A 65-Year-Old Man Brought to the ED by Military Police

Jeffrey S. Forrest, MD; Alexander B. Shortridge

Disclosures

August 06, 2019

Suicide is the single leading cause of premature death in patients with schizophrenia, making careful monitoring and assessment for suicidal ideation essential in this patient population. As many as 20%-50% of patients with schizophrenia make at least one suicide attempt.[2] Estimates suggest that as many as 10%-13% of patients with schizophrenia ultimately complete suicide. Patients with schizophrenia and a higher intelligence quotient have been found to be at greater risk for suicide, as have patients of younger age.[11] The second-generation antipsychotic clozapine has been associated with reduced suicidality in patients.

Substance abuse is another concern in patients with schizophrenia. The estimated prevalence of substance use disorders in patients with schizophrenia is thought to be at least 40%-50%; this has not changed over the past several decades.[12] A meta-analysis from 1990-2017 estimated that at least 26% of patients with schizophrenia are regular users of cannabis.[12] Regular cannabis usage has been postulated to be a risk factor for the development or potentiation of psychotic symptoms, with a potential relationship existing between the dose used and age of the first usage.[13] Increased use of street drugs is also demonstrated in patients with schizophrenia. Agents such as cocaine, methamphetamine, or phencyclidine may cause or exacerbate psychotic symptoms in their own right, making this issue of particular concern. Alcohol abuse is also common in patients with schizophrenia, with prevalence rates as high as 24%, which increases risk for both hospitalization and suicide.[12]

The long-term outcome of schizophrenia varies and is influenced by numerous factors, including access to resources and medication compliance.[14] A significant majority of patients require repeated hospitalizations for symptom exacerbations. Only a small minority of patients can be described as having a good outcome. Positive prognostic factors include later age of onset, female gender, rapid onset of symptoms, and presence of positive symptoms (as compared with negative symptoms). Negative prognostic indicators include multiple or severe negative symptoms, male gender, early age of onset, and insidious onset of psychotic symptoms.

The patient in this case was found to have self-discontinued an antipsychotic medication. After several weeks of admission and care coordination, he agreed to receive a long-acting injectable form of his medication, with careful plans and family involvement helping to ensure his participation in continued treatment going forward.

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