Review

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Insight and suicidal behavior

in first-episode schizophrenia
Expert Rev. Neurother. 12(3), 353359 (2012)

Ingrid Melle* and

Elizabeth Ann Barrett
Division of Mental Health and
Addiction, Building 49, Oslo University
HospitalUllevl, PO Box 4956,
Nydalen, 0424Oslo, Norway
*Author for correspondence:
Tel.: +47 23 02 73 50
Fax: +47 23 02 73 33
ingrid.melle@medisin.uio.no

Suicidal behavior and suicide is prevalent in schizophrenia, with an estimated lifetime risk of
approximately 5%. The risk is particularly high in the early phases of the disorder, and especially
during the years around treatment initiation. Suicide attempts before first treatment contact are
also prevalent, with the risk of suicide attempt associated with the length of untreated illness.
Several risk factors are in common with the general population, and include previous suicide
attempts, impulsive personality traits, substance abuse, depression and feelings of hopelessness.
Recent research examines how patients subjective experiences, including their insight into having
a severe mental illness and their beliefs about mental illnesses, may influence suicidal behavior. In
this article, we will present a review of studies illustrating the complex background of suicide risk
in schizophrenia, with a particular emphasis on the role of insight in the early phases of schizophrenia.
Keywords : beliefs about illness first-episode psychosis insight schizophrenia suicidal behavior suicide

Methods & limitations

This review is based on a comprehensive literature search in Medline and PsycLit using the
search terms suicide or suicidal and schizophrenia. For the first part and general part, the
review is selective based on the authors choice of
what, by most, are considered key publications in
the field. For the second and more specific part,
the first search was narrowed down using the
search terms first episode psychosis, insight
and beliefs about psychosis. The review does
not use meta-analytic techniques.
Suicidal behavior in the general
population

Suicidal behaviors are complex phenomena,

influenced by the individuals psychology, biology, culture, and social and political environment [1] . They vary in severity, from suicidal
ideas through to gestures, risky lifestyles, suicidal plans and suicidal attempts to completed
suicide [2] . A common definition of suicide is
self-inflicted death, with explicit or implicit evidence that the person intended to die [3] , while
suicide attempts usually involve self-injurious
behavior with the intent to die. Suicidal ideas
are thoughts of serving as the agent of ones own
death and vary in their severity depending on
the specificity of suicidal plans and degree of
suicidal intent [4] .
Suicide accounts for approximately 1.5% of
all deaths, making it the tenth leading cause of
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10.1586/ERN.11.191

death worldwide [5] . The prevalence of suicide

varies between regions and countries, with the
lowest annual rates in Latin America and Muslim
countries (<6.5 suicides per 100,000 persons per
year), the highest rates in Eastern Europe (>27
suicides per 100,000 persons per year) [6] and
with the rates in the UK, USA and most of the
Nordic countries in the mid-range (1218 per
100,000persons per year for men) [1] . Suicide
rates in immigrants tend to be more similar to
rates in their native country than to rates in their
current country of residence [7,8] . Suicide rates
are usually highest in the elderly, even if they
have increased in the young and decreased in the
elderly over the past 50years [9] . Men generally
die by suicide more often than women (24:1
ratio) [10] , while suicide attempts on the other
hand are more prevalent among women [11] .
There are no national or international surveillance systems for the monitoring of suicide
attempts [12] , which are actually believed to be
more prevalent than successful suicides (an estimated 1025:1 ratio) [2] . Suicidal thoughts are
even more common, as nearly 15% of American
youths report having seriously considered suicide within the previous year [4] . The different
suicidal behaviors are linked to each other, as
suicidal thoughts are related to increased risk for
suicide attempts [13] , the risk of attempts is higher
in the context of a suicidal plan [14,15] , one suicide
attempt increases the risk for later attempts and
a history of suicide attempts is the strongest risk

2012 Ingrid Melle

ISSN 1473-7175

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Melle & Barrett

factor for later death by suicide. There are indications of previous

attempts present in approximately 40% of deaths by suicide [10,16] .
The risk of suicidal behavior is related to personality traits, in
particular to impulsive and aggressive traits. Risk is also related
to cognition, in particular to disadvantageous decision-making
processes, affective lability and stress response disturbances [1719] .
The search for possible biomarkers has focused on serotonergic
neurotransmission, as earlier studies have reported an association between suicidal behavior and low levels of the serotonin
metabolite 5-hydroxyindoleacetic acid in the cerebrospinal fluid
in depressed patients. However, more recent studies fail to show
such associations for other patient groups outside of patients with
depression [20,21] . Low serum cholesterol levels have been associated with increased suicide risk. Suggested mechanisms behind
this increased risk have included interactions between cholesterol
and serotonergic function in the CNS [22] .
Twin and adoption studies show a clear genetic influence on
suicide risk [23,24] . Most molecular genetic studies carried out so
far have been candidate gene studies of the serotonergic system,
with reports of possible associations between several genetic variants in suicidal behavior, but current results are partly conflicting
[25] . Other studies have focused on the genetics of neurotrophins
(proteins that induce the survival and development of neurons);
again with conflicting results [26,27] .
Suicidal behavior in severe mental disorders

More than 90% of individuals who die by suicide in Europe and

the USA have a mental disorder at the time of death [16,28] . Mood
disorders (in particular depression) are most commonly associated
with suicide, followed by substance use-related disorders (in particular, alcohol use disorders), schizophrenia and personality disorders (in particular, borderline and antisocial personality disorders)
[28,29] . Comorbidity of disorders increases the suicide risk.
Patients with schizophrenia spectrum psychotic disorders have
a particularly high prevalence of suicide and suicidal behaviors.
Suicide is the leading single cause of premature death among
patients with schizophrenia, with a 12-times increased risk of
dying by suicide compared with the general population [30] and
estimates that 513% of patients with schizophrenia will die by
suicide [31,32] . While the 13% risk gives the percentage of a sample
who died by suicide at the point of follow-up (proportional mortality), the 5% risk reflects the percentage of an original sample
who died by suicide (casefatality rate). As proportionate mortality estimates assume a constant suicide risk over a lifetime,
it overestimates the suicide risk in schizophrenia and the 5%
figure is therefore probably the most accurate. The prevalence of
nonfatal suicidal behavior in schizophrenia is significantly higher,
with suicidal ideation and suicide attempts seen in approximately
50% of patients [33] . When a patient with schizophrenia brings
up the issue of suicide, this should always raise clinical concern.
General risk factors for suicide & suicidal behavior in
schizophrenia

Models of suicidal behavior in severe mental disorders must

address questions about both factors that contribute to long-term
354

vulnerability, precipitating factors in the here-and-now, and factors that might be both trait and state dependent [34] . The most
consistent demographic risk factor for suicide across all populations is being white and male. The case is the same in schizo
phrenia, even if gender differences are less pronounced [35,36] .
While the absolute risk for suicide is also highest in older patients
with schizophrenia, patients die by suicide at a younger age, with
the highest relative risk (compared with the general population)
in the age range 2240years [36] .
The most important risk factor for suicide in patients with
schizophrenia is previous suicide attempts, and these attempts
appear to be more serious than in the general population. Other
major risk factors shared with the general population are the presence of depression, feelings of hopelessness and lack of social support [36,37] , higher levels of impulsiveaggressive personality traits
[38] , and drug misuse or dependency [35,39] .
Illness-related risk factors for suicide in schizophrenia

Patients with a more severe course of illness have an increased suicide risk. This includes patients with more relapses, using higher
doses of medication and/or with more frequent or longer hospitalizations, and the risk is higher within the first few weeks after
hospital discharge [36] . In addition, poor treatment adherence to
medical or psychosocial treatments is associated with an increase
in suicide rates [35] . The presence of an active psychotic illness (i.e.,
relapses or exacerbations with high levels of psychotic symptoms)
is also associated with increased suicide risk [4042] . However,
studies of the relationship with specific psychotic symptoms, such
as delusions or hallucinations, have inconsistent findings [43,35,36] .
There are indications that a clinical picture characterized mainly
by hallucinations rather than delusions is associated with an
increased risk [44,45] , and there have been reports of attempted [46]
or completed suicides [47] as a result of command hallucinations.
Patients with monosymptomatic hallucinations or patients experiencing command hallucinations are relatively rare, so these are
not common causes of suicidal behavior in schizophrenia [36] .
Cognitive impairments, including episodic memory, processing
speed, verbal fluency, attention, executive function and working memory dysfunctions, are highly prevalent in schizophrenia,
independent of clinical symptoms and antipsychotic medications.
Suicidality in schizophrenia has been found to be associated with
higher IQ in some, but not all, studies examining this relationship
[4850] . There are also few and inconsistent findings regarding the
relationship between suicidality and specific cognitive domains;
while some find indications of better executive functioning in
patients with a history of suicide attempts [4850] , others do not
find any associations with suicidal behaviors [51] .
Suicidal behavior in the early phases of schizophrenia

The risk for suicide is highest in the early phases of schizophrenia

spectrum disorders [32,52] . Even if the risk continues over the
course of the disorder [53] , most deaths by suicide take place within
the first decade after treatment starts, with approximately 50%
occurring within the first 2years [36] . Parallel patterns are seen
in severe affective disorders, including major depression [54] and
Expert Rev. Neurother. 12(3), (2012)

Insight & suicidal behavior in first-episode schizophrenia

bipolar disorder [10] . This is somewhat at odds with the view that
suicidal behavior is primarily due to the negative consequences
of a chronic disorder. One reason for the early risk may be that
important risk factors, such as depression [35] and substance use
[55] , are prevalent both in the early treated period and before treatment starts [56,57] . Other subjective experiences with possible relations to suicidal behavior, such as self disorders, are also prevalent
in this phase of illness [58] .
There are also clear indications of an increased risk of suicidal
behavior before the start of a first treatment, and 1428% of
patients with first-episode psychosis have attempted suicide prior
to their first treatment contact [5961] . There are even indications
that untreated psychotic patients have higher risks for violent
and potentially lethal methods of attempting suicide than treated
patients [62] . The period between onset of the first psychotic episode and the start of treatment (the period of untreated psychosis) can, in some cases, be alarmingly long. Studies indicate that
714% of patients attempt suicide or are engaged in self-harm in
this period [61,6365] . Some find that a longer duration of untreated
psychosis is associated with increased risk for suicidal behavior
[63,65,66] , but this finding is not consistent [64,6769] . Focusing
explicitly on this period, we found that a longer duration of
untreated psychosis was associated with more attempts in this
period, but not before onset of psychosis [61] . This supports the
view that shortening the duration of untreated psychosis may
reduce the risk of severe suicidal behavior at the start of first
treatment [70] .
Insight, subjective experiences & suicidal behavior

Poor insight, or lack of awareness of being ill, is considered a

key feature of psychosis and has been seen by many as the actual
defining characteristic of a psychotic disorder. Traditionally,
insight was viewed as a unitary concept and an all or none phenomenon, comprising the patients experience of their disorder.
More recently, insight has been viewed as a multidimensional
and continuous construct. David defined insight along three
overlapping dimensions: the individuals recognition of having a
mental illness; compliance with treatment; and ability to relabel
unusual mental events as pathological [71] . Poor insight is found in
all psychotic disorders, and is most pronounced in schizophrenia
and bipolar disorder [72,73] . As many as 5080% of patients with
schizophrenia do not believe they have any disorder at all [74] . Lack
of insight does not seem to be a static phenomenon. Although it
may persist in some patients [75] , insight may also improve during
treatment [76] .
Overall, insight has been found to have contradictory associations with outcome. Higher insight is associated with lower symptom levels [77] , better treatment adherence and social functioning
[78] , and better work performance [79] . However, for some patients,
higher insight is also associated with more feelings of depression
[77] and hopelessness [80] , and a lower quality of life [81] . In patients
with delusions, low insight is associated with better self acceptance, and a higher sense of autonomy and personal growth than
high insight [82] . Insight has also been related to suicidal behavior.
Several studies indicate that high levels of insight, or aspects of
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Review

insight, may increase the risk for suicidal behavior [60,64,8386] .

Others find no relationships between insight and suicida lity
[35,87] , and a few studies report a protective effect of insight [88,89] ,
possibly through increasing compliance with treatment.
Another possible explanation for the association between high
insight and suicidality is that individuals with good premorbid
adjustment and high insight are more demoralized by their illness,
a model that receives some support from empirical studies [87] .
Another hypothesis in line with this is that of the assumed consequences of psychotic disorders (i.e., fear of mental disintegration
may increase the risk for suicide) [35] . One possible explanation
for the apparently contradictory findings regarding insight is thus
that the impact of insight depends on meanings attached to the
disorder [90] , or in other words, the patients beliefs about psycho
tic disorders. While insight into psychosis involves acceptance of
a personal illness regardless of knowledge and facts about their
illness [71] , beliefs about psychosis are cognitions about causation,
treatment options and prognosis of psychotic disorders [91] .
In general, beliefs about psychotic disorders seem to be highly
negative, and schizophrenia in particular appears to be among
the most stigmatized of mental disorders [92] . People with schizo
phrenia are considered unpredictable and dangerous; elicit uneasiness, uncertainty and fear in other people; and pessimistic beliefs
about the course of schizophrenia prevail. In addition, very negative views about pharmacological treatments for mental disorders
are common [93] . Beliefs about illness may shape the emotional
responses to illness and the ensuing health-related behavior. It is
not unlikely that patients who receive a diagnosis of schizophrenia
can be influenced by the existing negative beliefs about schizophrenia. Studies show that negative illness perceptions have been
related to depression and post-psychotic depression, anxiety and
low self-esteem [9496] , and to suicidality [97] .
It is therefore possible that the impact of insight on suicidality will depend upon the individuals beliefs about psychosis. A
patient who believes that having a psychotic disorder necessarily
leads to a deteriorating mental state can react differently to the
insight of having this disorder with a more optimistic view on the
course of the disorder. In line with this, several studies indicate
that beliefs about psychosis can moderate the association between
insight and other aspects of outcome, as patients with high insight
and low levels of stigmatizing beliefs report lower levels of depression, more hope, better self-esteem and better quality of life than
patients with high insight and high levels of negative beliefs [91,98] .
A relatively current review suggests that reports of associations
between insight and previous suicidal attempts in cross-sectional
studies may be based on selection and recall bias in depressed
patients [99] . However, in a more recent study, we examined the
moderating effect of beliefs about psychosis on the relationship
between insight and current suicidal behavior. Here, we found
that high levels of both insight and of negative beliefs had an
independent negative influence on suicidal behavior, without signs
of statistical mediation or moderation. This effect was present even
after correcting for current levels of depression, indicating that
apparent insight or negative beliefs were not just epiphenomena
of depressive mood [100] .
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Expert commentary

Suicidal behavior is a significant clinical problem in the treatment

of schizophrenia in general, and in the treatment of people with
first-episode psychosis in particular. Several significant risk factors, such as substance abuse and depression, are prevalent in this
particular patient population, and their evaluation should be a significant part of clinical risk assessment [101] . Specific to psychotic
disorders is the possible link between high insight and suicidality,
particularly in patients with negative beliefs about psychotic illnesses. The combination of previous suicide attempts, negative
views on course and outcome, depression and hopelessness in
the context of increasing insight and increasing suicidal ideation
should be taken as indications of high suicide risk.
The clinical consequences of this are that suicidal behavior,
level of depression, feelings of hopelessness and level of insight
should be monitored closely during treatment. Clinical depression should be treated adequately. While the emergence of insight
is a positive sign associated with remission of psychotic symptoms, patients in this phase of development should be monitored
even more closely for indications of suicidal behavior. Patients are
often transferred from inpatient to outpatient treatment at this
point in time, so the emergence of insight may also coincide with
the perceived loss of important treatment and social contacts. It is
important to ensure continuity of care to the next treatment level.
Adequate treatment of psychotic symptoms, with the simultaneous aim of reducing stressful side effects such as akathisia, is of
essence. The use of clozapine might be considered for patients
with persistent severe suicidal behavior. We also need to pay
attention to possible side effects of psychosocial interventions.
Information given to increase knowledge about psychotic disorders within the framework of psychoeducational interventions

may be interpreted negatively by patients. It is important that

the patients perception of the information is discussed, and that
there are efforts to install realistic hopes of a positive outcome.
Moreover, therapists should be aware that an increase in cognitive
insight through cognitive behavioral therapy may temporarily
increase suicidal ideation.
Five-year view

There are currently several lines of development that are important for progress in this area. Several large prospective studies of
first-episode patients are expected to publish results on long-term
course and outcome within the next few years. These studies will
give us important new data on the development of suicide risk
over the course of the disorders and on the relevant risk factors at
different points in time. In addition, the current explorations of
the role of subjective experiences in relation to suicidal behavior
may help to identify personal markers of increased suicide risk,
which can be used in treatment settings and for personal risk
assessments. Finally, the immense research activity in molecular
genetics, including genome-wide association studies, will hopefully give us new information on the biological underpinnings
of suicide risk. This may aid the development of clinically useful
biomarkers.
Financial & competing interests disclosure

The authors have no relevant affiliations or financial involvement with any

organization or entity with a financial interest in or financial conflict with
the subject matter or materials discussed in the manuscript. This includes
employment, consultancies, honoraria, stock ownership or options, expert
testimony, grants or patents received or pending, or royalties.
No writing assistance was utilized in the production of this manuscript.

Key issues
Suicide and suicidal behaviors are common in schizophrenia and related psychotic disorders.
Suicide attempts in schizophrenia are often with more violent and lethal methods.
The early treated phase of the disorder is a period of particularly high risk.
Risk factors for suicide and suicidal behaviors are, to a large extent, the same as in the general population.
These risk factors include previous suicide attempts, impulsive personality traits, drug abuse, depression and feelings of hopelessness.
While a more severe course of illness may increase risk, there are no clear indications of a particular risk associated with specific
psychotic symptoms, such as delusions and hallucinations. Insight into having a severe mental illness may increase suicide risk.
Negative beliefs about psychotic disorders may increase suicide risk.

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