Characteristics of schizophrenia suicides compared with suicides by other diagnosed psychiatric disorders and those without a psychiatric disorder

Suicide methods and severe mental illness: A systematic review and meta-analysis

INTRODUCTION

People with severe mental illness (SMI) have a higher risk of suicide compared with the general population. However, variations in suicide methods between people with different SMIs have not been examined. The aim of this pre-registered (PROSPERO CRD42022351748) systematic review was to pool the odds of people with SMI who die by suicide versus those with no SMI, stratified by suicide method.

METHODS

Searches were conducted on December 11, 2023 across PubMed, PsycInfo, CINAHL, and Embase. Eligible studies were those that reported suicide deaths stratified by SMI and suicide methods. Studies were pooled in a random-effects meta-analysis, and risk of bias was measured by the Joanna Briggs Institute checklist.

RESULTS

After screening, 12 studies were eligible (n = 380,523). Compared with those with no SMI, people with schizophrenia had 3.38× higher odds of jumping from heights (95% CI: 2.08-5.50), 1.93× higher odds of drowning (95% CI: 1.50-2.48). People with bipolar disorder also had 3.2× higher odds of jumping from heights (95% CI: 2.70-3.78). Finally, people with major depression had 3.11× higher odds of drug overdose (95% CI: 1.53-6.31), 2.11× higher odds of jumping from heights (95% CI: 1.93-2.31), and 2.33× lower odds of dying by firearms (OR = 0.43, 95% CI: 0.33-0.56). No studies were classified as high risk of bias, and no outcomes had high levels of imprecision or indirectness.

CONCLUSION

These findings could inform lethal means counselling practices in this population. Additionally individual, clinical, community and public health interventions for people with SMI should prioritise, where feasible, means restriction including access to heights or drugs to overdose.

Perioperative dexmedetomidine-induced delirium in a patient with schizophrenia: a case report

BACKGROUND

Dexmedetomidine is a selective α2 receptor agonist with sedative, analgesic, anxiolytic, and anti-sympathetic effects. Dexmedetomidine is widely used for various surgical procedures performed under general anaesthesia and sedation in the intensive care unit. Dexmedetomidine was known to relieve or improve the symptoms of delirium. Schizophrenia is a common psychiatric disease, and the number of surgical patients with schizophrenia is increasing gradually. Dexmedetomidine-induced delirium in patients with schizophrenia is a particular case.

CASE PRESENTATION

This patient was a 75-year-old woman (height: 156 cm; weight: 60 kg) with a 5-year history of schizophrenia. Her schizophrenia was well controlled with medications. She was scheduled for open reduction and internal fixation for a patellar fracture. Spinal anaesthesia was administered for surgery, and dexmedetomidine was administered intravenously to maintain sedation. The patient became delirious half an hour after the surgery began. The intravenous infusion of dexmedetomidine was discontinued immediately, intravenous propofol was subsequently administered, and the patient stopped experiencing dysphoria and fell asleep. After surgery, the patient stopped using propofol and recovered smoothly. She was transferred back to the general ward and was discharged from the hospital without any abnormal conditions on the 9th day after surgery.

CONCLUSIONS

To the best of our knowledge, this is the first report of a patient with schizophrenia who developed delirium during the infusion of a normal dose of dexmedetomidine without an intravenous injection of any other sedative. The exact mechanism causing dexmedetomidine-induced delirium remains unclear, and this adverse reaction is rare and easy to ignore. Clinicians and pharmacists should be vigilant in identifying this condition.

Prevalence, demographic characteristics, and clinical features of suicide risk in first episode drug-naïve schizophrenia patients with comorbid severe anxiety

BACKGROUND

Both anxiety symptoms and suicide risk are common in schizophrenia. However, previous findings about the association between anxiety and suicide risk in schizophrenia were controversial. This study is the first to examine the prevalence of suicide risk and related demographic, clinical features in a large sample of first episode drug-naïve (FEDN) schizophrenia patients with comorbid severe anxiety.

METHODS

In total, 316 patients with FEDN schizophrenia were enrolled in this study. Patients' symptoms were assessed using the Hamilton Depression Scale (HAMD), Hamilton Anxiety Rating Scale (HAMA), and Positive and Negative Syndrome Scale (PANSS). Serum levels of glucose, insulin, uric acid, and lipids including total cholesterol (TC), triglycerides (TG), high-density lipoprotein cholesterol (HDL-C) and low-density lipoprotein cholesterol (LDL-C), were evaluated.

RESULTS

In the current study, 56.3% patients presented comorbid severe anxiety. The rate of suicide risk was higher in the severe anxiety group (55.6%) than in the mild-moderate anxiety group (33.3%). The interactions among severe anxiety, uric acid and HDL-C were associated with suicide risk. Compared with patients with normal uric acid, those with abnormal uric acid exhibited a stronger association between HAMA scores and HAMD-suicide item scores. This enhanced association was also observed for patients with abnormal HDL-C levels.

CONCLUSIONS

In FEDN schizophrenia patients with comorbid severe anxiety, our findings suggested a high incidence of suicide risk. Abnormal levels of uric acid and low levels of HDL-C, as well as high depression may be associated with an increased risk of suicide in FEDN schizophrenia patients with comorbid severe anxiety.

A cognitive-behavioral treatment for suicide prevention among adults with schizophrenia spectrum disorders in community mental health: Study protocol for a pilot feasibility and acceptability randomized clinical trial

BACKGROUND

Suicide is among the leading causes of death for adults with schizophrenia spectrum disorders (SSDs), and there is a paucity of evidence-based suicide prevention-focused interventions tailored for this vulnerable population. Cognitive-Behavioral Suicide Prevention for psychosis (CBSPp) is a promising intervention developed in the UK that required modifications for delivery in community mental health (CMH) settings in the United States of American. This pilot trial evaluates the feasibility, acceptability, and preliminary effectiveness of our modified CBSPp intervention in comparison to services as usual (SAU) within a CMH setting in a Midwestern state of the USA.

METHODS

This is a single-site randomized pilot trial with a planned enrollment of 60 adults meeting criteria for both SSD and SI/A. Eligible participants will be randomized 1:1 to either 10 sessions of CBSPp or SAU. Clinical and cognitive assessments will be conducted within a 4-waive design at baseline (prior to randomization and treatment) and approximately 1 month (mid-treatment), 3 months (post-treatment), and 5 months (follow-up) after baseline assessment. Qualitative interviews will also be conducted at post-treatment. The primary objective is to determine whether CBSPp is feasible and acceptable, involving examinations of recruitment rate, treatment engagement and adherence, retention and completion rates, and experiences in the CBSPp treatment and overall study. The secondary objective is to preliminarily evaluate whether modified CBSPp is associated with reductions in clinical (suicide ideation, suicide attempt, symptoms of psychosis, depression, and emergency/hospital service, hopelessness, defeat, and entrapment) and cognitive (information processing biases, appraisals, and schemas) outcomes in comparison to SAU from baseline to post-treatment assessment.

DISCUSSION

This randomized pilot trial will provide clinically relevant information about whether CBSPp can improve SI/A, depression, and psychosis among adults with SSDs. Testing this modified cognitive-behavioral suicide prevention-focused intervention has the potential for a large public health impact by increasing the intervention's utility and usability in CMH where many individuals with SSDs receive care, and ultimately working towards reductions in premature suicide death.

TRIAL REGISTRATION

ClinicalTrials.gov NCT#05345184. Registered on April 12, 2022.

Impulsivity in fatal suicide behaviour: A systematic review and meta-analysis of psychological autopsy studies

Our aim is to review and perform a meta-analysis on the role of impulsivity in fatal suicide behaviour. We included papers who used psychological autopsy methodology, assessed adult death by suicide, and included assessment of impulsivity. We excluded papers about assisted suicide, terrorist suicide, or other cause of death other than suicide or postmortem diagnosis made only from medical records or database. 97 articles were identified. 33 were included in the systematic review and nine in the meta-analysis. We found that people who die by suicide with high impulsivity are associated with younger age, substance abuse, and low intention to die, whereas those with low impulsivity were associated with older age, depression, schizophrenia, high intention to die and low social support. In the meta-analysis, suicide cases had higher impulsivity scores than living controls (Hedges' g = 0.59, 95 % CI [0.28, 0.89], p=.002). However, studies showed heterogeneity (Q = 90.86, p<.001, I2=89.0 %). Impulsivity-aggressiveness interaction was assessed through meta-regression (β=0.447, p=.045). Individuals with high impulsivity would be exposed to a higher risk of fatal suicide behaviour, aggressiveness would play a mediating role. People who die by suicide with high and low impulsivity display distinct characteristics, which may reflect different endophenotypes leading to suicide by different pathways.

Mind the past: A systematic review on psychological autopsy

Psychological Autopsy (PA) has become widespread to the point of being applied in many diverse fields. However, it is difficult to identify a standard model. In this systematic review, we focused on PA studies assessing mental illness as a major risk factor for suicide. The research, performed on Scopus, Embase, and Pubmed to cover the last 20 years led to 321 reports of which 15 met the inclusion criteria. Results confirmed mental illness as the main risk factor for suicide, followed by specific socio-demographic factors and life events. The analysis of methodologies depicted a still highly heterogeneous scenario, especially regarding data collection and variables included. However, concerning psychiatric evaluations, an initial standardization process of PA models emerged. In conclusion, the approach is in evolution, and novel guidelines are needed to promote the application of PA as a fundamental tool to inform suicide prevention efforts and to assist forensic examiners in court.

[Factors Influencing Suicide Deaths in Patients With Schizophrenia Based on Cohort Data: An Empirical Study of a Sample of 170006 Patients in Sichuan Province]

Objective

To prospectively explore the risk factors of suicide in patients with schizophrenia.

Methods

Data on schizophrenia patients in Sichuan Province between 2006 and 2018 were obtained from the National Severe Mental Disorders Information System, and the Cox proportional hazards regression model was used to explore for risk factors for suicide in schizophrenia patients.

Result

A total of 170006 patients with schizophrenia were included in the study. At the end of the follow-up period, 160570 patients were alive and 9436 died from various causes, 929 of which being suicide deaths, resulting in a suicide rate of 223.61/100, 000 person-years. The Cox proportional hazards regression model suggested that risk factors for suicide in patients with schizophrenia included poverty ( HR=1.20, 95% CI: 1.02-1.41), higher education level (primary school [ HR=1.32, 95% CI: 1.09-1.60], middle school [ HR=1.40, 95% CI: 1.14-1.73], high school and above [ HR=1.93, 95% CI: 1.49-2.52]) in comparison with illiteracy and semi-literacy, suicide attempts ( HR=2.70, 95% CI: 1.70-4.29), strict medication compliance ( HR=1.91, 95% CI: 1.66-2.20), history of antipsychotic drug therapy ( HR=1.42, 95% CI: 1.06-1.90), younger age group of patients of 46-60 ( HR=1.95, 95% CI: 1.60-2.39), 31-45 ( HR=3.61, 95% CI: 2.92-4.47), and 15-30 ( HR=12.37, 95% CI: 9.69-15.78) compared with the 61-90 age group, and doing agriculture jobs ( HR=1.36, 95% CI: 1.13-1.65).

Conclusion

Young and middle-aged schizophrenia patients with higher education levels, especially those with a history of suicide attempts, are at high risk for suicide. Focused interventions should be directed at high-risk groups to reduce suicide deaths in patients with schizophrenia.

Validity and Reliability of Turkish version of the Schizophrenia Hope Scale

This study aimed to evaluate the validity and reliability of the Turkish version of the Schizophrenia Hope Scale (SHS). This methodological study was carried out with 214 participants diagnosed with schizophrenia who were followed up in the psychiatry outpatient clinics of a university hospital between August 2021 and August 2022. Data were collected using an Information Form and the Schizophrenia Hope Scale (SHS). Language and content validity, exploratory and confirmatory factor analyses, item-total correlation, Cronbach alpha coefficient, and test-retest reliability methods were used in the validity and reliability analysis of the scale. As a result of the exploratory factor analysis, no item was excluded from the scale and it was determined that the scale has nine items and a single-factor structure. The single-factor structure of the scale was confirmed with the confirmatory factor analysis. The Cronbach Alpha coefficient of the scale was 0.901 and the factor loads ranged between 0.70 and 1.0. The test-retest correlation coefficient was r=0.959. The Turkish version of the scale was found to be valid and reliable. SCH is important since it represents the subjective meaning of hope from schizophrenic patients’ perspective and allows an easier measurement of the level of hope in this population. Mental health professionals can use SHS to determine or increase the level of hope of schizophrenia patients in their studies.

Relatives' experiences of an equine-assisted intervention for people with psychotic disorders

PURPOSE

The aim of this study was to describe relatives' experiences of an equine-assisted intervention for people with psychotic disorders.

METHODS

The study has a qualitative and descriptive design. Ten semi-structured interviews were performed with relatives of people with a psychotic disorder who had participated in an equine-assisted intervention. A conventional content analysis was used to analyse the data.

RESULT

The overall category "Being with the horses strengthens health capabilities" summarizes the four identified subcategories "The horses contribute to a context with a common focus", "Interaction with the horses enhances self-confidence and motivation", "The interplay with the horses nurtures positive emotions" and "Being with the horses encourages physical activity".

CONCLUSIONS

The result of this study contributes to the growing body of research about the potential outcomes of equine-assisted interventions. The result also indicates that equine-assisted interventions may improve health capabilities among people with psychotic disorders. The generated knowledge may be useful in mental health services when developing equine-assisted interventions.

Prediction model for suicide based on back propagation neural network and multilayer perceptron

Introduction

The aim was to explore the neural network prediction model for suicide based on back propagation (BP) and multilayer perceptron, in order to establish the popular, non-invasive, brief and more precise prediction model of suicide.

Materials and method

Data were collected by psychological autopsy (PA) in 16 rural counties from three provinces in China. The questionnaire was designed to investigate factors for suicide. Univariate statistical methods were used to preliminary filter factors, and BP neural network and multilayer perceptron were employed to establish the prediction model of suicide.

Results

The overall percentage correct of samples was 80.9% in logistic regression model. The total coincidence rate for all samples was 82.9% and the area under ROC curve was about 82.0% in the Back Propagation Neural Network (BPNN) prediction model. The AUC of the optimal multilayer perceptron prediction model was above 90% in multilayer perceptron model. The discrimination efficiency of the multilayer perceptron model was superior to BPNN model.

Conclusions

The neural network prediction models have greater accuracy than traditional methods. The multilayer perceptron is the best prediction model of suicide. The neural network prediction model has significance for clinical diagnosis and developing an artificial intelligence (AI) auxiliary clinical system.

Comparing warning signs of suicide between suicide decedents with depression and those non-diagnosed psychiatric disorders

OBJECTIVE

Early recognition of a high-risk group impending suicide is important. We aimed to compare warning signs depending on the nature of the psychiatric disorder and whether it was a documented diagnosis.

METHODS

Data of suicide decedents were collected from police records from 2013 to 2017. We evaluate psychiatric symptoms and warning signs in three aspects (language, behavior, and affect) using the Korea-Psychological Autopsy Checklist for Police Records (K-PAC-PR).

RESULTS

A total of 13,265 suicide decedents were recruited for this study. Of them, 66.9% of females and 46.7% of males diagnosed psychiatric disorders, with depressive disorder being the most common one. Warning signs were observed in 93.0% of suicide decedents. They were observed more in those who were diagnosed with psychiatric disorders, especially in those with a depressive disorder. "Talking about dying or suicide" was the most common warning sign in all groups, and "apathetic behavior" was the most related warning sign for depressive disorder. Especially for "talking about dying or suicide," the proportion of observed "within a week" was high, making it valuable as a warning sign.

CONCLUSION

Warning signs were commonly found in suicide decedents regardless of gender. They were more common among the decedents diagnosed with psychiatric disorders, especially among those with a depressive disorder.

Personalizing interventions using real-world interactions: Improving symptoms and social functioning in schizophrenia with tailored metacognitive therapy

OBJECTIVE

When clients' lives are not reflected in therapy, they struggle to apply the skills learned in treatment to everyday situations. In this pilot study, we determined if using clients' real-world interactions in therapy could effectively target metacognitive capacity-yielding improved symptoms and social functioning-by tailoring treatment to focus on issues faced by clients in daily life.

METHOD

Using a randomized controlled trial design, schizophrenia subjects with metacognitive deficits completed 24 sessions of: (a) Standard Metacognitive Reflection and Insight Therapy (MERIT); or (b) Tailored MERIT. Real-world interactions were captured via the Electronically Activated Recorder (EAR), a smartphone application that passively records audio in daily life. All subjects wore the EAR; however, real-world interactions were only used to personalize sessions in Tailored MERIT.

RESULTS

Feasibility and acceptability were shown; those in Tailored MERIT wore the EAR 84% of their waking hours and reported minimal burden. When compared to Standard MERIT, Tailored MERIT participants showed large pre-post reductions in negative metacognitive beliefs and disorganized symptoms. Small, but nonsignificant, improvements in social functioning were also observed.

CONCLUSIONS

Compared to an evidence-based benchmark, we observed that real-world interactions can be used to tailor metacognitive therapy and improve outcomes in schizophrenia. Tailored MERIT has the potential to impact practice by personalizing treatment to account for individual variations in environment and lifestyle-aligning with the Precision Medicine Initiative-in a way that is not possible with current therapy. This is particularly salient in schizophrenia, where limited insight and cognitive deficits often make subjective reporting unreliable. (PsycInfo Database Record (c) 2022 APA, all rights reserved).

Suicide means, timing, intent and behavior characteristics of the suicides with schizophrenia

BACKGROUND

Studies have been reported on suicide and schizophrenic suicide, but few compared certain characteristics of suicides with and without schizophrenia.

METHODS

A sample of 392 suicides was consecutively recruited from 16 counties in three provinces of China. Psychological autopsy method was applied to collect the information through informants. The questionnaire of characteristics for suicidal behavior, Beck's Suicide Intent Scale (SIS), and the DSM-IV based SCID were applied.

RESULTS

About 9.7% of the sampled suicides (n = 38) were diagnosed with schizophrenia, and they were more likely to be female and older in age. No significant differences were found on violent suicide means, but significant differences within non-violent means between two groups. Schizophrenic suicide was more likely to happen in the second quarter of the year (April - June), middle of the month (11th-20th), and in the afternoon (3:01 pm - 6:00 pm). The schizophrenic suicides had higher suicide intent than those without schizophrenia and were more inclined to be isolated, more likely to tell people their suicide intent, and less likely to prepare posthumous papers.

CONCLUSION

Schizophrenic suicides have unique characteristics, and targeted preventive measures should be taken to prevent schizophrenic suicides. To accurately identify characteristics of suicide behavior is meaningful to prevent schizophrenic suicides in clinical practice.

Characteristics and Risk Factors for Suicide in People with Schizophrenia in Comparison to Those without Schizophrenia

BACKGROUND

Little research has been conducted that compares suicide cases with and without schizophrenia. The aim of the present study was to identify demographic, personal, social, relational, and psychological characteristics among suicides identified posthumously with schizophrenia compared to those without.

METHODS

The DSM-IV was used to independently assess the presence of schizophrenia among suicide cases by two psychiatrists. Data on risk factors was collected through a psychological autopsy method, which included structured interviews of two informants for each suicide case (a family member and a close friend). Interview questions included demographic characteristics, suicide risk factors, the Beck Hopelessness Scale, Dickman's Impulsivity Inventory, the Spielberger State-Trait Anxiety Inventory, the Hamilton Depression Scale and the Duke Social Support Inventory.

RESULTS

The prevalence of schizophrenia was 9.69% among suicide cases in this sample. The schizophrenia suicide group was more likely to be female, older, in poorer physical health, suffer from chronic disease, suffer other psychological disorders, and have a family history of psychological disorders compared to those not diagnosed schizophrenia. Other important risk factors included more frequent past suicide attempts, increased levels of depression and anxiety, lower levels of impulsivity, lower help seeking from friends, and lower social interaction social support.

CONCLUSIONS

There is a notable link between schizophrenia and suicide in China. Identification of social, personal, relational, and psychological risk factors could beneficially guide attempts to improve future preventive measures against suicide among those with schizophrenia in China.

Incidence and method of suicide mortality in patients with schizophrenia: a Nationwide Cohort Study

PURPOSE

Suicide is a leading cause of death in patients with schizophrenia. This nationwide cohort study investigated the incidence of each suicide method in patients with schizophrenia compared with the general population.

METHODS

In total, records of 174,039 patients with schizophrenia were obtained from the National Health Insurance Research Database in Taiwan from 2001 to 2016. This schizophrenia cohort was linked with the national mortality database, and 26,926 patients died during this follow-up period. Of the deceased, 3033 had died by suicide. Univariate Cox regression was used to estimate the demographic variables associated with suicide. We estimated the difference in the proportion of each suicide method used in patients with schizophrenia compared with the general population. The incidence and standardized mortality ratio (SMR) of each suicide method were calculated and stratified based on sex.

RESULTS

Patients aged 25-34 years exhibited the highest suicide risk. Compared with the general population, patients with schizophrenia were more likely to commit suicide by jumping and drowning and less likely to use charcoal-burning and hanging. Women showed a higher incidence of suicide by drowning and jumping than did men. Comorbidity with substance use disorders (SUDs) was associated with a high suicide SMR (26.9, 95% confidence interval [CI] = 23.4-28.9), particularly for suicide by jumping (61.2, 95% CI = 48.3-76.3).

CONCLUSIONS

Patients with schizophrenia had higher suicide rates for all methods than did the general population. Suicide method differed based on sex. Patients with SUDs exhibit a high SMR for each suicide method and warrant intensive clinical attention.

Comparisons between suicide in persons with serious mental illness, other mental disorders, or no known mental illness: Results from 37 U.S. states, 2003-2017

BACKGROUND

Suicide is a leading cause of death in persons with schizophrenia and other serious mental illnesses (SMI), however, little is known about the characteristics and circumstances of suicide decedents with SMI in the US compared to those with other or no known mental illness.

METHODS

This study was a retrospective analysis of suicide deaths in individuals aged ≥18 years from the National Violent Death Reporting System, 2003-2017. Odds ratios compared sociodemographic and clinical characteristics, cause of death, precipitating circumstances, and post-mortem toxicology results. All analyses were stratified by gender.

RESULTS

Of the 174,001 suicide decedents, 8.7% had a known SMI, 33.0% had other mental disorders, and 58.2% had no known mental illness. Relative to persons with other mental disorders, SMI decedents were younger and more likely to have previous suicide attempts and co-occurring drug use. Problems with intimate partners, poor physical health, and recent institutional release were the most common precipitating circumstances for SMI decedents. Firearms were the most common suicide method for males with SMI. Although 67.0% male and 76.0% of female SMI decedents were currently in treatment, toxicology results suggest many were not taking antipsychotic or antidepressant medications at the time of death.

CONCLUSIONS

Persons with SMI are over-represented in suicide deaths. Efforts to improve treatment of co-occurring substance use disorders, continuity of care following hospitalization, medication adherence, and to reduce access to firearms are important suicide prevention strategies.

The Importance of Suicide Risk Formulation in Schizophrenia

Suicide is a cause of early mortality in nearly 5% of patients with schizophrenia, and 25-50% of patients with schizophrenia attempt suicide in their lifetime. Evidence points to numerous individual, clinical, social, and psychological risk factors for suicide in patients with schizophrenia. Although recognizing suicidal risk factors in schizophrenia is extremely important in suicidal risk assessment, we have recently witnessed a change in suicide risk management that shifts the focus from suicide risk assessment to suicide risk formulation. Suicide risk formulation is dependent on the data gathered in the suicide risk assessment and assigns a level of suicide risk that is indispensable for the choice of treatment and the management of patients with a high suicidal risk. In this article, we extend the suicide risk formulation model to patients with schizophrenia. Suicide risk formulation results from four different areas that help clinicians collect as much information as possible for the management of suicidal risk. The four distinct judgments comprise risk status (the risk relating to the specific group to which the patient belongs), risk state (the risk for the person compared with his baseline or another reference point in the course of his life), available resources (on whom the person can count during a crisis) and foreseeable events (which can exacerbate the crisis). In schizophrenia, the suicide risk formulation model allows the clinician to evaluate in depth the clinical context of the patient, the patient's own history and patient-specific opportunities for better choosing and applying suicide prevention strategies.

Comparing Suicide Attempters With and Without Mental Disorders: A Study of Young Adults in Rural China

Over 90% of suicides in the West could be diagnosed with mental disorders, while only 50-70% of Chinese suicides had mental disorders. Using data from a case-control study on suicide attempt, we aimed to compare characteristics and risk factors between suicide attempters with and without mental disorders. Demographic and social psychological characteristics were compared between attempters with and without mental disorders. 19.1% of the suicide attempters were diagnosed with mental disorders. Suicide attempters with mental disorders endured more strain than those without. Strain was an independent risk factor for suicide attempt among people without mental disorders. Psychological strain might be an important reason for both mental disorders and following suicide attempt. More efforts on suicide prevention should be spent on people without mental disorders. The impact of social psychological factors, such as religion, negative life events, and psychological strains should be considered.

Effects of perceived social status and discrimination on hope and empowerment among individuals with serious mental illnesses

Hope and empowerment are key elements of recovery in the context of serious mental illnesses (SMI). We examined predictors of hope among individuals with SMI and tested a hypothesized path model in which perceived social status and perceived discrimination adversely impact hope, directly and through their impacts on depressive symptoms. Data from 232 individuals with SMI receiving care in public-sector settings were used in both a multiple linear regression (predicting Herth Hope Scale scores), and in path analyses examining both direct and indirect effects of perceived social status (Social Status Ladder) and perceived discrimination (Everyday Discrimination Scale). Depressive symptoms, perceived social status, and perceived discrimination were predictive of hope. Path analyses revealed that perceived social status has a direct effect on hope and empowerment but also impacts hope through its effects on depression. Similarly, perceived everyday discrimination affects hope and empowerment, though this effect is mediated through its effects on depression. Two alternative models and a trimmed hypothesized model did not fit the data or improve fit. These social determinants of mental health should provoke program and policy change to improve mental health and enhance recovery among persons with SMI.

Perception of social support and psychotic symptoms among persons with schizophrenia: A strategy to lessen caregiver burden

BACKGROUND

Improving patients' perception of social support is significant not only for their re-adaptation to life but also for alleviating caregivers' burden.

AIM

This study aims to examine an integrated model regarding social support, psychotic symptoms and caregiver burden.

METHODS

Persons with schizophrenia (N₁ = 300) and their family caregivers (N₂ = 300) in Xinjin County, Chengdu, China, completed the survey to report their demographics, patients' perception of social support (Duke Social Support Index), psychotic symptoms (Positive and Negative Syndrome Scale) and caregiver burden (Burden Scale for Family Caregivers, Short Version). Structural equation modelling was utilised to test the proposed model.

RESULTS

The degree of caregiver burden differed significantly within subgroups of patients' gender and education, as well as caregivers' gender, education and employment. Caregiver burden was negatively related to patients' age and household income. Social interaction partially mediated the relationship between instrumental and subjective social support (total effect = 0.451, p < .01). Subjective social support fully mediated the impact of social interaction on psychotic symptoms (total effect = -0.099, p < .05). In the final model, instrumental social support was positively associated with social interaction (p < .001) and increased subjective social support (p < .05). Increased subjective social support showed correlation with a lower degree of psychotic symptoms (p < .01), which was related to a lower level of caregiver burden (p < .001).

CONCLUSION

This study shows the associations of patients' social support with psychotic symptoms and caregiver burden. Culture-specific psychosocial interventions should be provided for both patients and caregivers to enrich external support and reduce psychotic symptoms and caregivers' burden within the health care environment.

Characteristics of help-seeking behavior among bipolar disorder patients: A study in Hunan, China

To analyze the factors that affecting the help-seeking behavior of bipolar disorder (BD) patients by conducting interviews BD individuals in Hunan province of China.In 2015, 72,999 people from 123 counties of Hunan province of China were interviewed through multistage stratified random sampling. Twelve items of general health questionnaire (GHQ-12) and abnormal behavioral clue questionnaire were used as screening tools. The Structured Clinical Interview for Diagnostic and Statistical Manual of Mental Disorders-IV (DSM-IV) (SCID) was used as a diagnostic tool.Among the 75 BD patients, 36% (27/75) sought help. Compared with help-seekers, non-help-seekers were more likely to be older, divorced, or widowed, mostly illiterate or elementary education, family monthly income at least 3000 ¥, more physically consulted in the past year, able to effective work or study, at a stable illness status. 70.4% help-seekers firstly sought help from a medical institution. The main reasons that patients did not seek help were economic problem, did not know where to seek help, unsatisfied with medical services, afraid of mental health stigma, and other problems, such as traffic inconvenience.Non-help-seekers were faced with more difficulties in their social functions and social interactions.

Psychiatric morbidity and suicidal behaviour in low- and middle-income countries: A systematic review and meta-analysis

BACKGROUND

Psychiatric disorders are reported to be present in 80% to 90% of suicide deaths in high-income countries (HIC), but this association is less clear in low- and middle-income countries (LMIC). There has been no previous systematic review of this issue in LMIC. The current study aims to estimate the prevalence of psychiatric morbidity in individuals with suicidal behaviour in LMIC.

METHODS AND FINDINGS

PubMed, PsycINFO, and EMBASE searches were conducted to identify quantitative research papers (any language) between 1990 and 2018 from LMIC that reported on the prevalence of psychiatric morbidity in suicidal behaviour. We used meta-analytic techniques to generate pooled estimates for any psychiatric disorder and specific diagnosis based on International classification of disease (ICD-10) criteria. A total of 112 studies (154 papers) from 26 LMIC (India: 25%, China: 15%, and other LMIC: 60%) were identified, including 18 non-English articles. They included 30,030 individuals with nonfatal suicidal behaviour and 4,996 individuals who had died by suicide. Of the 15 studies (5 LMIC) that scored highly on our quality assessment, prevalence estimates for psychiatric disorders ranged between 30% and 80% in suicide deaths and between 3% and 86% in those who engaged in nonfatal suicidal behaviour. There was substantial heterogeneity between study estimates. Fifty-eight percent (95% CI 46%-71%) of those who died by suicide and 45% (95% CI 30%-61%) of those who engaged in nonfatal suicidal behaviour had a psychiatric disorder. The most prevalent disorder in both fatal and nonfatal suicidal behaviour was mood disorder (25% and 21%, respectively). Schizophrenia and related disorders were identified in 8% (4%-12%) of those who died by suicide and 7% (3%-11%) of those who engaged in nonfatal suicidal behaviour. In nonfatal suicidal behaviour, anxiety disorders, and substance misuse were identified in 19% (1%-36%) and 11% (7%-16%) of individuals, respectively. This systematic review was limited by the low number of high-quality studies and restricting our searches to databases that mainly indexed English language journals.

CONCLUSIONS

Our findings suggest a possible lower prevalence of psychiatric disorders in suicidal behaviour in LMIC. We found very few high-quality studies and high levels of heterogeneity in pooled estimates of psychiatric disorder, which could reflect differing study methods or real differences. There is a clear need for more robust evidence in order for LMIC to strike the right balance between community-based and mental health focussed interventions.

Characteristics of the schizophrenia suicide attempts in comparison with the suicide attempts with other diagnosed psychiatric disorders: An Egyptian study

BACKGROUND

There has been much literature on schizophrenia, but little is known about the characteristic features of suicide attempts with schizophrenia in comparison with the suicide attempts with other diagnosed psychiatric disorders.

AIMS

The objective of this study was to clarify the specific characteristics and risk factors among suicide attempters with schizophrenia that differentiate them from other psychiatric disorders.

METHODS

Thirty-three suicide attempters diagnosed with schizophrenia and 87 suicide attempters with other psychiatric disorders were included. Suicide attempts seriousness were appraised by the Beck's Suicide Intent Scale (BSIS). Standardized scales were applied: Suicide Probability Scale (SPS) and Barratt Impulsiveness Scale, Version 11 (BIS-11). The Structured Clinical Interview for DSM-IV Axis I Disorders (SCID-I) and The Structured Clinical Interview for DSM-IV Axis II Disorders (SCID-II) based on the Diagnostic and Statistical Manual of Mental Disorders-IV (DSM-IV) was applied to assess the psychiatric status of individuals. Demographic and clinical characteristics, method of suicide and suicide probability scores and impulsivity were compared among both groups (schizophrenia group and other psychiatric disorders group).

RESULTS

In total, 27.5% of suicide attempts suffered from schizophrenia. The current study found that having more past history of medical diseases, longer duration of illness, using more violent suicidal methods, and having less significant suicidal ideations were the significant factors that differentiated schizophrenia suicide attempts from those diagnosed with other psychiatric disorders. The schizophrenia group did not show more impulsivity or hostility than other psychiatric disorders group.

CONCLUSION

These results indicated that each group shows its unique characteristics. They give us new perspectives to prevent suicides in schizophrenia according to their different characteristics.

Epidemiology of Suicide/Suicide Attempt and Its Association with Individual, Family, and Social Factors in Eastern Part of Iran: A Historical Cohort Study

BACKGROUND

Suicide/suicide attempt, as a major public health problem, has been included among anti-social behaviors. We aimed to investigate the epidemiology of suicide and some associated individual, family, and social factors.

METHODS

A historical cohort study was conducted among all cases (748 persons) reports related to suicide/suicide attempt that register in hospital reporting system and health care center in Gonabad and Bajestan, Iran, from 2009 to 2014. The required data were extracted through a checklist. Descriptive (mean and standard deviation) and analytic statistics (t-test, Chi-square, and logistic regression) applied to analyzed data. All data were analyzed using SPSS software.

RESULTS

Of the 748 reported suicide attempters, 17 cases (2.3%) had completed suicide. The annual average incidence rate of suicide was 110.03 per 100,000 populations. The mean age of suicide attempt had significantly decreased during the time (P=0.007). Furthermore, a significant association was observed between outcome of suicide and place of residence (P=0.019), history of physical illnesses (P=0.002), and method of suicide (P=0.001).

CONCLUSION

Due to trend of age among suicide attempters, considering intervention programs of suicide prevention for school pupils and university students especially individuals residing in rural areas, as well as individuals suffering from physical illness would be effective to reduce the rate of suicide.

Factors associated with help-seeking behavior among medically serious attempters aged 15-54 years in rural China

Increasing help-seeking behavior was one of the effective methods for suicide prevention. However, help-seeking behavior was less explored in rural China. In this study, we aimed to analyze the factors which were associated with help-seeking behavior among medically serious suicide attempters in rural China. Subjects were 791 medically serious suicide attempters aged 15-54 years in rural China. A face-to-face interview was conducted to evaluate the age, gender, education years, marital status, occupation, religious belief, living alone, physical disease, pesticide at home, family suicide history, negative life events, social support, impulsivity, mental disorder, prior suicide act, suicide intent and suicide method for the attempters. The results supported that there were 29.2% of attempters seek help before suicide behavior, and factors that male (OR = 1.45), experiencing negative life events (OR = 1.12), impulsivity (OR = 1.05), suicide intent (OR = 0.92) and suicide by pesticide (OR = 0.68) were associated with increased help-seeking behavior. It is helpful for us to understanding the features of suicide attempters who do not seek help before suicide behavior, and we also should pay more attention on people with these factors in Chinese suicide prevention.

BP neural network prediction model for suicide attempt among Chinese rural residents

OBJECTIVE

This study aimed to establish and assess the Back Propagation Neural Network (BPNN) prediction model for suicide attempt, so as to improve the individual prediction accuracy.

METHOD

Data was collected from a wide range case-control suicide attempt survey. 659 serious suicide attempters (case group) were randomly recruited through the hospital emergency and patient registration system from 13 rural counties in China. Each case was matched the control by same community, gender, and similar age (± 2 ages). Face to face interviews were conducted for each subject with structured questionnaire. Logistic regression was applied to preliminarily screen the factors and BPNN was used to establish the prediction model of suicide attempt.

RESULTS

Multivariate logistic regression indicated that family history of suicide (OR = 4.146), mental problem (OR = 3.876) Low education level, poor health, aspiration strain, hopelessness, impulsivity, depression are the risk predictors and social support, coping skills, healthy community are the protect predictors for suicide attempt. Repetitious data simulation process of BPNN indicated that three-layer BPNN with 9 hidden layer neurons is the optimal prediction model. The sensitivity (67.6%), specificity (93.9%), positive predictive value (86.0%), negative predictive value (84.1%), total coincidence rate (84.6%) manifested that it is excellent to distinguish suicide attempt case.

CONCLUSIONS

The BPNN method is applicative, feasible, credible and good discriminative effect for suicide attempt. The BPNN established has significant clinical meaning for the clinical psychiatrist and lay theoretical foundation for artificial intelligence expert assisted diagnosis system for suicide attempt in the future.

A randomized controlled study of bedside electrocardiograph-guided tip location technique & the traditional chest radiography tip location technique for peripherally inserted central venous catheter in cancer patients

Background & objectives:

The peripherally inserted central catheter (PICC) has the advantages of higher safety, lower infection rate and longer retention time than peripherally inserted catheter. This study was aimed to evaluate the accuracy and safety of bedside electrocardiograph (ECG)-guided tip location technique in PICC in cancer patients, and compared with traditional chest radiography tip location technique.

Methods:

Patients were randomly assigned into two groups: The ECG test group patients underwent PICC insertion with ECG-guided tip location, while the control group patients had PICC insertion by the conventional method. The precision of tip location was verified by chest radiography in both groups. The groups were compared with regard to the accuracy of tip placement, anxiety levels before and after the procedure; medical cost and incidence of complications at one week, three months and six months after PICC insertion.

Results:

Accurate tip location was achieved in 99.30 per cent in the ECG test group vs 92.30 per cent in the control group (P <0.001). At 24 h after the procedure, the anxiety level was significantly lower in the ECG test group. The presence of thrombogenesis was significantly lower in the ECG test group at both three months and six months after the procedure (P=0.04 and P=0.03, respectively).

Interpretation & conclusions:

The ECG-guided PICC tip location technique was accurate and caused fewer procedure-related complications and less anxiety in patients compared to chest radiography tip location technique. Radiographic confirmation of PICC tip position may not be needed when ECG guidance is used and thus it can help avoid radiation exposure.

Early warnings for suicide attempt among Chinese rural population

OBJECTIVE

This study was to explore the main influencing factors of attempted suicide and establish an early warning model, so as to put forward prevention strategies for attempted suicide.

METHOD

Data came from a large-scale case-control epidemiological survey. A sample of 659 serious suicide attempters was randomly recruited from 13 rural counties in China. Each case was matched by a community control for gender, age, and residence location. Face to face interviews were conducted for all the cases and controls with the same structured questionnaire. Univariate logistic regression was applied to screen the factors and multivariate logistic regression was used to excavate the predictors.

RESULTS

There were no statistical differences between suicide attempters and the community controls in gender, age, and residence location. The Cronbach`s coefficients for all the scales used were above 0.675. The multivariate logistic regressions have revealed 12 statistically significant variables predicting attempted suicide, including less education, family history of suicide, poor health, mental problem, aspiration strain, hopelessness, impulsivity, depression, negative life events. On the other hand, social support, coping skills, and healthy community protected the rural residents from suicide attempt.

CONCLUSIONS

The excavated warning predictors are significant clinical meaning for the clinical psychiatrist. Crisis intervention strategies in rural China should be informed by the findings from this research. Education, social support, healthy community, and strain reduction are all measures to decrease the likelihood of crises.

Features for medically serious suicide attempters who do not have a strong intent to die: a cross-sectional study in rural China

OBJECTIVE

Previous studies have implied that there were many Chinese suicide attempters who did not want to die by suicide. In the current study, we explored the factors which were associated with low levels of suicide intent. We also examined features for medically serious suicide attempters who do not have a strong intent to die in rural china.

DESIGN

Cross-sectional study.

SETTING

The interviews occurred between May 2012 and July 2013 in 13 rural counties in Shandong and Hunan provinces, China.

PARTICIPANTS

Subjects were 791 medically serious suicide attempters whose injury and wounds were so serious they required hospitalisation or immediate medical care.

RESULTS

The results supported that less years of education (β=-0.11, p=0.037), religious beliefs (β=1.20, p=0.005), living alone (β=1.92, p=0.017), negative life events (β=0.29, p=0.003), low levels of impulsivity (β=-0.10, p=0.013) and mental disorders (β=2.82, p<0.001) were associated with higher levels of suicide intent.

CONCLUSION

Results imply that there are some medically serious suicide attempters with a higher education and/or exhibit impulsivity who do not want to die by suicide. These findings can inform practice to prevent suicide in rural China.

Suicide Acceptability and Suicide Attempt: A Case-Control Study With Medically Serious Suicide Attempters Aged 15 to 54 Years in Rural China

In the past decades, many studies have discussed the topic of suicide acceptability. However, there is no empirical study which identified that suicide acceptability is associated with suicide attempt worldwide. In the present study participants were 791 medically serious suicide attempters and controls aged 15 to 54 years in rural China. Suicide acceptability was evaluated by four questions in the General Social Survey and some social psychological variables were collected in a face-to-face interview. Logistic regression analysis was performed to examine the association between suicide acceptability and suicide attempt. After controlling some social psychological variables, suicide acceptability was still associated with suicide attempt (odds ratio, 2.85; p < 0.001). Tired of living was the most acceptable reason for the medically serious suicide attempters (32.7%). Suicide acceptability should be assessed when we evaluate an individual's suicide risk. The results contribute to our understanding about suicide acceptability, and they may also be translated into practice in suicide prevention.

Safety and efficacy of paliperidone palmitate 1-month formulation in Chinese patients with schizophrenia: a 25-week, open-label, multicenter, Phase IV study

RATIONALE

Long-acting injectable (LAI) paliperidone palmitate 1-month formulation (PP1M) has demonstrated acceptable tolerability and favorable clinical outcomes in Western and Asian patients with schizophrenia. Hence, analysis of the outcomes of long-term PP1M treatment specifically in Chinese patients is of interest.

OBJECTIVE

The aim of this study is to evaluate the long-term safety and efficacy of PP1M treatment in Chinese patients with schizophrenia.

METHODS

In this 25-week, open-label, Phase IV study, patients (18-65 years) diagnosed with schizophrenia and having a baseline Positive and Negative Syndrome Scale (PANSS) total score of 60-120 (inclusive) were enrolled. All patients received injections of PP1M 150 mg eq. (day 1) and 100 mg eq. (day 8), followed by a flexible once-monthly maintenance dosing (75, 100, or 150 mg eq.).

RESULTS

Of the 353 patients, 234 (66.3%) completed the study treatment (mean age, 31.1 years; 52.7% men). The PANSS total score (primary end point) improved significantly over the 6-month treatment period (mean [standard deviation] change from baseline to end of treatment, -27.2 [18.30]; P<0.0001). The Clinical Global Impressions-Severity and Personal and Social Performance scores (secondary end points) also improved significantly (P<0.0001). At 6 months, PP1M had a positive impact on medication satisfaction, adherence, and increased preference for LAIs. Treatment-emergent adverse events (TEAEs) were reported by 181 (51.3%) patients (TEAEs ≥5%: extrapyramidal disorder [15.3%], akathisia [10.5%], blood prolactin increase [8.8%], insomnia [5.4%]). A total of 8 deaths were reported, including 4 completed suicides.

CONCLUSION

Long-term treatment with PP1M was efficacious, and no new safety concerns were identified in Chinese patients with schizophrenia. Overall, the results were comparable with observations from previous studies.

Gender differences among medically serious suicide attempters aged 15-54 years in rural China

China is one of few countries which reported higher female suicide rates in the worldwide. However, little is known about the gender differences among Chinese rural suicide attempters. This study aims to analyze the gender differences among medically serious suicide attempters aged 15-54 years in rural China. Subjects were 791 medically serious suicide attempters and 791 controls aged 15-54 years in rural China. Socio-demographic, psychological and some critical variables were assessed in the interview. The results showed that all of the factors (education years, family suicide history, negative life events, social support, impulsivity and mental disorder) associated with male suicide attempters also could be found for females. Physical disease, mental disorder and pesticide ingestion played more roles on male suicide attempters. Ever married, peasant, religious belief, and less social support played more roles on female suicide attempters. Compared with male suicide attempters, female ones are mainly influenced by social factors. A gender-specific approach should be emphasized in suicide prevention.

Personal Recovery as a Protective Factor Against Suicide Ideation in Individuals With Schizophrenia

Suicide rates are elevated in individuals with schizophrenia, yet evidence is mixed regarding the roles of positive and negative symptoms as risk factors for suicide in this population, suggesting that there may be other influential variables. One such variable may be personal recovery. Therefore, the purpose of this study was to test the hypothesis that personal recovery would moderate the relationship between symptoms of schizophrenia and suicide ideation. This hypothesis was tested in a sample of 169 individuals diagnosed with schizophrenia or schizoaffective disorder using a Poisson regression model. Results suggested that there was no significant interaction between recovery and symptoms of schizophrenia. However, recovery was a significant predictor of suicide ideation after controlling for psychiatric symptoms. These findings indicate that recovery is associated with lower suicide ideation and thus may protect against it. Thus, recovery should be assessed, and potentially intervened upon, to reduce suicide risk in individuals with schizophrenia.

Medically Serious Suicide Attempters With or Without Plan in Rural China

Although previous studies have discussed the risk factors of unplanned suicide behavior in several countries, the unplanned suicide attempt in China was not explored in a large sample. We aim to look into the characteristics of unplanned suicide attempters in China and compare them with those suicide attempters with plans. Subjects were 791 medically serious suicide attempters aged 15-54 years in rural China. The sixth item of Beck's Suicide Intent Scale was used to estimate the planned and unplanned suicide attempt. Logistic regression analysis was performed to examine the factors related to planned or unplanned suicide attempt. The results showed that the planned suicide attempts were associated with higher education, hopelessness, and previous suicide act. The unplanned suicide attempt tends to be suicide by pesticide and store pesticide at home. A ban of lethal pesticides may be a method for suicide prevention in rural China.

Sense of Belonging and Hope in the Lives of Persons with Schizophrenia

This qualitative study used semi-structured interviews to explore the meaning of sense of belonging and hope in the lived experiences of 20 persons with chronic schizophrenia-spectrum disorders receiving acute inpatient treatment. Experience of treatment was also explored. Sense of belonging and hope were both identified as valuable or even vital, yet the experiences of not belonging and/or feeling hopeless was more prevalent. Participants frequently felt like an outsider and experienced loneliness and isolation, suggesting a need for further exploration of the impact of sense of belonging and hope on recovery and even treatment adherence in persons with schizophrenia.

The interactive effects of negative symptoms and social role functioning on suicide ideation in individuals with schizophrenia

Findings regarding the protective effect of social role functioning on suicide ideation in individuals with schizophrenia have been mixed. One reason for such inconsistencies in the literature may be that individuals with prominent negative symptoms of schizophrenia may not experience a desire for social closeness, and therefore social role functioning may not influence suicide risk in these individuals. The aim of this study was to examine the moderating effects of self-reported desire for social closeness and interviewer-rated negative symptoms on the relationship between social role functioning and suicide ideation. Our sample consisted of 162 individuals who had been diagnosed with schizophrenia-spectrum disorders; all participants completed self-report questionnaires and clinician-administered interviews, and moderation hypotheses were tested with a non-parametric procedure. The results indicated that motivation and pleasure-related negative symptoms moderated the relationship between social role functioning and suicide ideation; self-reported desire for social closeness and negative symptoms related to expression did not have such a moderating effect. Specifically, better social role functioning was associated with less suicide ideation only in those individuals who had low motivation and pleasure-related negative symptoms; no significant relationship was observed between social role functioning and suicide ideation among those with elevated motivation and pleasure-related negative symptoms. These findings suggest that assessing for negative symptoms and social role functioning may inform suicide risk assessments in individuals with schizophrenia, and improving social role functioning may reduce suicide ideation among those with few motivation and pleasure-related negative symptoms.

Suicides and medically serious attempters are of the same population in Chinese rural young adults

BACKGROUND

Suicide rates in China are among the highest in the world, although there has been a decreasing trend in the past few years. One practical approach to study the characteristics and risk factors of suicide is to interview the suicide attempters. It was to compare completed suicides with serious attempters that may shed lights on suicide prevention strategies.

METHOD

This is a combination of two case control studies for suicide completers and suicide attempters respectively. After a sample of suicides (n=392) and community living controls (n=416) were obtained and studied in rural China, we collected in the same rural areas data of suicide attempt and studied 507 medically serious attempters and 503 community counterparts.

RESULTS

Characteristics and previously observed risk factors were compared between the suicides and the attempters, and we found that the demographic characteristics and risk factors for the suicides were also for the medically serious attempters but at some lesser degrees for the attempters than for the suicides. It was especially true of suicide intent, deficient coping, negative life events, and impulsivity. While most of the demographic characteristics were not significantly different between the suicides and the attempters, most of the clinical variables could distinguish the two groups.

CONCLUSIONS

The suicide victims and the serious attempters could be of the same group of people who were at the edge of fatal self-injury, and the same clinical risk factors but of different degrees have divided them into the life and death groups.

Severe Burns and Amputation of Both Arms in the First Psychotic Episode of a Schizophrenic Patient

An alleged reduction of sensitivity to pain in people with schizophrenia has been reported, but the nature of this complex phenomenon has not been elucidated yet. Reports of insensitivity to burns from people with schizophrenia are extremely rare. We report the case of a 24-year-old man who set both of his arms on fire during the first break of paranoid schizophrenia. As a result of severe tissue damage, both of his limbs had to be amputated. Today, at the age of 59, the patient is physically and mentally rehabilitated and is adherent to treatment. Additionally, given the uncertainty about the true nature of the alleged hypoalgesia in schizophrenia, we postulate the need for a comprehensive phenomenological approach in the study of embodiment in people with this condition.