Risk assessment ratings were unavailable for a number of patients and the risk factors evaluated by this instrument may have changed from the time of assessment to death.

Older age at first contact with mental health services and lack of suicidal history and suicidal ideation emerged as useful protective markers indicative of those less likely to end their own lives.

This study used a large clinical database linked to national mortality data to investigate the role of risk assessment in predicting suicide in patients with schizophrenia spectrum disorder (SSD) under secondary mental healthcare over a 5-year period. Those patients with SSD who took their lives over the study period (cases) were compared with a control group drawn from the same database (those participants with SSD who did not die from suicide).

Introduction

Suicide is a major public health problem with nearly one million deaths across the world per year.1 Suicide rates in the UK have remained unchanged over the past 5 years.2

Bleuler3 ,4 stated that ‘suicidal drive is the most serious of all schizophrenic symptoms’. The rate of suicide in schizophrenia has been recently reported to be from 2%5 to 5%6 lifetime risk, which, while lower than the previously quoted estimate of 10%,7 ,8 remains unacceptably high, representing the largest single cause of excess mortality in schizophrenia.9–11

Some recognised general suicide risk factors have been replicated in people with schizophrenia such as being male, living alone, depression, hopelessness, previous suicide attempts,12–14 number of previous admissions,14 self-devaluation, agitation and insomnia.13 Interestingly, prior suicidal ideation has been found to be relatively uncommonly reported in patients with psychosis who take later their own lives.15 Moreover, schizophrenia has been linked to specific suicide risk factors such as poor treatment compliance.12 ,13 ,16 Therefore, certain aspects of insight associated with compliance17 may prevent patients with psychosis from ending their lives,18 and this is supported by a recent 12-month follow-up first-episode study.19

With regard to suicide method, patients with schizophrenia have been reported to frequently use violent suicide methods, particularly jumping from a height or in front of a train.5 ,20 ,21 This has implications for suicide prevention as restricting access to methods has been demonstrated to reduce suicide rates at a population level.21–24

Over the past two decades, the UK Department of Health has aimed to reduce suicides at a national level.25 In keeping with this, structured clinical risk assessments were strongly recommended by the UK National Institute for Health and Care Excellence (NICE) guidelines in 200426 and widely used. However, recent reviews of the NICE guidelines have voiced concerns about the limited role of risk assessment tools and scales in the clinical management of the patients.27 Moreover, a recent meta-analysis showed that risk scales are of little use for predicting repeat self-harm in suicide attempters.28 However, the extent to which these instruments can predict suicide risk in patients with schizophrenia spectrum disorders (SSDs) receiving secondary mental healthcare has not been sufficiently examined.29 Moreover, concerns have been voiced regarding the role of risk assessment in preventing suicide in patients with schizophrenia.30 Also, it remains poorly understood what specific factors evaluated by the risk assessment lead patients with schizophrenia under the care of mental health services to take their own lives.

We aimed to investigate the role of risk assessment in predicting suicide in patients with SSDs receiving secondary mental healthcare. Specifically, risk assessment ratings were compared between patients with SSD who died by suicide (cases) and those attending the same service who did not (controls), while adjusting the analyses for potential confounders, including sociodemographic and clinical variables and ‘service use’-related factors. We postulated that, although previous suicide attempts and suicidal ideation are common risk factors among those who go on to end their lives, risk assessment plays a limited role in predicting suicide in patients with SSD under secondary mental health services due to the high prevalence of the classic risk factors evaluated by these instruments within SSD and suicide being a very rare outcome.