Suicide Attempt and Functional Change for Individuals with Chronic Mental Illness: Implications for Risk and Rehabilitation

Background:  Suicide is a major cause of premature death among those with Schizophrenia, and those with a history of suicide attempt (attempters) are at markedly higher risk for completed suicide than those without a history of suicide attempt (non-attempters).  Given the association between functional level and suicide, change in functioning over time carries implications for change in suicide risk.  Although we know that community-based support programs (CSPs) can improve functioning, no known studies have examined whether or not these programs are equally effective for attempters and non-attempters.  It is critical to determine whether or not these groups are differentially responsive to treatment to better guide suicide prevention programming in CSPs.

Purpose: The current study aimed to (1) examine the rate and character of change in functional level (independent living, occupational and social relationships) among suicide attempters and non-attempters in CSPs (2) test for differences in functional level change between attempters and non-attempters in CSPs.

Methods: Analyses were performed using data from attempters (n=81) and non-attempters (n=85) in a seven-wave NIMH-funded longitudinal study investigating psychosocial rehabilitation among individuals with Schizophrenia; measures were taken every 6 months over a 3-year period.  Established measures for suicide attempt status, functional level, and clinical variables (symptoms and self esteem) were used.  Using the functional domains as outcomes, two-level growth curve analyses were employed.  A series of unconditional growth models were compared to determine the polynomial function of time that provided the best fit.  An interaction of time with attempt status was then entered into the model to test for group differences.

Results:  For the domain of social relationships, attempters and non-attempters were found to change differently over time.  Non-attempters demonstrated positive linear change over time (b = 0.19, SE = 0.05, p < .001), while attempters did not demonstrate any change.  For the domains of independent living and work, attempters and non-attempters changed similarly over time.  Specifically, a quadratic model best fit the data for both groups in the domains of independent living (linear b = 0.23, SE = 0.05, p < .001; quadratic b = -0.02, SE = 0.01, p < .01) and work (linear b = 0.10, SE = 0.06, p < .010; quadratic b = -0.03, SE = 0.01, p < .05), indicating that individuals exhibit improvement followed by decline over time.

Conclusions and Implications: Given the role of social connectedness in protecting against suicide, it is problematic that the group of attempters did not show any change in social functioning while non-attempters showed significant improvement over time. This calls for targeting the development of social skills among attempters engaged in CSP treatment.  Given that poorer functioning can increase suicide risk, it is reassuring that both groups showed time-limited improvement in the areas of employment and independent living.  However, the subsequent drop-off in functioning in these areas may be more concerning for suicide attempters because the decline may leave them more vulnerable to suicide risk.  The finding of “tipping points” in these domains suggests critical windows within which clinicians can intervene.