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Cognitive function and suicide risk in Han Chinese inpatients with schizophrenia
Psychiatry Research, 1-2, 220, pages 188 - 192
The lifetime risk of suicide in patients with schizophrenia is estimated to be 4.9–13%. While there are many known risk factors for suicide in schizophrenia, the relationship between cognitive function and suicide risk is unclear, particularly in non-Caucasian populations. In our cross-sectional study, we administered the Repeatable Battery for the Assessment of Neuropsychological Status (RBANS) to 316 Han Chinese chronic inpatients with schizophrenia and compared the performance of those who had attempted suicide (n=25) to non-attempters (n=291). The lifetime suicide attempt data were collected from medical records and interviews with patients and their family members. We found a lifetime suicide attempt rate of 7.9%. Suicide attempters were more likely to be single, but showed no significant differences in other demographic factors such as age, gender, or living arrangements. Contrary to our hypothesis, there was no significant relationship between performance on the RBANS test and lifetime risk of suicide attempts in Han Chinese inpatients with schizophrenia. The literature remains mixed on this topic. Culturally influenced differences in suicidal behavior may have affected the outcome of this study and further investigation of this topic is necessary.
- We examined the relationship between cognition and suicide attempts in schizophrenia.
- We found lower rates of suicide attempts in Han Chinese than in Western patients.
- We found a higher rate of suicide attempts in single than married patients.
- We found no relationship between cognition and suicide attempts in our patients.
Keywords: Suicide attempt, Risk factors, Cognition, IQ, China.
Suicide is a significant cause of mortality in schizophrenia (Caldwell and Gottesman, 1992 and Sartorius et al, 1986), particularly after the first episode of psychosis ( Pompili et al., 2011 ). About 20–40% of individuals with schizophrenia attempt suicide in their lifetime ( Pompili et al., 2007 ) and about 4.9–13% die by suicide (Caldwell and Gottesman, 1990 and Palmer et al, 2005). Risk factors for suicide in patients with schizophrenia are generally similar to those in the general population: male gender, substance abuse, history of previous suicide attempts, family history of suicide, single status, living alone, recent loss, hopelessness, and depression (Hawton et al, 2005, Haukka et al, 2008, and Siris, 2001). Suicide risk factors specific to schizophrenia include non-compliance with antipsychotic medication ( Tiihonen et al., 2006 ), genetic polymorphisms such as rs6313 (T102C) ( Gonzalez-Castro et al., 2013 ), higher premorbid IQ ( De Hert et al., 2001 ), fear of mental disintegration, and increased positive and decreased negative symptoms ( Hor and Taylor, 2010 ). However, the impact of cognitive functioning on suicide risk in this population has yet to be fully understood.
Cognitive impairment is regarded as one of the cardinal features of schizophrenia (Harvey, 2008 and Rajji and Mulsant, 2008). A recent literature review by Bowie et al., 2008 highlighted different cognitive spectrum deficits including attention, working memory, verbal learning and memory, language skills, social cognition, and executive function. To date, studies examining the relationship between cognition and suicide risk in schizophrenia, mostly focusing on Caucasian patients, have been largely mixed in their findings. Previous studies suggest that higher cognitive functioning increases suicidality risk in this population (De Hert et al, 2001 and Kim et al, 2003). Nangle et al. (2006) concluded that patients with higher executive functioning are more likely to carry out their suicide plan. Higher cognitive functioning, particularly in the realm of executive function, would allow for more effective initiation, planning, mental set-shifting, and goal directed behavior. Thus, we hypothesize that individuals with better executive functioning would have a greater ability to formulate plans and initiate a suicide attempt. Additionally, increased insight into one׳s illness, which is thought to be correlated with higher cognitive functioning, has been shown to be associated with higher suicidality ( Kim et al., 2003 ).
In contrast, Potkin et al. (2003) and Barrett et al. (2011) found that risk of suicidality in patients with schizophrenia is not correlated with cognitive function. Using the Repeatable Battery for the Assessment of Neuropsychological Status (RBANS) ( Randolph et al., 1998 ) as a measure of cognitive functioning, we performed a cross-sectional study to test the hypothesis that higher cognitive function is associated with an increase in suicide attempts in a population of Han Chinese patients suffering from schizophrenia.
2.1. Setting and subjects
This cross-sectional pilot study was conducted in Beijing, China at the Hui Long Guan Hospital, one of the largest psychiatric hospitals, serving a population of 30 million people. The participants, who were inpatients at the Hui Long Guan Hospital, were included using the following criteria: 1) age of 18–75 years, Han Chinese; 2) diagnosis of schizophrenia confirmed by two psychiatrists using the Structured Clinical Interview for DSM-IV (SCID); 3) ability to provide written informed consent; 4) had been receiving stable doses of oral antipsychotic medication at least 6 months prior to the start of the study date; 5) ability to participate in the RBANS.
2.2. Data collected
2.2.1. Demographic and social assessment
The patients were given a questionnaire in their local language which assessed their demographic and psychosocial history including age, gender, marital status, education, living arrangements, and family history of psychotic illness. The psychiatric history, including age of onset of schizophrenia and number of past hospitalizations, was recorded.
2.2.2. Clinical measures
The RBANS is comprised of 12 subtests that are used to calculate 5 age-adjusted index scores and a total score. The average score of the general population is 100 with a standard deviation of 15. Test indices include: Immediate Memory (comprised of List Learning and Story Memory tasks), Visuospatial/Constructional (comprised of Figure Copy and Line Orientation tasks), Language (comprised of Picture Naming and Semantic Fluency tasks), Attention (comprised of Digit Span and Coding tasks), and Delayed Memory (comprised of List Recall, Story Recall, Figure Recall, and List Recognition tasks). Our group previously translated RBANS into Chinese and established its clinical validity and test-retest reliability among patients with schizophrenia ( Zhang et al., 2009 ). Each subject came to the testing room on a separate day to be introduced to our research center by a research member. Patient psychopathology was assessed using the Positive and Negative Syndrome Scale (PANSS), which was measured by four psychiatrists who had attended a training session in the use of the PANSS before the study began. After training, repeated assessment showed that an inter observer correlation coefficient greater than 0.8 was maintained for the PANSS.
2.2.3. Statistical analysis
Participants were divided into suicide attempters and non-attempters based on the definition of a suicide attempt as a life-threatening act with the intent of putting one׳s life in danger or giving the appearance of such intent. This definition includes acts that were aborted by others before actual self-harm occurred. History of suicide attempts were confirmed by a review of medical records supplemented by a clinical diagnostic interview of patients and, whenever possible, their relatives by a qualified psychiatrist.
The data was analyzed using Stata 12 software. We compared demographic and clinical variables of the suicide attempters and non-attempters using Student׳s t tests for continuous variables and Pearson׳s χ2 tests for categorical variables. We compared RBANS scores between the two groups using Student׳s t tests. Relevant variables were added to the analysis model as covariants. The relationship between the RBANS and other variables, such as gender, marital status, living arrangement, and family history were examined by binary logistic regression analysis. In these analyses, all variables were initially entered simultaneously to determine the overall influence. Data were presented as mean and standard deviation. All p values were two-tailed with significance level set at 0.05.
A total of 316 subjects underwent RBANS testing. The mean age was 51.6 years (S.D.=8.4) and 234 participants (74%) were male. The majority resided with family members (60%), a quarter were married, and the mean education level was 9.59 (S.D.=2.35) years of education. The mean age of first hospitalization was 27.45 years (S.D.=7.69), and the mean number of hospitalizations was 3.65 (S.D.=2.78). A total of 25 (7.9%) patients attempted suicide.
3.1. Demographic, social, and clinical characteristics
Table 1 presents data about the demographic and social details of the suicide attempters and non-attempters. There was no significant difference in gender, family history of psychotic illness, smoking status, or living arrangement among suicide attempters and non-attempters. However, single individuals were more likely to attempt suicide than those who were married (χ2(2, n=311)=9.29, p=0.026). In Table 2 , we present data regarding clinical characteristics of suicide attempters and non-attempters. We found no significant difference in mean age, age of schizophrenia onset, education level, or performance on the PANSS Positive, Negative, and General psychopathology symptom scale between suicide attempters and non-attempters.
|Suicide attempters (N=25)||Suicide non-attempters (N=291)||χ 2||Fischer||p|
|N (%)||N (%)|
|Male||17 (68)||219 (75.2)||0.6414||0.423|
|Female||8 (32)||72 (24.8)|
|Lives alone||2 (9)||31 (11.8)||3.1125||0.396||0.375|
|Lives with others (non-family)||3 (13.6)||75 (28.6)|
|Lives with family members||17 (77.27)||154 (58.8)|
|Other||0 (0)||2 (0.8)|
|Family history of psychotic disorder|
|History||15 (60)||191 (68.9)||0.8764||0.505||0.645|
|No history||9 (36)||76 (27.5)|
|Unknown||1 (4)||10 (3.6)|
|Never smoker||9 (36)||106 (36.6)||1.3331||0.513|
|Former smoker||0 (0)||14 (4.8)|
|Current smoker||16 (64)||169 (58.4)|
|Single||15 (60)||147 (51.4)||9.2864||0.007||0.026 ⁎|
|Married||10 (40)||68 (23.8)|
|Divorced||0 (0)||71 (24.8)|
a Full data sample size is 316 participants. What is shown is data computed minus missing data.
|Suicide attempters (N=25)||Suicide non-attempters (N=291)||d.f.||t||p|
|Mean (S.D.)||Mean (S.D.)|
|Age||49.32 (6.73)||51.86 (8.59)||314||1.44||0.15|
|Education (years)||9.91 (2.24)||10.20 (7.85)||306||0.17||0.86|
|Age at onset of schizophrenia||23.32 (6.34)||24.57 (6.26)||311||0.96||0.33|
|PANSS a scores|
|Positive symptoms||12.84 (5.58)||12.62 (5.45)||312||−0.18||0.85|
|Negative symptoms||22.2 (6.71)||21.39 (7.22)||312||−0.53||0.59|
|General psychopathology||27.80 (8.23)||26.21 (5.06)||312||−1.41||0.15|
a PANSS: Positive and Negative Syndrome Scale ( Kay et al., 1989 ).
3.2. RBANS scores
Table 3 depicts the total and subtest RBANS scores for suicide attempters (n=25) and non-attempters (n=291). There was no significant statistical difference in total RBANS scores between the suicide attempters and non-attempters. Similarly, there was no statistical difference between the groups and index RBANS score of Immediate Memory (comprised of List Learning and Story Memory tasks), Visuospatial/Constructional (comprised of Figure Copy and Line Orientation tasks), Language (comprised of Picture Naming and Semantic Fluency tasks), Attention (comprised of Digit Span and Coding tasks), and Delayed Memory (comprised of List Recall, Story Recall, Figure Recall, and List Recognition tasks) with all p>0.46. We performed binary logistic regression analysis to predict suicide attempts with the following variables: age, gender, living arrangement, marital status, family history of psychotic illness, smoking status, hospitalization, PANSS positive and negative symptoms, PANSS general psychopathology, and performance on RBANS overall and Immediate Memory, Visuospatial, Language, Attention, Delayed Memory subtests. Variables with values p<0.2 were stepwise forwarded to the multivariate regression model. However, none of the predictor variables were significant in predicting the outcome.
|Suicide attempters (N=25)||Suicide non-attempters (N=291)||t||d.f.||p|
|Mean (S.D.)||Mean (S.D.)|
|Immediate Memory||64.36 (22.79)||64.05 (18.63)||−0.0779||314||0.9379|
|Attention||82.6 (15.05)||81.52 (15.93)||−0.3238||314||0.7463|
|Language||84.56 (18.77)||86.78 (14.03)||0.7370||314||0.4616|
|Visuospatial skills||83.24 (20.94)||84.51 (19.22)||0.3161||314||0.7521|
|Delayed Memory||71.72 (22.08)||72.16 (20.60)||0.1030||314||0.9180|
|Total score||72.16 (18.85)||71.91 (16.04)||−0.0725||314||0.9423|
To the best of our knowledge, this is the first study to examine the relationship between cognition and risk for suicide in Han Chinese patients with schizophrenia. Our results show that, contrary to our hypothesis, there is no significant relationship between performance on the RBANS test and suicide attempts. Single patients were more likely than married patients to attempt suicide (p=0.026).
Our findings regarding suicide risk and cognitive function were consistent with the results of past studies by Potkin et al. (2003) and partially consistent with Kim et al. (2003) ; however, there are significant differences between our study and theirs. They both used Caucasian subjects and different neurocognitive assessments than the RBANS. Additionally, they included suicidal ideation in addition to suicide attempts in their definition of suicidality. Kim et al. (2003) found that those who had attempted suicide were less cognitively impaired; however, after controlling for hopelessness, cognitive ability alone could not predict suicide risk.
Our study did not replicate the findings of De Hert et al. (2001) , Nangle et al. (2006) , and Delaney et al. (2012) which found a correlation between better cognitive functioning and increased suicide risk. There are several reasons that this may be the case. De Hert et al. (2001) studied patients exclusively under the age of 30 who had completed suicide as opposed to attempted suicide. The significant age discrepancy could account for differences in our findings given that the frequency of suicide is increased following the first episode of psychosis ( Pompili et al., 2011 ). Moreover, it is possible that patients who complete suicide have a different neurocognitive profile than those who attempt suicide. Also, the three aforementioned studies all used subjects of European descent, and socio-cultural and genetic differences could account for differences in the outcome. For example, the allele frequency distribution of suicide-related gene polymorphisms such as 5HTR2A-T102C varies significantly between Chinese and Caucasian individuals ( Gonzalez-Castro et al., 2013 ).
There is a significant difference in the prevalence of lifetime suicide attempts in Chinese patients with schizophrenia when compared with existing worldwide estimates. In our Chinese inpatient population, the rate of lifetime suicide attempts was 7.9% which is close to the rate of 7.5% reported by Ran et al. (2005) among rural patients with schizophrenia in China׳s Sichuan province. These rates are significantly lower than existing Western estimates of 18–55% (Fenton et al, 1997 and Bolton et al, 2007). Given the stigmatization of suicide-related behaviors as an ineffective problem-solving device in Chinese culture ( Chiles et al., 1989 ), there may have been significant underreporting of suicide attempts in addition to reduced suicidality. Interestingly, Xiang et al. (2008) reported a lifetime suicide attempt rate of 33.6% in Beijing patients and 20% in Hong Kong patients with a history of refractory schizophrenia who sought treatment at a major psychiatric clinic in Beijing. They attributed these differences to Hong Kong׳s Western influence and British-style political and legal institutions in addition to its mental health services. They attributed the higher suicide attempt rate in Beijing to its traditional Chinese influence and cultural values, which is in direct contrast with previous studies. Another recent study in Beijing found a prevalence of lifetime suicide attempts of 12% in Chinese outpatients with schizophrenia ( Yan et al., 2013 ). The vastly differing rates of suicide attempts amongst Chinese subjects in the literature highlights the complexity and difficulty in determining an accurate rate of lifetime suicide attempts in this population.
There are several methodological limitations of our study. First, our study is limited by the relatively small sample size of suicide attempters. This study is a secondary analysis which was not initially powered for the purpose of assessing the relationship of cognitive function and suicide attempts. The sample size is currently powered to detect a difference in mean RBANS scores of 12 points (S.D.=15) with a power of 80% and an alpha of 0.05. Second, while the RBANS has been validated as a reliable screening test for cognitive impairment, it is not designed to be sensitive for cognitive impairment specific to schizophrenia, particularly in domains such as executive functioning ( Hobart et al., 1999 ). Thus, there may be important differences in cognitive functioning that were not captured with the RBANS. Also, though the two groups were not significantly different in age, worsening RBANS performance with advancing age could have affected performance on the test. Furthermore, we did not control for risk factors that may have contributed to previous suicide attempts such as depression, hopelessness, or pre-morbid cognitive functioning. Another issue is the known effect of anti-psychotic medication on cognition in schizophrenia ( Woodward et al., 2005 ). We were not able to measure reliably the effects of anti-psychotic medication on cognition due to the relatively small sample size of the suicide attempter group. Lastly, we cannot rule out recall and response bias in our study. We sought to reduce the impact of recall bias with medical record review and the initial comprehensive diagnostic interview.
There are also several population-related limitations which may affect the generalizability of our findings in addition to the ultimate conclusion. First, our results are applicable to chronically ill patients of Han Chinese descent who have been receiving an oral antipsychotic treatment for greater than 6 months. Additionally, there may be a sampling bias skewed towards higher functioning inpatients given that our participants were functional enough to attend to and participate in the RBANS test and were able to be maintained on oral antipsychotics alone. Lastly, as previously mentioned, due to cultural beliefs and the stigmatization of suicide-related behavior, there may have been underreporting by patients and their families.
Suicide is a significant cause of mortality in schizophrenia and the most common cause of premature death (Montross et al, 2008 and López-Moríñigo et al, 2012). Physicians and mental health professionals have multiple methods to reduce the risk of suicide. Pharmacologic agents such as clozapine have been shown to significantly reduce the risk of suicide in schizophrenia ( Meltzer, 1998 ). Psychosocial interventions such as vocational rehabilitation and individual, group, and family psychotherapy have less scientific evidence but aim to reduce known risk factors such as social isolation, depression, and hopelessness ( Pompili et al., 2004 ).
Further examination of the relationship between cognitive functioning and suicidality in schizophrenia is necessary as evidenced by the lack of consistency in the literature. To date, the few studies that exist on this topic have looked at different patient demographics, measures of suicidal behavior, and tests of cognitive function, making drawing a definitive conclusion much more difficult. As cognitive deficits in schizophrenia become a target for therapeutics, understanding the relationship between cognitive function and suicide risk will be crucial to determine whether patients will be at an increased, decreased, or unchanged risk for suicide.
This work was funded by the grant from the Beijing Municipal Natural Science Foundation (#7132063and #7072035), National Natural Science Foundation of China (#81371477), NARSAD Independent Investigator Grant (#20314), and the Stanley Medical Research Institute (03T-459 and 05T-726). These sources had no further role in study design, data collection and analysis, decision to publish, or preparation of the paper.
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a Department of Psychiatry, Columbia University, 1051 Riverside Drive, New York, NY 10032, USA
b Menninger Department of Psychiatry and Behavioral Sciences, Baylor College of Medicine and Michael E. DeBakey VA Medical Center, Houston, TX 77030, USA
c Psychiatry Research Center, Beijing HuiLongGuan Hospital, Peking University, Chang-Ping District, Beijing 100096, PR China
d Department of Psychiatry and Behavioral Sciences, Harris County Psychiatric Center, The University of Texas Health Science Center at Houston, Houston, TX 77054, USA
⁎ Corresponding author. Tel.: +86 10 62715511; fax: +86 10 62912169.
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