Suicide risk in schizophrenia: Explanatory models and clinical implications, the schematic appraisal model of suicide (SAMS)

Purpose. The objective of this paper was to evaluate the Cry of Pain model of suicide behaviour as applied to psychosis and to derive theoretically driven guidelines for prevention. Suicide risk in psychotic patients is a serious but poorly understood clinical and social problem. There is a dearth of psychological models to explain suicidal behaviour and to guide effective preventative clinical interventions. Understanding suicidal behaviour in psychosis may be facilitated by utilizing models from depression. The 'Cry of Pain' model of suicide is founded on an evolutionary approach to understanding suicidal behaviour in depression. Methods. The model was critically evaluated and relevant literature reviewed. Results. Although strengths of the model were identified, lack of clarity regarding the concepts of defeat, entrapment, and lack of rescue appeared to limit its theoretical and clinical utility. We suggest a modification to this model which replaces concepts of defeat, entrapment, and lack of rescue with a four-stage appraisal process in conjunction with information-processing biases and suicidal schema. Conclusions. Methods of testing this model are suggested and guidelines for a clinical intervention (Cognitive Behavioural Suicide Prevention for Psychosis; CBSPP) are outlined.