‘Heed not the oracle’: risk assessment has no role in preventing suicide in schizophrenia

Suicide rates among patients with schizophrenia are hugely elevated relative to the general population. Globally, about 12 in 100 000 people suicide annually (1). In contrast, suicide rates of patients with schizophrenia reported in 2014 alone include 240 per 100 000 per year among participants in a multination trial (2), 360 per 100 000 among first episode patients (3), and 900 per 100 000 among recently discharged patients (4). Faced with this extraordinary mortality – 20 to 75 times that of the general community – we must translate research findings on suicide in schizophrenia into everyday clinical practice. With this aim squarely in mind, in this issue, Popovic and colleagues present 14 consensus recommendations on the assessment and management of schizophrenia (5). The authors reviewed the literature on suicide in schizophrenia to generate a shortlist of 25 recommendations that they believed could have been relevant and useful for clinicians. They then used a Delphi method to present a panel of 52 Spanish experts with the recommendations. The final 14, appearing in table three, were those independently endorsed as ‘essential or important’ for inclusion by at least 80% of the experts. The final recommendations concern both the assessment and management of patients with schizophrenia. Some, such as the recommendation 6 that comorbid drug use be considered in all such patients and recommendation 11 that all wards should incorporate all reasonable means to prevent suicide behavior, are important but have probably already been widely adopted. Many though, such as the recommendation that all patients receive a suicide risk assessment immediately on admission, will be controversial and still others will likely be rejected by most clinicians as overly prescriptive or insensitive to the needs of individual patients. The latter group include recommendation 8 that all patients with schizophrenia be directly asked about the presence of suicidal ideation at every interview and recommendation 14 implying that all patients with an acute episode of schizophrenia who express suicidal ideation should be hospitalized regardless of the rest of their presentation and their broader circumstances. The author’s review of the literature is excellent and their utilization of the Delphi method sound, so why are so many of their final recommendations either controversial or misplaced? We believe that the answer lies in two widely held assumptions – one of which is false. The first assumption is that patients with schizophrenia can be reliably divided into groups that have a higher or a lower risk of suicide. This assumption is true – there is good evidence, for example, that patients with schizophrenia and a history of suicide attempt are more likely to suicide in the future than those without such a history (6). The second assumption, though, is that patients with schizophrenia belonging to high-risk and low-risk groups should be managed differently on the basis of their risk status. This second assumption is deeply flawed and as a result the recommendations adopted in light of this assumption need to be considered more closely. The flaw in this second assumption derives from the rates cited in the first paragraph of this editorial – simply being diagnosed with schizophrenia greatly multiplies a person’s risk of suicide compared to that of the population base rate. Compared to the increased risk associated with diagnosis of schizophrenia, the increased risk associated with well-validated risk factors, such as past history of suicide attempt (odds ratio = 3.19), depression (odds ratio = 2.67), or suicidal ideation (2.79), is trivial (7). It follows that it is neither possible to define a group of patients with schizophrenia who do not have an elevated absolute suicide risk when compared to the general community nor is it possible to define a high-risk group among patients with schizophrenia who have an absolute risk of suicide in any given year of more than a few Jocasta’s plea to her husband, Oedipus Rex, line 724