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eLetters: Electronic letters published:
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Confounds in historical contrast
- John H Noble Jr (10 March 2006)
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Closure of Asylums: the unseen side
- Dr Adil Yusufshah Kadri, Cefn Coed Hospital, Swansea, Wales (12 April 2006)
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Lifetime suicide rates in treated schizophrenia: 1875-1924 and 1994-1998 cohorts compared
- Arpan Dutta, Dr. Frances Lindon, Consultant in Old Age Psychiatry (31 October 2006)
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John H Noble Jr, Retired professor Professor Emeritus, State University of New York at Buffalo
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jhnoble{at}verizon.net John H Noble Jr
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The lifetime suicide rates for the 1875-1924 and 1994-1998 cohorts could easily be explained by historical differences in (1) diagnosis of schizophrenia and (2) locale of treatment. Psychiatric diagnoses are notoriously unreliable and subject to temporal circumstances. Treatment in the 1875-1924 pre-psychotropic drug era was largely in institutions, where supervision made suicide more difficult than in the post-psychotropic drug era of largely unsupervised community care. Either or both of these two variables interacting provide an alternative explanation for the different suicide rates. Valid comparison of the suicide rates for the two eras require statistical control for the two aforementioned confounds. |
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Dr Adil Yusufshah Kadri, Psychiatrist Swansea Psychiatric Education Centre, Cefn Coed Hospital, Swansea, Wales
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adilkadri{at}hotmail.com Dr Adil Yusufshah Kadri, et al.
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Many thanks to the authors for doing such an interesting piece of research. It has certainly altered my way of thinking about the historical epidemiology and risk of suicide in schizophrenia. As the authors rightly point out in their discussion, one reason for the increased risk for suicide appears to be the increased emphasis on encouraging patients to live in the community. Though on the surface, living in the community does appear to be the way forward it has not been without pitfalls. As we all know there is a sub-group of patients with schizophrenia who we feel may unfortunately never be able to live in the community for various reasons; some of which are severity of illness, lack of insight, poor compliance with treatment with relapse having severe consequences to but name a few. Historically such patients lived in their own 'communities' within an 'asylum'. With the move towards 'care in the community' such psychiatric institutions are being shut down with patients being forced to move out and live in the community (not willingly in all cases). There are also some patients with schizophrenia whom we treat and follow-up in the community but whom some of us feel may be better treated in a psychiatric unit as in-patients. Unfortunately this is not always possible for various reasons, not the least of which is the dwindling number of psychiatric in-patient beds. Matters are furthermore not helped by the very nature of today's society. There is increased pressure on all of us to conform, behave in a certain manner, maintain a certain standard of living, maintain relationships, perform well in jobs, meet deadlines, etc. This is stressful enough for 'normal' individuals and one can but imagine what effect this can have on the mental state of those suffering with an illness such as schizophrenia. As somebody once said 'it is a jungle out there' and this saying could easily be applied to the way at least how some of our patients may feel about living in the community. It is is therefore not surprising that living in the community coupled with the stresses of modern day life may all contribute at least in part to the increased risk of suicide in those with schizophrenia. |
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Arpan Dutta, ST1 SHO Psychiatry , Dr. Frances Lindon, Consultant in Old Age Psychiatry
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arpandutta{at}o2.co.uk Arpan Dutta, et al.
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Dear Sir, Dr. Healy and colleagues (2006) looked at lifetime suicide rates in two cohorts of patients with schizophrenia, schizotypal and delusional disorders (1875-1924 and 1994-1998) that were admitted to mental health services from North West Wales. Although the study provides controversial findings, they appear flawed. The title suggests the paper looks only at schizophrenia yet it actually looks at the entire spectrum of schizophrenia and delusional disorders. The groups have not been matched appropriately, not enough detailed demographic data is provided and they appear not to be directly comparable. There may well have been selection bias in the 1994-98 dataset since they were selected from an ongoing study. It is also difficult to believe that the World Wars I and II as well as cultural and lifestyle changes have not affected North Wales. The population may well in a broad 15-55 year age category be the same, but there may be changes in ethnicity and modal age of the population are not demonstrated. The comparison of 1303 patients over a 50 year period to 133 admissions in a 4 year period seems due to convenience than methodological reasoning. No account is taken for the severity of patients admitted today compared to historically or the stage of their illness. Compared to studies in Taiwan the current suicide rate itself is increased at 3.75% over the four year modern cohort, compared to 2% rate of a 15 year period studied in Taiwan (Phillips, 2004). It is also well known that suicide occurs most commonly in the first year after diagnosis (Department of Health, 2001), yet the study looked only compared data to patients who had completed suicide in the first 5 years of contact with asylum services as a subgroup. There is also no calculation of whether the difference in incidences of suicide is statistically significant. Clinically the study, although reporting a higher suicide rate, has not actually demonstrated any explainable reasons for this, and hence has not added to the knowledge which may contribute to reducing the 22% of preventable suicides in schizophrenics and other delusional disordered patients. References Healy D, et al. (2006) Lifetime suicide rates in treated schizophrenia: 1875-1924 and 1994-1998 cohorts compared British Journal of Psychiatry, 188, 223-228 MR Phillips et al. (2004) Suicide and the unique prevalence pattern of schizophrenia in mainland China: a retrospective observational study. Lancet, 364,1062-1068 Department of Health (2001) Safety First: five year report of the national cofidential enquiry into suicide and homocide by people with mental illness London: Department of Health Declaration of interest None Dr. Arpan Dutta, ST1 (pilot) SHO Psychiatry 5 Boroughs Partnership, Sherdley Unit, Whiston Hospital, Merseyside,L35 5DR Dr. Frances Lindon, Consultant in Old Age Psychiatry 5 Boroughs Partnership, Peasley Cross Hospital, Marshalls Cross Road, St. Helens, Merseyside,WA9 3DA |
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