The relationship between suicide and violence in schizophrenia: analysis of the Clinical Antipsychotic Trials of Intervention Effectiveness (CATIE) dataset

Katrina Witt, Keith Hawton, Seena Fazel, Katrina Witt, Keith Hawton, Seena Fazel

Abstract

Background: Suicide and violence often co-occur in the general population as well as in mentally ill individuals. Few studies, however, have assessed whether these suicidal behaviors are predictive of violence risk in mental illness.

Aims: The aim of this study is to investigate whether suicidal behaviors, including suicidal ideation, threats, and attempts, are significantly associated with increased violence risk in individuals with schizophrenia.

Method: Data for these analyses were obtained from the Clinical Antipsychotic Trials of Intervention Effectiveness (CATIE) trial, a randomized controlled trial of antipsychotic medication in 1460 adults with schizophrenia. Univariate Cox regression analyses were used to calculate hazard ratios (HRs) for suicidal ideation, threats, and attempts. Multivariate analyses were conducted to adjust for common confounding factors, including: age, alcohol or drug misuse, major depression, antisocial personality disorder, depression, hostility, positive symptom, and poor impulse control scores. Tests of discrimination, calibration, and reclassification assessed the incremental predictive validity of suicidal behaviors for the prediction of violence risk.

Results: Suicidal threats and attempts were significantly associated with violence in both males and females with schizophrenia with little change following adjustment for common confounders. Only suicidal threats, however, were associated with a significant increase in incremental validity beyond age, diagnosis with a comorbid substance use disorder, and recent violent behavior.

Conclusions: Suicidal threats are independently associated with violence risk in both males and females with schizophrenia, and may improve violence risk prediction.

Trial registration: ClinicalTrials.gov NCT00014001.

Keywords: Psychosis; Risk assessment; Risk factors; Schizophrenia; Suicide; Violence.

Copyright © 2014 The Authors. Published by Elsevier B.V. All rights reserved.

References

    1. Addington D., Addington J., Maticka-Tyndale E. Assessing depression in schizophrenia: the Calgary Depression Scale. Br. J. Psychiatry. 1993;22:s39–s44.
    1. Apter A., Plutchik R., van Praag H.M. Anxiety, impulsivity and depressed mood in relation to suicidal and violent behavior. Acta Psychiatr. Scand. 1993;87:1–5.
    1. Apter A., Gothelf D., Orbach I., Weizman R., Ratzoni G., Har-Even D., Tyano S. Correlation of suicidal and violent behavior in different diagnostic categories in hospitalized adolescent patients. J. Am. Acad. Child Adolesc. Psychiatry. 1995;34:912–918.
    1. Asnis G.M., Kaplan M.L., van Praag H.M., Sanderson W.C. Homicidal behaviors among psychiatric outpatients. Hosp. Community Psychiatry. 1994;45:127–132.
    1. Botsis A.J., Coldatos C.R., Liossi A., Kokkevi A., Stefanis C.N. Suicide and violence risk I. Relationship to coping styles. Acta Psychiatr. Scand. 1994;89:92–96.
    1. Broos N., Schmaal L., Wiskerke J., Kostelijk L., Lam T., Stoop N., Weierink L., Ham J., de Geus E.J.C., Schoffelmeer A.N.M., van den Brink W., Veltman D.J., de Vries T.J., Pattij T., Goudriaan A.E. The relationship between impulsive choice and impulsive action: a cross-species translational study. PLoS One. 2012;7:e36781.
    1. Caroff S.N., Miller D.D., Rosenheck R.A. Extraprymidal side effects. In: Stroup T.S., Lieberman J.A., editors. Antipsychotic Trials in Schizophrenia: The CATIE Project. Cambridge University Press; New York, NY: 2010.
    1. Cheng K.K., Leung C.M., Lo W.H., Lam T.H. Risk factors of suicide among schizophrenics. Acta Psychiatr. Scand. 1990;81:220–224.
    1. Christoffersen M.N., Soothill K., Francis B. Who is most at risk of becoming a convicted rapist? The likelihood of a rape conviction among the 1966 birth cohort in Denmark. J. Scand. Stud. Criminol. Crime Prev. 2005;6:39–56.
    1. Citrome L., Stroup T.S. Schizophrenia, Clinical Antipsychotic Trials of Intervention Effectiveness (CATIE) and number needed to treat: how can CATIE inform clinicians. Int. J. Clin. Pract. 2006;60:933–940.
    1. Conner K.R., Cox C., Duberstein P.R., Tian L., Nisbet P.A., Conwell Y. Violence, alcohol and completed suicide: a case–control study. Am. J. Psychiatry. 2001;158:1701–1705.
    1. Convit A., Jaeger J., Lin S.P., Meisner M., Volavka J. Predicting assaultiveness in psychiatric inpatients: a pilot study. Hosp. Community Psychiatry. 1988;39:429–434.
    1. Crosby A.E., Ortega L., Melanson C. Centers for Disease Control and Prevention; National Center for Injury Prevention and Control; Atlanta, GA: 2011. Self-direction Violence Surveillance: Uniform Definitions and Recommended Data Elements. (Version 1.0)
    1. Eckhardt C.I., Barbour K.A. Anger and hostility in maritally violent men: conceptual distinctions, measurement issues, and literature review. Clin. Psychol. Rev. 1997;17:333–358.
    1. Fazel S., Gulati G., Linsell L., Geddes J.R., Grann M. Schizophrenia and violence: systematic review and meta-analysis. PLoS Med. 2009;6:e1000120.
    1. Fazel S., Långström N., Hjern A., Grann M., Lichtenstein P. Schizophrenia, substance abuse and violent crime. JAMA. 2009;301:2016–2023.
    1. Feinstein R., Plutchik R. Violence and suicide risk assessment in the psychiatric emergency room. Compr. Psychiatry. 1990;31:337–343.
    1. Gilbody S., Wahlbeck K., Adams C. Randomized controlled trials in schizophrenia: a critical perspective on the literature. Acta Psychiatr. Scand. 2002;105:243–251.
    1. Greenwald D.J., Reznikoff M., Plutchik R. Suicide risk and violence risk in alcoholics: predictors of aggressive risk. J. Nerv. Ment. Dis. 1994;182:3–8.
    1. Grønnesby J.K., Borgan Ø. A method for checking regression models in survival analysis based on the risk score. Lifetime Data Anal. 1996;2:315–328.
    1. Guy W. US Department of Health, Education and Welfare; Rockville, MD: 1976. Assessment Manual for Psychopharmacology.
    1. Harris E.C., Barraclough B. Suicide as an outcome for mental disorders: a meta-analysis. Br. J. Psychiatry. 1997;170:205–228.
    1. Hawton K., Sutton L., Haw C., Sinclair J., Deeks J.J. Schizophrenia and suicide: systematic review of risk factors. Br. J. Psychiatry. 2005;187:9–20.
    1. Hofer A., Hummer M., Huber R., Kurz M., Walch T., Fleischhacker W.W. Selection bias in clinical trials with antipsychotics. J. Clin. Psychopharmacol. 2000;20:699–702.
    1. Hunt I.M., Kapur N., Windfuhr K., Robinson J., Bickley H., Flynn S., Parsons R., Burns J., Shaw J., Appleby L. Suicide in schizophrenia: findings from a National Clinical Survey. J. Psychiatr. Pract. 2006;12:139–147.
    1. Ioannidis J.P.A., Tzoulaki I. What makes a good predictor? The evidence applied to coronary artery calcium score. JAMA. 2010;303:1646–1647.
    1. Kay S.R., Fiszbein A., Opler L.A. The Positive and Negative Syndrome Scale (PANSS) for schizophrenia. Schizophr. Bull. 1987;13:261–276.
    1. Kennedy H.G., Iveson R.C.Y., Hill O. Violence, homicide and suicide: strong correlation and wide variation across districts. Br. J. Psychiatry. 1999;175:462–466.
    1. Kleinbaum D.G., Klein M. 3rd ed. Springer Science + Business Media, LLC; New York: 2012. Computer Appendix: Survival Analysis on the Computer Survival Analysis: A Self-learning Text; pp. 525–694.
    1. Kontaxakis V., Havaki-Kontaxaki B., Margariti M., Stamouli S., Kollias C., Christodoulou G. Suicidal ideation in inpatients with acute schizophrenia. Can. J. Psychiatry. 2004;49:476–479.
    1. Montross L.P., Zisook S., Kasckow J. Suicide among patients with schizophrenia: a consideration of risk and protective factors. Ann. Clin. Psychiatry. 2005;17:173–182.
    1. Nead K.T., Zhou M.J., Caceres R.D., Sharp S.J., Wehner M.R., Olin J.W., Cooke J.P., Leeper N.J. Usefulness of the addition of beta-2-microglobulin, cystatin C and C-reactive protein to an established risk factors model to improve mortality risk prediction in patients undergoing coronary angiography. Am. J. Cardiol. 2013;111:851–856.
    1. Nock M.K., Marzuk P.M. Suicide and violence. In: Hawton K., van Heeringen K., editors. The International Handbook of Suicide and Attempted Suicide. John Wiley & Sons, LTD.; Chichester: 2000.
    1. Palmer B.A., Pankratz S., Bostwick J.M. The lifetime risk of suicide in schizophrenia: a reexamination. Arch. Gen. Psychiatry. 2005;62:247–253.
    1. Pencina M.J., D'Agostino R.B. Overall C as a measure of discrimination in survival analysis: model specific population value and confidence interval estimation. Stat. Med. 2004;23:2109–2123.
    1. Perlick D.A., Kaczynski R., Rosenheck R.A. Family outcomes. In: Stroup T.S., Lieberman J.A., editors. Antipsychotic Trials in Schizophrenia: The CATIE Project. Cambridge University Press; New York, NY: 2010.
    1. Plutchik R., van Praag H.M., Conte H.R. Suicide and violence in psychiatric patients. In: Shagass C., Josiassen R.C., Bridger W.H., Weiss K.J., Stoff D., Simpson G.M., editors. Biological Psychiatry 1985. Elsevier; New York, NY: 1986.
    1. Rosenheck R.A., Leslie D.L. Study design and protocol development process. In: Stroup T.S., Lieberman J.A., editors. Antipsychotic Trials in Schizophrenia: The CATIE Project. Cambridge University Press; New York, NY: 2010.
    1. Royston P. Explained variation for survival models. Stata J. 2006;6:1–14.
    1. Royston P., Sauebrei W. A new measure of prognostic separation in survival data. Stat. Med. 2004;23:723–748.
    1. Saha S., Chant D., McGrath J. A systematic review of mortality in schizophrenia: is the differential mortality gap worsening over time? Arch. Gen. Psychiatry. 2007;64:1123–1131.
    1. Sanz J., García-Vera M.P., Magán I. Anger and hostility from the perspective of the Big Five personality model. Scand. J. Psychol. 2010;51:262–270.
    1. Sarchiapone M., Carli V., Di Giannantonio M., Roy A. Risk factors for attempting suicide in prisoners. Suicide Life Threat. Behav. 2009;39:343–349.
    1. StataCorp . StataCorp LP; College Station, TX: 2007. Stata Statistical Software: Release 11.
    1. Stroup T.S., McEvoy J.P., Swartz M.S., Byerly M.J., Glick I.R., Canive J.M., McGee M.F., Simpson G.M., Stevens M.C., Lieberman J.A. The National Institute of Mental Health Clinical Antipsychotic Trials of Intervention Effectiveness (CATIE) project: schizophrenia trial design and protocol development. Schizophr. Bull. 2003;29:15–31.
    1. Stroup T.S., Lieberman J.A., McEvoy J.P., Swartz M.S., Davis S.M., Rosenheck R.A., Perkins D.O., Keefe R.S.E., Davis C.E., Severe J., Hsiao J.K., for the CATIE Investigators Effectiveness of olanzapine, quetiapine, risperidone, and ziprasidone in patients with chronic schizophrenia following discontinuation of a previous atypical antipsychotic. Am. J. Psychiatry. 2006;163:611–622.
    1. Stroup T.S., Lieberman J.A., McEvoy J.P., Davis S.M., Swartz M.S., Keefe R.S.E., Miller A.L., Rosenheck R.A., Hsiao J.K. Results of phase 3 of the CATIE schizophrenia trial. Schizophr. Res. 2009;107:1–12.
    1. Stroup T.S., McEvoy J.P., Lieberman J.A. Study design and protocol development process. In: Stroup T.S., Lieberman J.A., editors. Antipsychotic Trials in Schizophrenia: The CATIE Project. Cambridge University Press; New York, NY: 2010.
    1. Suokas J.T., Perälä J., Suominen K., Saarni S., Lönnqvist J., Suvisaari J.M. Epidemiology of suicide attempts among persons with psychotic disorder in the general population. Schizophr. Res. 2010;124:22–28.
    1. Swanson J.W., Swartz M.S., Van Dorn R.A., Elbogen E.B., Wagner H.R., Rosenheck R.A., Stroup T.S., McEvoy J.P., Lieberman J.A. A national study of violent behavior in persons with schizophrenia. Arch. Gen. Psychiatry. 2006;63:490–499.
    1. Swartz M.S., Stroup T.S., McEvoy J.P., Davis S.M., Rosenheck R.A., Keefe R.S.E., Hsiao J.K., Lieberman J.A. What CATIE found: results from the schizophrenia trial. Psychiatr. Serv. 2008;59:500–506.
    1. Tardiff K., Sweillam A. Assault, suicide and mental illness. Arch. Gen. Psychiatry. 1980;37:164–169.
    1. Tardiff K., Sweillam A. Factors related to increased risk of assaultive behavior in suicidal patients. Acta Psychiatr. Scand. 1980;62:63–68.
    1. van der Oord E.J.C.G., Adkins D.E., McClay J., Lieberman J.A., Sullivan P.F. A systematic method for estimating individual responses to treatment with antipsychotics in CATIE. Schizophr. Res. 2009;107:13–21.
    1. Verona E., Patrick C.J., Joiner T.E. Psychopathy, antisocial personality, and suicide risk. J. Abnorm. Psychol. 2001;110:462–470.
    1. Webb R.T., Långström N., Runeson B., Lichtenstein P., Fazel S. Violent offending and IQ as predictors of suicide in schizophrenia: national cohort study. Schizophr. Res. 2011;130:143–147.
    1. Winstanley C.A., Eagle D.M., Robbins T.W. Behavioral models of impulsivity in relation to ADHD: translation between clinical and preclinical studies. Clin. Psychol. Rev. 2006;26:379–395.
    1. Witt K., van Dorn R., Fazel S. Risk factors for violence in psychosis: systematic review and meta-regression analysis of 110 studies. PLoS One. 2013;8:e55942.
    1. Wood A.M., Greenland P. Evaluating the prognostic value of new cardiovascular biomarkers. Dis. Markers. 2009;26:199–207.
    1. Zhang J., Liang B., Zhou Y., Brame W. Prison inmates' suicidal ideation in China: a study of gender differences and their impact. Int. J. Offender Ther. Comp. Criminol. 2010;54:959–983.

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