Risk Factors for Suicide in Pregnancy Identified

Nancy A. Melville

January 22, 2016

Suicide during pregnancy and in the postnatal period, though uncommon, is associated with important risk factors, including a greater likelihood of having received a diagnosis of depression and a lower chance of having received treatment, compared with suicides occurring outside of the perinatal period, according to a new study of patients in the United Kingdom.

"The key message [from the study] is that clinicians should ensure adequate follow-up and treatment for perinatal women with moderate to severe mental illness who are under the care of psychiatric services ― including not only those with a psychotic illness but also those with other diagnoses, including depression, personality disorder, and anxiety," first author Hind Khalifeh, MRCPsych, told Medscape Medical News.

The study was published online January 15 in the Lancet Psychiatry.

Violent Death

The investigators analyzed data from 1997 to 2012 in the UK National Confidential Inquiry into Suicides and Homicides by People with Mental Illness, including data regarding all suicides among patients aged 10 years or older who had contact with psychiatric services in the previous year.

Among 4785 women who had died as the result of suicide between the ages of 16 and 50 years, 98 (2%) died during the perinatal period; of 1485 who died by suicide between the ages of 20 and 35 years, 74 (4%) died in the perinatal period.

In examining potential risk factors, the authors found that women who died from suicide during the perinatal period were more likely to have received a diagnosis of depression compared with women who died by suicide but who were not in the perinatal period (adjusted odds ratio [OR], 2.19; 95% confidence interval [CI], 1.43 - 3.34; P < .001), and they were less likely to be receiving any active treatment (OR, 0.46; 95% CI, 0.24 - 0.89; P = .022) at the time of death.

Perinatal women who died as a result of suicide were younger than the women who died by suicide but who were not in the perinatal period (crude OR, -6.39; P < .0001). They were more likely to be married (OR, 4.46; P < .0001), to have had illness of shorter duration (OR 2.93; P < .001), and to have no history of alcohol misuse (OR, 0.47; P = .027).

Although there was a downward trend in the mean number of nonperinatal women who died by suicide during the course of the study (-2.07 per year; P = .02), no such decline was observed in suicides among perinatal women (-.07 per year; P = .58).

Notably, women who died by suicide in the perinatal period were more likely to have used a method of suicide considered more violent compared with women who died by suicide outside of the perinatal period.

"Almost three quarters of women who died by suicide in the perinatal period used a violent method, such as hanging or jumping from a height ― a likely indication of more severe illness and serious suicidal intent," said Dr Khalifeh, who is with the Section of Women’s Mental Health, Health Service and Population Research Department, in the Institute of Psychiatry, Psychology, and Neuroscience, King's College London, United Kingdom.

Among the perinatal suicide group as a whole, the most common diagnosis was depression, followed by schizophrenia, personality disorder, bipolar disorder, and anxiety.

The most common symptoms that were reported at the last clinical contact were similar to those reported by nonperinatal women: emotional distress, depressed mood, recent self-harm, suicidal ideas, and hopelessness. Delusions or hallucinations were rarely reported, Dr Khalifeh said.

"Around a fifth of women had not been seen for more than a month, and more than 1 in 10 were not receiving any active treatment at the time of death, suggesting the need for more proactive follow-up and treatment in this group," he said.

Although the incidence of suicide in the perinatal period in general is lower than the rate outside the perinatal period, previous research has suggested higher suicide rates among those with severe postpartum mental illness.

In the current study, 80 (2%) women among the 4785 women aged 16 to 50 years died by suicide in the first postnatal year, compared with only 18 (< 1%) who died by suicide during pregnancy, indicating that approximately 80% of the suicides occurred in the postnatal period.

Furthermore, although depression had been diagnosed in approximately half of the postnatal suicide cases, the diagnosis was present for only about a third of suicides during pregnancy, which is the same rate as for nonperinatal suicide cases.

Dr Khalifeh noted that those figures do not necessarily tell the whole story.

"In this study, depression comprised a greater proportion of postnatal than pregnancy suicides, [but] I would be cautious about drawing too many conclusions from the comparison between suicides in pregnancy and the postnatal period, as the number of suicides in pregnancy was small (n = 18)."

Screen for Depression During Pregnancy

Richard K. Silver, MD, chairman and chief academic officer of the Department of Obstetrics and Gynecology at NorthShore University Health System, in Evanston, Illinois, agreed that the high- profile risks of postpartum depression extend into pregnancy as well.

"The literature on this topic has made very clear that there is arguably as great a risk of a woman developing depression while she's pregnant as there is after she's delivered," he told Medscape Medical News.

"The period is considered to be equally as important to be attentive to depression, and that's why the American Congress of Obstetricians and Gynecologists insists that we screen people during pregnancy and not just afterwards."

Dr Silver, who published recent research on perinatal suicide and depression, also commented that one of the study's key limitations is that all patients were among a population that had received psychiatric services.

"The authors gathered these cases from people who already had contact with psychiatric services, and that would be, as they acknowledge, an important shortcoming, because there are a lot of women who may develop their first episode of depression, anxiety, or mania around the perinatal time period and have no mental health history," he told Medscape Medical News.

"So a big challenge is how generalizable this is to the general population, because the challenge to the field isn't just people seeing psychiatric care but to focus on everyone coming through the office."

The study received funding from the Healthcare Quality Improvement Partnership. Coauthor Louis Appleby, MD, chairs the National Suicide Prevention Strategy Advisory Group at the Department of Health and is a nonexecutive director for the Care Quality Commission in the UK. The other authors and Dr Silver have disclosed no relevant financial relationships.

Lancet Psychiatry. Published online January 15, 2016. Abstract

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