Letters to the Editor

Suicide in Schizophrenic Patients: A Neglected Issue

to the editor: We read with great interest the article1 by Drs. Stovall and Domino on approaching the suicidal patient, which is a fundamental subject in everyday clinical practice. In fact, according to estimates from the World Health Organization, approximately 1 million people died from suicide, and 10 to 20 times more people attempted suicide worldwide in the year 2000. This averages out to one death every 40 seconds and one attempt every three seconds. Persons affected by psychiatric illness are more represented among those who manifest suicidal behavior. Patients who have schizophrenia contribute excessively to the number of patients who commit or attempt suicide. Family physicians are likely to experience the loss of a schizophrenic patient by suicide. Accurate analysis of follow-up studies estimated that 10 to 13 percent of schizophrenic patients die by suicide.2

Family physicians may have a role in the prevention of suicide in patients who have schizophrenia, which is the first cause of death among patients affected by this illness; however, its role is underestimated and seldom recognized. A search of PubMed/Medline found only one English scientific paper (editorial)3 that stressed plainly the need for prevention of suicide in patients with schizophrenia in general practice. One study4 found that 63 percent of patients who committed suicide had seen their general practitioners in the month before death and 36 percent had seen them in the week before death. A later report5 found fewer patients having seen general practitioners shortly before death, which may be a result of improved detection and treatment of patients at risk. Thus, the recognition of risk factors is an element of prevention and prediction.

Most authors agree that the schizophrenic patient who is more likely to commit suicide is young, male, white, has never been married, has good premorbid function and postpsychiatric depression, and a history of substance abuse and suicide attempts. Hopelessness, social isolation, awareness of illness, and hospitalization also are important risk factors in schizophrenic patients who commit suicide. Deteriorating health with a high level of premorbid functioning, recent loss or rejection, limited external support, and family stress or instability are other risk factors for attempted suicide in patients with schizophrenia. These patients usually fear further mental deterioration and experience excessive treatment dependence or a loss of faith in the treatment. These risk factors should always be traced by family physicians to assess the patients' suicide risk.

Although family physicians may have an ancillary role in the treatment of schizophrenic patients, they may be in a strategic position to detect early risk factors or to contribute to the changing of state-dependent risk factors. Also, family physicians may have a fundamental role in dealing with patients' family members. Most often the family is subjected to stigma because of the schizophrenic member, and family members may develop hostility toward the sick family member that may contribute to the development of suicidal behavior.6 Family physicians may promote patient information and assist families during exhausting periods or when they feel isolated and lacking adequate support.

MAURIZIO POMPILI, M.D.
PAOLO GIRARDI, M.D.
ROBERTO TATARELLI, M.D.
University of Rome "La Sapienza"
Ospedale Sant' Andrea
Via di Grottarossa, 1035-9
Rome, Italy 00189

References

Bradley Method Offers Option for Natural Childbirth

to the editor: I read with interest the excellent article1 on nonpharmacologic pain relief in labor in the September 15, 2003, issue of American Family Physician. The authors are to be applauded for describing drug-free methods of labor pain relief, especially in an era when the use of epidurals is widespread.

I would like to point out the Bradley method of husband-coached natural childbirth (http://www.bradleybirth.com). Described by Robert Bradley, M.D., an American obstetrician, the Bradley method supports nonpharmacologic labor pain relief through extensive prenatal patient education.2 Bradley prenatal classes provide couples with prenatal exercises, training in deep abdominal breathing, husband-coaching techniques of pain management, stress reduction methods, and labor management techniques.

I am happy to report that my 41-year-old primigravida wife recently delivered a beautiful, healthy, full-term 6 lb, 4 oz baby girl without any pharmacologic intervention using the Bradley natural childbirth method. It is noteworthy that I was never informed of this helpful childbirth method during any of my formal family practice residency training. Rather, my wife learned of the Bradley method in a college class on developmental psychology. Family physicians and obstetricians need to be aware of this useful method of natural childbirth.

ROBERT J. SIGNORE, D.O.
17730 S. Oak Park Ave., Suite C
Tinley Park, IL 60477

References

Send letters to Jay Siwek, M.D., Editor, American Family Physician, 11400 Tomahawk Creek Pkwy., Leawood, KS 66211-2672; fax: 913-906-6080; e-mail: afplet@aafp.org.

Please include your complete address, telephone number, fax number, and e-mail address. Letters should be submitted on disk, double-spaced, fewer than 500 words, and limited to one table or figure and six references. Please submit a word count.

Letters submitted for publication in AFP must not be submitted to any other publication. Possible conflicts of interest must be disclosed at time of submission. Submission of a letter will be construed as granting the AAFP permission to publish the letter in any of its publications in any form. The editors may edit letters to meet style and space requirements.