*Limitations*

When interpreting the results of this review, several limitations should be considered. First, all reviews of research are retrospective and, therefore, are subject to bias. Second, we selected only articles in English, omitting relevant articles in other languages from our review. Third, we did not examine the role of gender on suicide risk. Fourth, it was not always simple to apply the concept of "demoralization" retroactively to studies that did not specifically set out to study it, for example ones that look at "hopelessness" or "helplessness". Moreover, given this di fficulty, the division of the two sub-chapters of the result section can sometimes seem confusing. Specifically, we included in the first section the studies that presented the main focus on suicidal risk and in the second chapter the

studies that mainly considered demoralization, insight, stigma, and quality of life in patients a ffected by schizophrenia.

Finally, not all the studies reviewed in this paper distinguished completed suicide from attempted suicide. Suicide attempters and completers with schizophrenia appear to represent two overlapping but distinct groups, with di fferent clinical and demographic profiles.

## **5. Conclusions**

Despite increased screening for depression in clinical settings, demoralization symptoms in patients with schizophrenia are often either missed or dismissed by clinicians. This is at least in part because of the di fficulty of distinguishing between symptoms of a concurrent mood disorder and those of the schizophrenia syndrome itself, in which disturbed a ffect and di fficulty expressing emotions are central negative symptoms. Our results sugges<sup>t</sup> that, in clinical practice, it is important to recognize the symptoms of demoralization, in particular hopelessness, using appropriate psychological tools in order to better approach the su ffering of our patients and implement suicide prevention programs in patients with schizophrenia. Identifying specific subgroups of patients with schizophrenia with di fferent suicide risk profiles, including the presence of demoralization symptoms, is an important goal for future research. Furthermore, in clinical practice, clinicians should definitely focus on the degree of insight in their clients in order to evaluate the suicidal risk, through a careful clinical evaluation and through the use of appropriate tools that evaluate and prevent suicidal risk.

**Author Contributions:** I.B. wrote the manuscript, S.S., E.R., M.H., G.C. and D.E. contributed to the collection of articles, D.L. corrected and reviewed the article. M.P. provided the original idea and the intellectual impetus.

**Funding:** This research received no external funding.

**Acknowledgments:** No Acknowledgments.

**Conflicts of Interest:** The authors declare no conflict of interest.
