Managing suicidality in schizophrenia

Objective: The primary objective of this review article is to provide a coherent, systematic synthesis of the literature on the management of suicidality in schizophrenia that is relevant to the front-line clinician. Method: Literature searches were conducted on MEDLINE (1996 to 2007) and PubMed (1993 to 2007), using the key words "schizophrenia" and "suicide," as well as references from the resulting articles. I used my own clinical experience to create fictional case examples to illustrate the applicability of the literature discussed in this paper. Results: Suicidality in schizophrenia is high, and early detection relies on the appreciation and evaluation of the clinical manifestations of depression, despair, and hopelessness, as well as on the nature and severity of the psychotic experience itself, particularly in recent-onset patients with higher cognitive function and educational background. Clinical management includes ensuring immediate safety, the use of psychosocial techniques to address depression and psychosocial stressors, targeted pharmacotherapy for depression and psychosis, and adequate discharge planning. Clozapine is the only antipsychotic with good evidence for efficacy in decreasing suicidal behaviour in schizophrenia. Conclusions: The optimal management of suicidality in schizophrenia involves the incorporation of traditional bedside clinical skills, selection of psychosocial modalities based on individual needs, and selective pharmacotherapy directed primarily at psychotic and depressive symptoms.