European Journal of Cardiovascular Medicine

Suicide is an important public health problem. According to the World health Organization (WHO), each year, about one million people die by suicide across the world. [1] It implies that every 40 s, an individual dies by suicide someplace on the globe and many more people make non-lethal suicide attempts. It has been proposed that the number of persons who make non-lethal suicide attempts is about 10–15 times the amount of people who die by suicide. [2] Deaths by suicide and non-lethal suicide attempts greatly affect families, communities, and societies. [3] In the United States, the expenses of managing suicide attempters and examining deaths by suicide have been assessed as being $190 million per year. [4] A recent study showed that non-lethal suicide attempts are associated with decreased life span. [5] It is worth noting that this study found that most additional deaths are attributable to physical/medical conditions. [6]

Medical disorders, particularly illnesses associated with chronic pain, significantly increase suicide risk. ^[7] While many deaths due to opioid overdoses are accidental, an increasing amount of data indicates that the presence of pain plays a role in the decision to end life via opioid overdoses. ^[8] Neurological conditions such as stroke, epilepsy, head injury, or Huntington’s disease also confer greater suicide risk. ^[10] Obstacles to preventing suicidal behavior include inadequate rates of detection of persons with psychiatric illnesses, insufficient dissemination of evidence-based methods among community providers, and enormous complexity in detecting imminent suicide risk, even in persons who are being cared for psychiatric conditions. ^[11]

Comorbid depression and a history of suicidal behavior are important contributors to suicide risk in patients with schizophrenia. ^[12] One study showed that depressive symptoms, suicidal ideation and plans and a history of suicide attempts are amongst the most important forecasters of suicidal behavior in the early phases of schizophrenia. Two studies suggest that patients with schizophrenia who were hospitalized after a suicide attempt had the greatest risk, of all variables examined, of dying by suicide. Other works also indicate that suicide risk in individuals with schizophrenia is associated with mood syndromes, especially depressed mood, hopelessness and demoralization. Panic symptoms may also contribute to suicidal behavior in patients with schizophrenia.  ^[13]

This is a cross - sectional study was conducted in the Department of Psychiatry at Osmania Medical College, Institute of Mental Health, Hyderabad from July 2021 to December 2021. In this study, 50 schizophrenia patients, 50 controls were recruited at Institute.

Inclusion Criteria:

1. Patients meeting ICD -10 diagnostic criteria for
2. Age between 18 to 65 years
3. Has not taken ECT in last one
4. Has not identified with serious physical illness, uncontrolled physical
5. On regular medication in past 6 months.
6. Who are willing to give consent cooperative and with reliable informant.

Exclusion Criteria:

1. Patients with schizoaffective disorder, post psychotic
2. Patients with other psychotic disorders, mental retardation and personality disorders.
3. Patients with somatization
4. Patients with negative symptoms.
5. Patients with alcohol dependance or any other psychoactive substance
6. Patients with organic psychosis.
7. Patients who are not cooperative for

Male and Female patients attending in and out patients at Institute were considered for study. Following this, patients meeting the inclusion criteria are taken for study. Age and gender matched controls without any psychopathology were taken from neighborhood.

MATERIALS

1. Positive and negative syndrome scale (PANSS).
2. Calgary depression scale for schizophrenia (CDSS).
3. Scale for suicidal ideation (SSI).
4. Socio economic status assessed by Modified Kuppuswamy

Positive And Negative Syndrome Scale

(Panss):

The positive and negative syndrome scale was developed specially to address the psychometric limitations, a well-researched psychometric instrument for evaluating positive and negative schizophrenic symptoms and syndromes. It is more comprehensive in its range of assessment and thoroughly standardized it has good inter-rater reliability, adequate construct validity. The measurement is a 35 to 45 minutes clinical interview. This is followed by 7 - point rating on thirty symptoms, for which each item and each symptom severity is defined. The ratings provide summary scores on a 7- item positive, 7- item negative scale, 16- item general psychopathology scale.

Calgary Depression Scale For

Schizophrenia:

This is designed and published by Donald Addington, Jean Addington and Fleanor Maticka-Tyndale. Which was designed for the assessment of depression in schizophrenia, CDSS is a 9 - item structured interview scale in which each item has a 4 - point measure last item depends on the observation of entire interview, tested the reliability and validity and point- ed out its usefulness.

Scale For Suicide Ideation:

This is one of the most widely used measures of suicide ideation. It is a 19 - item interviewer administered rating scale that measures the current intensity of specific attitudes, behaviors, and plans to commit suicide each item consists of three options graded according to the intensity of the suicidality and rated on a 3 - point scale ranging from 0 to 2 are then summed to yield a total score, which ranges from 0 to 38, The SSI has been standardized with adult psychiatric patients, internal reliability, concurrent validity has been established.

Procedure

This study which has a cross - sectional design is conducted after obtaining written informed consent from the patients who were diagnosed schizophrenia according to ICD 10. They were administered PANSS, CDSS, and SSI. CDSS indicated by cut off score of 6. Age and gender matched controls are taken from neighbor- hood without any psychopathology.

Statistical analysis:

The data was collected and subjected to statistical analysis using SPSS 26. Descriptive statistics was used to measure means, percentages and graphs. For continuous variables mean, standard deviation, T test will be used. For categorical variables chi - square will be used. Pearson correlation test was used to measure correlation between variables. p value was set at 0.05.

Table 1: Distribution of demographics

As shown in table 1 among the test sample 64% were males, 36% females and among controls 48% were males, 52% females. It is not statistically significant (p=0.107).

Among the test sample 36% were illiterate,24% studied up to primary school,22% high school,10% were into intermediate and 8% graduates. Among controls 40% were illiterate, 44% studied up to primary school, 12% high school, 4% were into intermediate and graduates none. It is statistically significant (p=0.037).

Among test subjects 66% were unemployed and 34% employed. 20% were unemployed among controls and 80% employed and it is statistically significant (p=0.000).

Among the test subjects 24% were of lower class, 42% belonged to upper lower class and 34% of upper middle class. Among the controls 28% were of lower class, 32% belonged to upper lower and 40% of upper middle class. Which is not statistically significant (p=0.585).

Among the test subjects 38% were unmarried, 60% married and 2% divorced. Among the controls 4% were unmarried, 96% married. It is statistically significant (p=0.000). Among test subjects 44% belonged to nuclear type of family, 56% were living in a joint family. Among the controls 56% belonged to nuclear type of family, 44% in a joint family. Which is not statistically significant (p=0.230).

Among the test subjects 74% lived in rural area and 36% in the urban. Among the controls 48% were from rural population and 52% in urban. It is statistically significant (p=0.218). Among the test subjects 2% were with hypertension, 98% free of any physical illness. Among the controls 4% were with diabetes, 4% hypertensive and 92% devoid of any physical illness . Which is not statistically significant (p=0.297).

Among the test subjects 42% using substance and 58% were not. Among the controls 28% using substances and 72% were not. It is statistically significant (p=0.001).

TABLE 2: Distribution of various parameters

As shown in table 2, the mean age of test subjects is 27.44+/- 5.350 and that of controls is 33.54+/- 8.894. Mean score of Positive scale for test subjects is 15.14+/-3.93 and that of controls is 7.00+/-0.000. The mean score for Negative scale is 7.00+/-0.000 for both test and controls subjects. The mean score on General scale is 23.66+/- 4.570 for test subjects and 16.00+/- 0.000 for controls.

TABLE 3: Distribution of Depressed and Suicidal Intent

As shown in table 3, among the test subjects 36% of them were depressed and 32% of them had suicidal ideation.

TABLE 4: Depressed subjects

As shown in table 4, among 18 depressed subjects in test sample, 28% were illiterates and 72% literate (p=0.147). 50% were unemployed and 50% employed. 28% were of lower class, 34% belonged to upper lower class and 38% of upper middle class (p=0.648). 44% were unmarried, 55% married (p=0.618). 50% were belonged to nuclear family, 50% in a joint family (p=0.522). 66% lived in rural area and 33% in the urban (p=0.375). 38% using substance and 61% were not. The chi square value is 0.738 (p= 0.112) all the above values were statistically not significant. 33% were having insight, 38% with partial and in 27% insight was absent. It is statistically significant (p=.000).

As shown in table 4, among 16 subjects with suicidal ideation in test sample, 31% were illiterates and 68% literate. The chi square value is 6.548 and it is statistically not significant (p=0,162). 43% were unemployed and 56% employed (p=0.023) and it is statistically significant. 31% were of lower class, 31% belonged to upper middle class and 38% of upper middle class (p=0.536).43% were unmarried,56% married (p=0.694). 50% were belonged to nuclear family ,50% in joint family (p=0.558). 75% lived in rural area and 25% in the urban (p=0.912). 37% using substance and 62% were not (p=0.658) all these values were statistically not significant. 37% insight, 44% with partial and in 18% insight was absent. It is statistically significant (p=.000).

TABLE 5: Depressive symptomatology

As shown in table 5, depressive symptomatology in test subjects depression was 36%, among males it was 26% and in females 10%. Hopelessness was 32%, among males it was 24% and in females 8%. Self-depreciation was 20%, among males it was 14% and in females 6%.

Guilt was 8% in males it was 6% and in females 2%. Pathological guilt was not seen. Morning depression was 24%, among males it was 16% and in females 8%.Suicide was 28%, in males it was 20% and in females 8%.

Early morning depression was 14%, among males it was 12%, in females 2%. Observed depression was 12%, in males it was 10% and in females 2%.

Our study found that 36% of the test subjects were depressed compared to controls, this is consistent with previous research by different authors Balci et al 42%.[14] There was no significant effect of demographic variables on presence of depressive symptoms in patients with schizophrenia in our study. Similar to our study is Zisook et al, [15] who found that depressive symptoms were more common in patients with schizophrenia, no correlation with age, gender, and negative symptoms.

Our study is also in accordance with Gulcan Balci et al, in his study, no statistically significant association was found with age, gender, marital status, education status, occupation and domicile. [16] In Pabbathi et al study, age, urban domicile had a significant positive correlation with depressive symptoms, which is not in alliance with our study. [17] They also found no association between presence of depressive symptoms and gender which is in alliance with our study. Major depression is more common in female gender, whereas most of the studies in schizophrenic patients did not show significant difference between gender regarding the rate of depression (Siris SG). [18]

Vikas Gaur et al in their study found no significant relationship in depressed patients with respect to age, gender, education and socio-economic status which is replicated in our study. [19]

In our study the prevalence of depression in patients with schizophrenia negatively correlated with scores of positive symptoms and general psychopathology of PANSS but not with negative symptoms. It was also replicated in other studies. In study by Baynes et al the depressive symptoms in schizophrenia were significantly correlated with hostility, suspiciousness and positive symptoms but there was no evidence of relationship with negative symptoms. [20]

Our results are not in concordance with the research findings of Pabbathi et al,. [21] where they found an association between depressive symptoms and positive symptoms. [22] Vikas Gaur et al in their study no significant correlation was found between BDI, PANSS, CGI, and GAF scores suggesting that depression probably is an independent component of schizophrenia rather than a byproduct of psychotic symptoms, this is in alliance with our study results. [23] Gulcan et al reported that depression correlated with both positive and negative symptoms. There are also studies to show that negative symptoms are independent of depression. [24] Kullhara et al uphold that vegetative symptom such as psychomotor retardation, energy loss, weight loss, depressive mood, suicidal thoughts, self-accusation and hopelessness are not significantly related to the negative symptoms. They claim that although negative and depressive symptoms are similar in looks and observed behaviours, they are rooted from entirely different processes, [25] our study is compatible with this finding. Subjects with depressive symptoms were significantly having suicidal ideation compared to those who are not depressed which was evident by positive correlation between CDSS and SSI scores in our study. Similar findings were found in previous studies by various authors, making depression as one of the key risk factors for suicide in depressed schizophrenia subjects. Pabbathi et al their study found CDSS scores in positive correlation with SSI, [26] Vasile et al study found patients who attempted suicide presented with high scores on CDSS, [27] Gulcan et al found there is a moderate positive correlation between depressed group of patients with suicidal history, [28] Vikas Gaur et al found patients with schizophrenia and concurrent depressive symptoms have poor long term functional outcomes, with impaired functioning, higher rates of relapse and suicide. [29]

Our study found statistically significant results between CDSS, SSI scores and insight. Ampalam et al their study found insight and depression were positively correlated more in males, urban population and literates. [30] Insight and depression decreases with increasing age, duration of illness concluding that depression is more in young and acute phase. Lancon C et al in their study they found greater the acknowledgement by patients that they had mental illness the more depressed they were and greater the likelihood that they would attempt suicide, [31] which is in alliance with our results.

Our study used CDSS based on several studies on CDSS as more specific instrument to measure depressive symptoms in schizophrenia (Matthias et al). [32] Our study evidence that depressive symptoms and suicidal ideation are increased significantly in compare with general population. As there is strong relationship between depressive symptoms and suicidal ideation which is replicated in our study which has to be addressed. All socio demographic factors did not have any influence on the presence of depression except unemployment which is statistically significant with suicidal ideation So targeting with treatment approaches might improve quality of life and prevent suicides. It is important that depressive symptoms in patients with schizophrenia should not be missed, but thoroughly evaluated and adequately treated. Further studies have to be focused on depressive symptoms and suicidal ideation in all phases of schizophrenia to find out the intensity and severity, and influence of treatment, adherence of treatment on outcomes.

Among CDSS items depression, hopelessness, self-deprecation, morning depression and suicide were increased in frequency. In schizophrenia patients’ depressive symptoms and suicidal ideation were significantly present in compare of healthy controls. Most of socio demographic factors did not influence depressive symptoms but unemployment was significantly present among patients with suicidal ideation. Depressive symptoms and suicidal ideation showed to have strong relation.

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