[Factors related to suicide attempts in a Tunisian sample of patients with schizophrenia]

The mortality rate in schizophrenia is 4.5 times higher than in the general population. Suicide is one of the main causes of premature death in this affection. Life time prevalence of this behavior ranges from 10 to 15%, which represents a risk 20 to 50 times higher than in the general population. In addition, 40 to 93% of patients who committed suicide had attempted suicide previously. Thus, assessment of correlated variables with suicide attempts is a fundamental issue for developing preventive and therapeutic strategies in suicidal behavior. To the best of our knowledge, no systematic study has yet investigated suicide attempts in an Arabic Muslim population with schizophrenia, although many authors have demonstrated cultural differences in socio-demographic and clinical variables related to suicide attempts within many geographic areas around the world.

The objectives of this study were to assess the frequency and characteristics of lifetime suicide attempts in Tunisian schizophrenic outpatients and to determine the correlated socio-demographic, clinical and therapeutic variables.

A total of 134 patients with a DSM-IV diagnosis of schizophrenia who attended the outpatient department of the university psychiatric hospital of Tunis were included. The main demographic and lifetime clinical variables considered were: gender, marital status, family history of psychiatric disorders and suicide attempts, age at time of recruitment, age at onset of illness, duration of untreated psychosis defined as the interval between the onset of the illness and the first antipsychotic treatment, the type and dose of current treatment, dose of antipsychotic drugs converted to chlorpromazine equivalents, extrapyramidal side effects assessed with the Simpson Angus rating scale, number of hospitalizations, comorbid substance abuse, cigarette smoking, severity of psychopathology measured with the Positive And Negative Syndrome Scale (PANSS), and history of at least one suicide attempt. A suicide attempt was defined as a self-destructive act carried out with at least some intent to end one's life. We also assessed the number, the used methods and the causes of suicide attempts. We subdivided the sample into two sub samples according to the presence or absence of suicidal attempts. We analyzed and compared the demographic, clinical and therapeutic variables.

Out of the 134 patients, 45 (32%) had attempted suicide at least once. Half of them (49%) had attempted suicide more than once. The number of suicide attempts varied from one to five with an average of 1.8. The most used methods were medication overdose (n=18, 23.4%), followed by organophosphate poisoning (n=11, 14.3%), defenestration (n=9, 11.7%) and hanging or using sharp objects (n=7, 9.1% for each of them). The main reported reasons of suicide attempts were depressive symptoms (n=46, 60%) including depressed mood and hopelessness, stressful life events (bereavement, divorce, separation) (n=35, 46%) and presence of delusions and/or auditory hallucinations (n=25, 32.5%). No differences were found between the two groups regarding the different socio-demographic variables. Significant differences were found with respect to a duration of untreated psychosis equal to or more than one year (P<0.001), smoking in men (P=0.03), positive symptoms score on the PANSS (P<0.001), scores of Simpson-Angus scale (P=0.029) and poor medication compliance (P=0.02).

Demographic variables as suggested by other studies are less valuable predictors of suicide attempts in patients with schizophrenia. Interventions for reducing such behavior should focus on clinical variables and integrate an early diagnosis of the disease, reduce positive psychotic symptoms and tobacco consumption, correct extrapyramidal signs and improve medication compliance.