Family Practice Vol. 19, No. 3, 221
© Oxford University Press 2002
Editorial |
GPs' role in the prevention of suicide in schizophrenia
Dipartimento di Scienze Psichiatriche e Medicina Psicologica, Università ‘La Sapienza’, Via Panama 68/70, 00198 Roma, Italy.
Pompili M, Mancinelli I and Tatarelli R. GPs' role in the prevention of suicide in schizophrenia. Family Practice 2002; 19: 221.
Received 27 July 2001; Accepted 7 January 2002.
Follow-up studies have estimated that 10–13% of individuals with schizophrenia die by suicide, which is the main cause of death among these patients.1 The recognition of risk factors for suicide involves prediction and prevention. Psychiatric research no doubt is a very important source of information in assessing who is at risk. There is evidence that those affected by schizophrenia who are more likely to commit suicide are young, male, white, have good pre-morbid function, have never married, have post-psychotic depression, and have a history of substance abuse and suicide attempts. Hopelessness, awareness of illness and hospitalization are also very important risk factors.
Very often, schizophrenic patients interact with GPs. During these meetings, it is crucial to establish a good patient–doctor relationship and provide an environment in which the patient is accepted as a person, avoiding any type of stigma that very often surrounds these individuals. There are studies that suggest that medical staff unconsciously may accept a patient's wish to commit suicide when they are not able to deal with the disease.2 People with schizophrenia spend their entire life striving for social contact. GPs can emphasize their availability with a message of solidarity and hope. An important example of this process is observed during therapy with clozapine. In order to avoid the main side effect of this drug, agranulocytosis, patients have to undergo weekly checks of white blood cells. These encounters with medical staff are said to reduce the suicidality of patients as they have the opportunity to break their isolation and hopelessness. GPs should consider this example in spite of the fact that it is psychiatrists who treat these patients directly. GPs, as doctors, are a symbol of caring; if they do not provide enough support in the critical period, they can undermine the patient's compliance with medication and counselling.3 Frequently, schizophrenic patients are not reached easily by psychiatrists, especially when they are homeless. Instead, they seek help from GPs, who are generally more accessible than psychiatrists. It is paramount to remember that these patients desperately need to receive empathic support, and doctors should always consider their hopelessness and helplessness. GPs should also provide practical information about substance abuse as it is this behaviour which precedes a psychotic crisis, worsens the disease and ultimately leads to suicide.4 GPs should ask these patients about any substance abuse and negotiate a reduction.
The relationship between the GP and the patient's family is really very important. When doctors provide support and understanding, family members can share their responsibility as caregivers, and being understood allows them to improve the family environment, which contributes to reduced suicidality. Also, GPs can focus on the events that usually precede a relapse and instruct the family how to cope during the crisis. Various changes characterize a relapse in each patient, and being given the opportunity to familiarize themselves with these changes gives the family a better chance to deal with symptoms.5
During antipsychotic therapy, patients may experience various side effects. It is advisable to examine a patient's health periodically. Patients over 40 years of age should have a check-up scheduled each year.4 Sexual dysfunctions may arise during therapy due to an increase in the level of prolactin. Also, extrapyramidal side effects can represent a risk factor for suicide in schizophrenia. GPs can not only monitor these symptoms and explain them to patients, but they can also refer them to psychiatrists. It should not be forgotten that patients may seek help outside the psychiatrist's room, and being able to provide this help even with a gesture can reduce hopelessness and the wish to die.
References
1 Caldwell CB, Gottesman II. Schizophrenics kill themselves too: a review of risk factors for suicide. Schizophr Bull 1990; 16: 571–589.
2 Saarinen PI, Lehtonen J, Lonnqvist J. Suicide risk in schizophrenia: an analysis of 17 consecutive suicides. Schizophr Bull 1999; 25: 533–542.
3 Tatarelli R. Drugs and human interactions. Ann Ist Super Sanità 1992; 28: 197–202.[Medline]
4 Carr VJ. The role of the general practitioner in the treatment of schizophrenia: specific issues. Med J Aust 1997; 166: 143–146.[Medline]
5 Phelan JC, Bromet EJ, Link BG. Psychiatric illness and family stigma. Schizophr Bull 1998; 24: 115–126.
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