Suicidal risk in patients with aggression in schizophrenia: a systematic review

Lidia V. Bravve ^1* Maria A. Kaydan ¹ Georgy P. Kostyuk ^1,2,3,4

• ¹ Psychiatric Clinical Hospital № 1 named after N.A. Alekseeva, Moscow, Russia
• ² Faculty of Psychology, Lomonosov Moscow State University, Moscow, Moscow Oblast, Russia
• ³ I.M. Sechenov First Moscow State Medical University, Moscow, Moscow Oblast, Russia
• ⁴ Department of Psychiatry, Federal State Budgetary Educational Institution of Higher Education Russian Biotechnological University, 125080 Moscow, Russia, Moscow, Russia

Suicide is the primary risk factor for mortality among individuals with schizophrenia, with a mortality rate that is 10 times higher than in the general population. In the study of individuals who have committed suicide, some exhibited a high risk of aggression and impulsivity, which permitted the consideration of these indicators as predictors of suicide risk. The extant literature contains a number of debates concerning diverse conceptualisations of aggression and impulsivity in the context of suicidal behaviour. In schizophrenia, the level of verbal aggression is 43% and physical aggression is 24%. An analysis of the psycho-emotional state of patients with suicidal behaviour in the anamnesis reveals an indication that the suppression of emotions (including aggression) and the avoidance of harm may result in suicide. This finding is at odds with the previously mentioned results, and the present review sought to assess the impact of aggressive behaviour on suicide risk in patients with schizophrenia. Methods: The search was conducted in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses statement. The search was conducted in PubMed, Cochrane Library, PsychINFO and Mendeley Data. The search terms used were "aggress*" and "suicid*" or "autoaggress*" and "schizophrenia*". It was limited to papers published between 2009 and 2024 and continued until November 2024 (PROSPERO CRD42024628033). Results: Six studies demonstrated a positive association between aggression and suicidal behaviour, or employed a logistic regression model in which the risk of aggression increased the risk of suicide and vice versa. Two studies revealed no association between suicide risk and aggression.Conclusions: Patients with a history of suicide attempts and aggressive behaviour are considered to be at risk of suicide, thus emphasising the necessity for preventive measures to be implemented for this cohort of patients. The conclusion of the research may not be entirely accurate and may not reflect the true extent of the problem, due to the significant number of methodological inaccuracies and discrepancies in the design of the studies included in the review.