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Patients recovering from schizophrenia may experience significant fear regarding the future, hopelessness, loneliness, future hospitalizations, concern about employment, problems with social relationships, all of which elevate the risk of suicide and depression. Clinicians must work on addressing these issues with the patient and teach them strategies to cope with their feelings of loss and grief and finding meaning in their lives. Most importantly, the patient, family, and friends must understand that if the patient has any thoughts about suicide, or speaks about suicide in any way, they must seek help immediately from a psychiatrist or a suicide hotline.

The goal of treatment is to prevent suicide ideation (thoughts of suicide) and, if they occur, to prevent any attempted suicide. The major modality for treating suicide risk is medication. In 2004, a study called the International Suicide Prevention Trial (InterSePT) compared two atypical antipsychotic drugs, clozapine (Clozaril) and olanzapine (Zyprexa) for efficacy in reducing suicidality in patients with schizophrenia. Results indicated a 26% reduction of suicide attempts and hospitalizations to prevent suicide for the patients taking clozapine vs. a 20% reduction for those taking olanzapine. This significant difference resulted in the U.S. Food and Drug Administration (FDA) noting that clozapine is specifically indicated for the treatment of suicidality in schizophrenic patients. Investigation continues regarding the comparison of efficacy of other atypical antipsychotics for reducing suicidal behavior.

In addition to directly treating the patient to prevent suicidal behavior, it is important to treat symptoms that increase the risk for suicide, including:

• Depression
• Substance abuse
• Poor self-esteem
• Development of akathisia (inner restlessness and constant urge to keep moving)

Debate continues regarding the use psychosocial therapy and deeper understanding of schizophrenia for reduction of suicidal behavior. There is an indication from one study that deeper insight into their condition actually may increase suicide ideation in schizophrenics. Research about this issue is ongoing.

Adjunct Treatment

Additional medication may be necessary in the treatment of schizophrenia either to enhance the effect of antipsychotics or to treat other symptoms such as:

• Residual positive symptoms
• Negative symptoms
• Depression
• Cognitive deficits
• Agitation or aggression
• Anxiety
• Obsessions or compulsions

Medications to treat these conditions that may be combined with antipsychotic include:

• Anticonvulsants (carbamazepine, valproate)
• Antidepressants
• Additional antipsychotics for augmentation
• Benzodiazepines
• Beta blockers
• Glutamatergic agents (glycine, D-cycloserine, D-serine)
• Lithium

In addition, there are non-drug related therapies noted by the American Psychiatric Association (APA) which may be of benefit to schizophrenic patients under certain circumstances, including:

• Electroconvulsive therapy (ECT) - when combined with antipsychotics, ECT may be effective for patients with schizophrenia or schizoaffective disorder who have severe psychotic symptoms that are resistant to treatment with antipsychotic medication alone and for catatonic patients. Electroconvulsive therapy combined with medication has also been studied as a treatment during the maintenance phase of treatment-resistant schizophrenia and the rate of recurrence or relapse was less than half of that of patients treated with ECT or medication alone. Side effects include changes in cognitive status; headache; general muscle ache; and nausea/vomiting. Most side effects are temporary.