BACKGROUND Mental disorders have a strong association with suicide. This meta-analysis, or statistical overview, of the literature gives an estimate of the suicide risk of the common mental disorders.

METHOD We searched the medical literature to find reports on the mortality of mental disorders. English language reports were located on MEDLINE (1966-1993) with the search terms mental disorders', 'brain injury', 'eating disorders', 'epilepsy', 'suicide attempt', 'psychosurgery', with 'mortality' and 'follow-up studies', and from the reference lists of these reports. We abstracted 249 reports with two years or more follow-up and less than 10% loss of subjects, and compared observed numbers of suicides with those expected. A standardised mortality ratio (SMR) was calculated for each disorder.

RESULTS Of 44 disorders considered, 36 have a significantly raised SMR for suicide, five have a raised SMR which fails to reach significance, one SMR is not raised and for two entries the SMR could not be calculated.

CONCLUSIONS If these results can be generalised then virtually all mental disorders have an increased risk of suicide excepting mental retardation and dementia. The suicide risk is highest for functional and lowest for organic disorders with substance misuse disorders lying between. However, within these broad groupings the suicide risk varies widely.

Suicide as an outcome for mental disorders. A meta-analysis.

Schizophrenia is a disabling, chronic psychiatric disorder that poses numerous challenges in its management and consequences. It extols a significant cost to the patient in terms of personal suffering, on the caregiver as a result of the shift of burden of care from hospital to families, and on society at large in terms of significant direct and indirect costs that include frequent hospitalizations and the need for long-term psychosocial and economic support, as well as life-time lost productivity. ‘Burden of care’ is a complex construct that challenges simple definition, and is frequently criticized for being broad and generally negative. Frequently, burden of care is more defined by its impacts and consequences on caregivers. In addition to the emotional, psychological, physical and economic impact, the concept of ‘burden of care’ involves subtle but distressing notions such as shame, embarrassment, feelings of guilt and self-blame. The early conceptualization of ‘burden of care’ into two distinct components (objective and subjective) has guided research efforts until the present time. Objective burden of care is meant to indicate its effects on the household such as taking care of daily tasks, whereas subjective burden indicates the extent to which the caregivers perceive the burden of care. Research contributions in later years (1980s to the present) have added more depth to understanding of the construct of burden of care by exploring important determinants and factors that likely contribute or mediate the caregiver’s perception of burden of care. Several studies examined the role of gender, and reported that relatives of male patients with schizophrenia frequently experience more social dysfunction and disabilities than those of female patients. Similarly, a number of other studies documented the contribution of ethnicity and cultural issues to subjective burden of care. Although there is no complete agreement on whether a specific cluster of psychotic symptoms has the most impact on a caregiver’s burden of care, there is agreement that the severity of symptoms increases it. An extensive literature concerning family interventions in schizophrenia has demonstrated the positive impact of various family interventions in improving family environment, reducing relapse and easing the burden of care. Although the evidence of such positive impact of family interventions in schizophrenia is well documented, such interventions are neither widely used nor appropriately integrated in care plans, and are frequently underfunded. Although the cost of caregiving is considered to be significant, there are no reliable estimates of the costs associated with such care. The majority of available literature categorized the cost of burden of care among the indirect costs of schizophrenia in general. In recent years, attempts to compare the costs of caregiving in several countries have been reported in the evolving literature on this topic. ‘Burden of care’ as a complex construct certainly requires the development of appropriate methodology for its costing. In achieving a balance between the patients’ and caregivers’ perspectives, caregivers have to be included in the care plan and adequate information and support extended to the family and caregivers. Access to better treatment for patients, including medications, psychosocial interventions and rehabilitation services, are important basic elements in easing the burden on caregivers. Other measures such as availability of crisis management, provision of legally mandated community treatment to avert hospitalization, and well informed and balanced advocacy are also important. Although research efforts have been expanded in the last 3 decades, an urgent need exists for enhancing such efforts, particularly in the development and evaluation of effective family interventions strategies. There is also a need for continued improvement in the delivery of psychiatric services to the severely psychiatrically ill and their families. As there is a lack of reliable cost information about the family burden of care specific to schizophrenia, there is an urgent need to develop reliable approaches that can generate data that can inform in policy making and organization of services.

The burden of schizophrenia on caregivers: a review.

Suicide rates among schizophrenic individuals are disturbingly high. At present, suicide is the number one cause of premature death among schizophrenics, with 10 to 13 percent killing themselves. Recent studies place the risk of suicide for persons with schizophrenia at a level comparable to that for persons with affective disorder. Depression, especially the symptom of self-reported or perceived hopelessness, is an important comorbidity factor in assessing this risk. Young white schizophrenic men with high levels of premorbid functioning and high expectations are at particularly high risk. Schizophrenic women, unlike women in the general population, behave more like men when it comes to choosing suicide. This article reviews recent studies reporting suicide rates and risk factors for suicide among schizophrenic patients. Current issues concerning the prediction, prevention, and treatment of suicidality among persons with schizophrenia are also discussed.

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Schizophrenics Kill Themselves Too: A Review of Risk Factors for Suicide

OBJECTIVES: Pediatric chronic physical illness and adult psychiatric disorders are substantial sources of burden for family care-takers, but little attention has been paid to parental burden resulting from children's or adolescents' psychiatric disorders. This paper describes the predictors of perceived parental burden and its impact on the use of specialty mental health and school services. METHODS: A representative general population sample of 1015 9-, 11-, and 13-year-olds and their parents completed structured psychiatric diagnostic interviews and the Child and Adolescent Burden Assessment. RESULTS: Weighted estimates indicated that 10.7% of parents in the general population perceived burden resulting from their children's symptomatology. Significant predictors of perceived burden were levels of child symptomatology and impairment and parental mental health problems. Children's depressive and anxiety disorders were associated with less burden than other diagnoses. The effects of child disorder severity on specialty mental health service use appeared to be mediated by the level of burden induced. CONCLUSIONS: Substantial levels of parental burden resulted from child psychiatric disorders and were a major reason for specialist mental health service use.

Perceived parental burden and service use for child and adolescent psychiatric disorders.

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Perceived Parental Burden andService UseforChild andAdolescent Psychiatric Disorders

et al., 1961, Grad et al., 1963, Hoenig et crl., 1965). Wing et al. (1964) have pointed out, however, that this may only be achieved at a price: ... &dquo;the policy of early discharge of schizophrenic patients is based to a large degree on the willingness of relatives to attempt the role of nurse and put up with considerable discomfort and distress&dquo;. Financial and other difficulties for the family may also be involved.

The schizophrenic patient in the community and his effect on the household.

General Psychopathology, Vol. 1

General Psychopathology, translated from the German 7th Edition

One of the main differences of an extra-mural psychiatric service based on a General Hospital and a conventional type of service based on a Mental Hospital is that the patient spends much less time in hospital in the former service and much more time in his home (Hoenig et al. 1965). Mental Hospital patients have been found to show a higher death rate than the General Population (Shepherd 1957, Norris 1959). It seems pertinent, therefore, to ask whether the death-rate in the extra-mural type of service shows any change from that of the Mental Hospital service. Change in either direction could be expected. I t might be argued that in the General Hospital psychiatric unit the level of general medical care for the patients might be higher; also that admission to Mental Hospital may be traumatic and in many cases, particularly in the elderly, be a factor in itself which hastens death. If this were so, patients in an extra-mural service would show a lower death-rate. It is also arguable to the contrary that if patients spend most of the time in Mental Hospital rather than at home, they may find medical care closer at hand and professional nursing care can be given to a greater extent than if the patient were left with his relatives or others. Thus according to this argument the more time the patient spends out of hospital, the more he becomes exposed to the effects of serious illness. The extra-mural service provided by certain General Hospital psychiatric units in the Manchester Region gave us an opportunity to investigate this matter.

J. Hoenig

Papers

The schizophrenic patient in the community and his effect on the household.

General Psychopathology, Vol. 1

General Psychopathology, translated from the German 7th Edition

Mortality of psychiatric patients

Extramural care of psychiatric patients