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Am Fam Physician. 2004;70(4):648-649

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.

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This series is coordinated by Kenny Lin, MD, MPH, deputy editor.

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