medication and medication only in patients with depression. METHODS: A randomized controlled trial of 1 year of M-ECT with medication or medication only investigated relapse/recurrence among 56 patients in remission after electroconvulsive therapy (ECT) for depression was conducted. The results of the first year are published already and showed a significant advantage of M-ECT with medication.The current study was a long-term follow-up. When the randomized treatment allocation ended, medication was continued in both groups but M-ECT was terminated. Patients were followed for up to 10 years via Swedish national registers until the study endpoint of a new psychiatric diagnosis as an inpatient, suicide, suspected suicide, or death of another cause. Time to relapse was compared between the M-ECT with medication group and the medication-only group using Kaplan-Meier estimates. RESULTS: The median follow-up time was 6.5 years for the M-ECT and medication group and 3.1 years for the medication-only group. One year after randomization 22 patients remained in the M-ECT and medication group, and 14 patients remained in the medication-only group. Relapse patterns between the treatment groups after the completion of M-ECT seemed to be similar according to visual inspection. CONCLUSIONS: This long-term follow-up study suggests that most of the benefit achieved during the treatment period with M-ECT is maintained over several years, but the small sample size, with accompanying large statistical imprecision, makes the results uncertain. More long-term studies of M-ECT are required.Trial registration: ClinicalTrials.gov identifier: NCT00627887.

Patient-Initiated Brief Admission for Individuals with Emotional Instability and Self-Harm: An Evaluation of Psychiatric Symptoms and Health-Related Quality of Life.

Patient-initiated brief admission (PIBA) was developed for patients with emotional instability and self-harm, to cope with crises. The hypothesis was that psychiatric symptoms would decrease, and health-related quality of life (HRQoL) increase, after 1-3 days at hospital. One hundred and thirteen patients were recruited from a psychiatric clinic in Stockholm during 2016-2020. At admission and discharge, the patients completed the Hospital Anxiety and Depression Scale (HADS) and the EuroQoL-5 Dimension Questionnaire (EQ-5D). The patients also evaluated PIBA as a crisis intervention. A significant decrease in symptoms of anxiety and depression was found. HRQoL increased significantly assessed with EQ-5D and 95.2% of the participants found PIBA to be a constructive intervention.

Columbia-Suicide Severity Rating Scale Screen Version: initial screening for suicide risk in a psychiatric emergency department.

BACKGROUND: Suicide screening is routine practice in psychiatric emergency (PE) departments, but evidence for screening instruments is sparse. Improved identification of nascent suicide risk is important for suicide prevention. The aim of the current study was to evaluate the association between the novel Colombia Suicide Severity Rating Scale Screen Version (C-SSRS Screen) and subsequent clinical management and suicide within 1 week, 1 month and 1 year from screening. METHODS: Consecutive patients (N = 18 684) attending a PE department in Stockholm, Sweden between 1 May 2016 and 31 December 2017 were assessed with the C-SSRS Screen. All patients (52.1% women; mean age = 39.7, s.d. = 16.9) were followed-up in the National Cause of Death Register. Logistic regression and receiver operating characteristic curves analyses were conducted. Optimal cut-offs and accuracy statistics were calculated. RESULTS: Both suicidal ideation and behaviour were prevalent at screening. In total, 107 patients died by suicide during follow-up. Both C-SSRS Screen Ideation Severity and Behaviour Scales were associated with death by suicide within 1-week, 1-month and 1-year follow-up. The optimal cut-off for the ideation severity scale was associated with at least four times the odds of dying by suicide within 1 week (adjusted OR 4.7, 95% confidence interval 1.5-14.8). Both scales were also associated with short-term clinical management. CONCLUSIONS: The C-SSRS Screen may be feasible to use in the actual management setting as an initial step before the clinical assessment of suicide risk. Future research may investigate the utility of combining the C-SSRS Screen with a more thorough assessment.

[Higher risk to fail knowledge test for Swedish medical authorization for interns graduated outside of EU or in Poland]. / Resultat på eAT-provet varierar stort beroende på examensland.

We present the results of the medical knowledge test after fulfilled internship for Swedish medical authorization during three periods; the years 1995 to 2008, 2009 to the spring of 2015 and from august of 2015 to 2019. During the last period a total of 6089 tests were further analysed. Interns graduated from Swedish universities failed between 0 percent to 5.5 percent of the test subsections. Interns who graduated from countries within the European Union (EU) failed in 22.1 percent and interns graduated from a non-EU country failed in 42.9 percent. A logistic regression showed that the risk of failing the first attempt increases with higher age, education outside of EU or in Poland. Most of the participants passed the test after three or four attempts. Proper measures have to be implemented for doctors graduated from a non-Swedish university to improve the outcome and introduction to the Swedish health care system to secure patient safety.

Brief admission for patients with emotional instability and self-harm: A qualitative analysis of patients' experiences during crisis.

Previous studies report that individuals diagnosed with borderline personality disorder have been met by negative attitudes from healthcare professionals and their care needs have often been neglected during hospitalizations. When symptoms of emotional instability are combined with self-harm, the resulting crisis often becomes difficult to handle for patients and healthcare professionals. To meet their care needs during these crises, an intervention called 'brief admission' (BA) has been developed. The purpose of BA is to provide a timeout, in situations of increased stress and threat, in order to foster self-management in a safe environment. In the present study, we explored the following research questions: What are patients' experiences with BA? What do patients consider to be the key components of BA? What improvements are considered relevant by patients? A qualitative design was employed, and 15 patients (13 females, 2 males; mean age 38.5 ± 12.9, range 20-67 years) were interviewed using a semi-structured interview guide. Thematic analyses were performed, which yielded four themes related to the patients' experiences: 'a timeout when life is tough', 'it is comforting to know that help exists', 'encouraged to take personal responsibility', and 'it is helpful to see the problems from a different perspective'. Four themes also described the key components: 'a clear treatment plan', 'a smooth admission procedure', 'a friendly and welcoming approach from the staff', and 'daily conversations'. Lastly, three themes described areas for improvements: 'feeling guilty about seeking BA', 'room occupancy issues', and 'differences in staff's competence'. Collectively, the findings indicate that BA constructively supports patients with emotional instability and self-harm during a period of crisis.

Predicting suicide: A comparison between clinical suicide risk assessment and the Suicide Intent Scale.

BACKGROUND: How suicide risk should be assessed is under discussion with arguments for both actuarial and clinical approaches. The aim of the present study was to compare the predictive accuracy of a clinical suicide risk assessment to that of the Suicide Intent Scale (SIS) in predicting suicide within one year of an episode of self-harm with or without suicidal intent. METHODS: Prospective clinical study of 479 persons assessed in a psychiatric emergency department after an episode of self-harm. The clinical risk assessment and the SIS rating were made independently of each other. Suicides within one year were identified in the National Cause of Death Register. Receiver operating characteristic (ROC) curves were constructed, optimal cut-offs were identified and accuracy statistics were calculated. RESULTS: Of 479 participants, 329 (68.7%) were women. The age range was 18-95 years. During one-year follow up, 14 participants died by suicide. The area under the curve (AUC) for the clinical risk assessment and the SIS score were very similar, as were the accuracy statistic measures at the optimal cut-offs of the respective methods. The positive predictive value (PPV) of each assessment method was 6%. LIMITATIONS: The clinical suicide risk assessment is not standardized. The number of suicides is small, not allowing for stratification by e.g. gender or diagnosis. CONCLUSION: Predictive accuracy was similar for a clinical risk assessment and the SIS, and insufficient to guide treatment allocation.

Patients' experiences of the caring encounter with the psychiatric emergency response team in the emergency medical service-A qualitative interview study.

BACKGROUND: Mental illnesses are increasing in the population; consequently, the number of psychiatric emergencies handled by the emergency medical services (EMS) has also increased. Alternative response systems have been developed and evaluated, but there is still a lack of knowledge concerning the patients' experiences of being cared for in the EMS by a psychiatric emergency response unit (In Swedish: Psykiatrisk Akut Mobilitet [PAM]). OBJECTIVE: The aim of this study was to explore patients' experiences of the caring encounter with the PAM team. DESIGN: A qualitative study design with 14 patients' interviews and content analysis was used. RESULTS: The patients expressed that the PAM team created a safe environment and actively involved the patient in their care by creating an open and safe place for dialogue. In this safe environment, the patients described how they participated in the decision making and received care without fear of being dismissed, ignored or judged. DISCUSSION AND CONCLUSION: The patients' experiences of being cared for by the PAM team show that person-centred care was achieved by involving the patients in their own care. This participation was possible because mutual trust and confidence existed, and the patients acknowledged the specialist response unit to be a valuable part of the EMS. However, further studies are needed to explore whether the PAM as a response unit in the EMS decreases the risk of suicide and to examine different health economic aspects of using PAM in the EMS.

Patient preferences for medicine administration for acute agitation: results from an internet-based survey of patients diagnosed with bipolar disorder or schizophrenia in two Nordic countries.

The objective was to elicit patient preferences for medicine administration method in the management of acute agitation episodes among patients diagnosed with bipolar disorder or schizophrenia. The patients' experiences of acute agitation episodes and their management of episodes were also explored. Data were collected via an anonymous, internet-based survey of residents in Denmark or Sweden with schizophrenia or bipolar disorder (October 2014 to December 2014). Inclusion criteria were having a diagnosis of schizophrenia or bipolar disorder, and being above 18 years of age. The questionnaire included questions about preferences for medication attributes, experiences with pharmacological treatment for agitation and involvement in treatment plans. A total of 237 diagnosed patients (61 with schizophrenia; 176 with bipolar disorder) completed the questionnaire. Agitation episodes were experienced by 90% of the respondents. In total, 83% of the respondents reported having received treatment with tablets. When patients were presented with the attributes of an inhalation method, respondents stated that the fast onset of action, low risk of adverse reactions and least invasive form of drug delivery were positive attributes of treatment with inhalation. Inhalation is a new delivery route for treatment of acute agitation in patients diagnosed with bipolar disorder or schizophrenia. Inhalation is the preferred treatment method for acute agitation among Danish and Swedish patients with bipolar disorder or schizophrenia.

The effect of the medicine administration route on health-related quality of life: Results from a time trade-off survey in patients with bipolar disorder or schizophrenia in 2 Nordic countries.

BACKGROUND: Agitation episodes are common among patients with schizophrenia or bipolar disorder. Oral and intramuscular administration methods are commonly used in pharmacological treatment of acute agitation. Recently, an innovative inhalation product with loxapine(Adasuve®)has become available for treatment of acute agitation episodes associated with bipolar disorder or schizophrenia. The objective for the present study was to investigate the impact of the pharmacological treatment's administration methods on the health-related quality of life (HRQoL) in patients with bipolar disorder or schizophrenia in Denmark and Sweden using a time trade-off (TTO) approach. METHODS: The TTO methodology was used to examine the HRQoL impact of administration method of pharmacological treatment of acute agitation. Data were collected via an internet-based survey, using an existing panel of respondents with schizophrenia or bipolar disorder. RESULTS: Respondents considered living with schizophrenia/ bipolar disorder, having one yearly agitation episode treated with inhaler better than living with the same conditions and receiving treatment with tablet or injection. The utility value was 0.762 for inhalable treatment, 0.707 for injection and 0.734 for tablet treatment. CONCLUSIONS: Patients' preference for treatment delivery options showed that inhalation was associated with a significant utility gain when compared to injection or tablets. Inhalable loxapine may be a new tool for control of agitation episodes for strengthening the patient provider alliance when taking patient's preference for delivery method into consideration.

[Internship-test reveals increased knowledge gaps]. / AT-provet avslöjar ökade kunskapsklyftor - Drygt 40 procent av AT-läkare med examen utanför EU underkänns - knappt 4 procent av dem med svensk examen.

We present the results of the medical knowledge test after fulfilled internship for Swedish medical authorization during the years 2009 to the spring of 2015. A total of 7,613 tests were analyzed. Interns graduated from Swedish universities failed in 2.7% to 3.8% of the test moments. Interns who graduated from countries within the European Union (EU) failed in 21.2% and interns graduated from a non-EU country failed in 41.6%. The results from those who graduated from EU and non-EU countries have worsened compared to an earlier study in 2009. Proper measures have now to be implemented for doctors graduated from a non-Swedish university to improve the outcome and introduction to the Swedish health care system.

Characteristics of bipolar disorder patients treated with immediate- and extended-release quetiapine in a real clinical setting: a longitudinal, cohort study of 1761 patients.

OBJECTIVES: The objective of this work was to study characteristics and clinical treatment patterns of bipolar disorder (BD) patients admitted to hospital and treated with quetiapine (immediate-release [IR] or extended-release [XR] formulations). METHODS: BD patients admitted to hospital and prescribed quetiapine IR were followed by linking two Swedish nationwide registries; the hospitalization and drug dispense registries [ClinicalTrials.gov identifier: NCT01455961]. The study period was from 1 January 2008, to end of 31 December 2011. Data was primarily analysed using descriptive methods. RESULTS: Quetiapine IR was used in 1761 patients of whom 1303 subsequently switched to XR (switch XR) and 458 remained on IR (continuous IR). At baseline, Switch XR patients were younger (-3.3 years), more frequently employed (+7.1%), had higher prevalence of single depressive episodes (+6.7%) and anxiety disorders (+5.8%), lower mean daily IR dose (-19.3%) and fewer medications for somatic disorders (-7.5%) than continuous IR patients. During follow up, the number of concomitant psychiatric medications was lower in switch XR patients (-6%) and higher in continuous IR patients (+6%). Mean daily quetiapine dose was 21% higher in switch XR versus continuous IR patients. Prescriptions of lower quetiapine dosages calculated below 50 mg per day in the XR switch and IR continuous groups were seen in 8% versus 10% of the patients, respectively. CONCLUSIONS: Differential use of quetiapine XR and IR in bipolar disorder patients with different and important characteristics was demonstrated. Patients who were switched to quetiapine XR had a higher psychiatric disease burden, were younger and had a higher degree of employment. These differences demonstrate the heterogeneity among bipolar disorder patients and indicate the need in clinical practice for individualized treatment to reduce the risk for both patient and society related losses.

Population study of disease burden, management, and treatment of bipolar disorder in Sweden: a retrospective observational registry study.

OBJECTIVES: The aim of the study was to describe temporal changes in bipolar disorder during 20 years within the Swedish population and to investigate clinical and socioeconomic characteristics, drug treatment, and mortality among patients with bipolar disorder. METHODS: We conducted a retrospective, nationwide registry study (the Swedish Population Register) that included all patients diagnosed with bipolar disorder (1991-2010) and linked individual data from the Swedish National Patient Register, the National Prescribed Drug Register, and the Population Register (NCT01455961). A cross-sectional cohort analysis was performed for years 2006 versus 2009. Data were analyzed using descriptive statistics. RESULTS: During the study period, the annual incidence of diagnosed bipolar disorder increased 3.5-fold, and patients were diagnosed at a younger age. Mortality among patients with bipolar disorder was twice that of the general population. Compared to an age-standardized population, 30% fewer patients with bipolar disorder were available for work. Among the 40% employed, 64% reported sick leave (46% >100 days/year). Despite similar education levels, disposable income was lower compared to the general population. The most commonly preceding psychiatric diagnoses were depressive or anxiety disorders. Comparing the data for 2006 and 2009 demonstrated similar somatic comorbidity burdens and socioeconomic levels. There was also a decrease in dispensed antipsychotic medications and lithium, while antiepileptic prescriptions increased slightly. Antidepressant dispenses remained virtually unchanged. CONCLUSIONS: In Sweden, the incidence and prevalence of diagnosed bipolar disorder have increased during the last 20 years. Compared to the general population, these patients had similar education levels, lower employment levels, less disposable income, more sick leave, and twice the mortality. A trend towards earlier diagnosis, more use of antidepressants, and less use of lithium was seen.

Continuation electroconvulsive therapy with pharmacotherapy versus pharmacotherapy alone for prevention of relapse of depression: a randomized controlled trial.

OBJECTIVE: The primary aim of the study was to test the hypothesis that relapse prevention with continuation electroconvulsive therapy (ECT) plus pharmacotherapy is more effective than pharmacotherapy alone after a course of ECT for depression. METHODS: A multicenter, nonblinded, randomized controlled trial with 2 parallel groups was performed from 2008 to 2012 in 4 hospitals in Sweden. Patients eligible had unipolar or bipolar depression and had responded to a course of ECT. The patients (n = 56) were randomly assigned (1:1) to receiving either 29 treatments of continuation ECT with pharmacotherapy or pharmacotherapy alone for 1 year. The pharmacotherapy consisted of antidepressants (98%), lithium (56%), and antipsychotics (30%). The main outcome was relapse of depression within 1 year. Relapse was defined as 20 or more points on the Montgomery Åsberg Depression Rating Scale or inpatient psychiatric care or suicide or suspected suicide. All 56 patients randomized were analyzed according to an intention to treat analysis. RESULTS: Sixty-one percent of the patients treated with pharmacotherapy versus 32% of the patients treated with ECT plus pharmacotherapy relapsed within 1 year (P = 0.036). The Cox proportional hazard ratio was 2.32 (1.03-5.22).Cognitive function and memory measures were stable for patients without relapse in both groups.One suspected suicide and 3 suicide attempts by intoxication occurred, all in the pharmacotherapy-alone group. CONCLUSIONS: The post-ECT relapse rates were substantial in both treatment groups with a statistically significant advantage for combined treatment with pharmacotherapy and continuation ECT. Further studies are needed to define indications for continuation ECT, pharmacotherapy, and their combination.

CSF kynurenic acid and suicide risk in schizophrenia spectrum psychosis.

Relationships between concentrations of cerebrospinal fluid (CSF) kynurenic acid (KYNA) and suicidal behavior were evaluated in 59 patients with psychosis after 22 years of follow-up. Three patients died from suicide and nine patients had a history of attempted suicide. Patients with attempted suicide had significantly lower concentrations of CSF KYNA.

A retrospective study of clinical usage of quetiapine XR and quetiapine IR in outpatients with schizophrenia in Denmark.

OBJECTIVES: The atypical antipsychotic quetiapine is a first-line treatment for schizophrenia. This non-interventional study (NCT01212575) evaluated the clinical use of its two formulations, extended release (XR) and immediate release (IR), in outpatients with schizophrenia spectrum disorder. METHODS: Patients who had received at least one dose of quetiapine XR and/or IR were included. A dosage ≥400 mg/day was defined as antipsychotic. Medical records data were collected retrospectively. RESULTS: Of 186 enrolled patients, 99 (53%) and 87 (47%) received quetiapine XR and IR, respectively. Use in antipsychotic dosage was seen for 89% XR versus 63% IR patients (mean daily dose ≥400 mg/day; p < 0.0001). 75% XR and 53% IR patients used dosages ≥600 mg/day (p = 0.0019). Quetiapine XR was used at higher mean daily dosages than IR (748 vs 566 mg/day; p = 0.006). Forty-three patients (23%) used both formulations concomitantly; 55 patients (30%) used either XR or IR. Quetiapine IR was used as-needed in 44 patients (23%); one patient used XR as-needed. CONCLUSIONS: Quetiapine XR was used more often in higher (antipsychotic) dosages; quetiapine IR more frequently on an as-needed administration basis. Concomitant use was seen. These findings probably reflect the different profiles of XR/IR and advocate the need for both formulations to offer treatment choice.

Use of quetiapine XR and quetiapine IR in clinical practice for hospitalized patients with schizophrenia: a retrospective study.

Quetiapine fumarate, a first-line treatment for schizophrenia, exists in two formulations: extended release (XR) and immediate release (IR). This naturalistic, noninterventional study evaluated use of quetiapine XR/IR among in-patients with schizophrenia [ClinicalTrials.gov identifier: NCT01214135]. Data were collected from medical records. Categorical and numerical outcomes were compared using χ(2) and t tests. Of 178 enrolled patients, 66% and 34% used quetiapine XR and IR respectively. Based on mean daily dose, XR was used as antipsychotic medication in 64% of patients compared with 40% of patients on IR (dose ≥ 400 mg/day; p = 0.002) and in higher doses than IR (494 versus 345 mg/day; p = 0.001; calculated averages). Schizophrenia was more commonly reported as reason for use of XR than IR (20% versus 0%; p = 0.0003). Patients with comorbid substance abuse or somatic disease were more likely to receive XR (p = 0.003; p = 0.03). Treatment cessation due to nonadherence was less common in patients on XR (3.4% versus 12%; p = 0.03). Polypharmacy was seen in 98% of patients. Quetiapine XR/IR usage varies in hospitalized patients with schizophrenia. XR is more often used in antipsychotic dosage; IR is more commonly used at lower doses as add-on therapy. Both quetiapine XR and IR have their place in clinical practice and provide treatment choice in schizophrenia.

Early death and CSF monoamine metabolites in schizophrenia spectrum psychosis.

INTRODUCTION: Patients with schizophrenia have higher rates of mortality than the general population. Lower concentrations of the cerebrospinal fluid (CSF) monoamine metabolites homovanillic acid (HVA) and 5-hydroxyindoleacetic acid (5-HIAA) have been associated with suicidal, aggressive and impulsive behavior. Mortality has been suggested as a measure of impulsivity and a relationship between early death and lower concentrations of CSF monoamine metabolites has been reported but the studies are few with short periods of follow-up and small numbers. AIM: The objective of this study was to investigate a relationship between early death and concentrations of CSF 5-HIAA and HVA. METHODS: Three hundred and eighty-five inpatients with schizophrenia spectrum psychosis were lumbar punctured in a standardized manner and followed for a median of 26 years. Patients were searched to identify those who had died. Causes of death were obtained from the Causes of Death Register. RESULTS: During the time of follow-up, 97 patients died. Schizophrenia spectrum psychosis patients died at an earlier age from both natural and unnatural causes of death. No significant associations were found between CSF 5-HIAA and HVA concentrations and non-suicidal death. Attempted suicide was not a risk factor for non-suicidal death at younger age. CONCLUSION: Patients with schizophrenia spectrum psychosis die at an earlier age from both natural and unnatural causes of death. Attempted suicide is not a risk factor for non-suicidal death at younger age. Low concentrations of CSF HVA and 5-HIAA were not a risk factor for non-suicidal death at younger age in schizophrenia spectrum psychosis.

Suicide in schizophrenia.

Schizophrenia is a disorder with an estimated suicide risk of 4-5%. Many factors are involved in the suicidal process, some of which are different from those in the general population. Clinical risk factors include attempted suicide, depression, male gender, substance abuse and hopelessness. Biosocial factors, such as a high intelligence quotient and high level of premorbid function, have also been associated with an increased risk of suicide in patients with schizophrenia. Suicide risk is especially high during the first year after diagnosis. Many of the suicides occur during hospital admission or soon after discharge. Management of suicide risk includes both medical treatment and psychosocial interventions. Still, risk factors are crude; efforts to predict individual suicides have not proved useful and more research is needed.