Increased Risk for Suicide, Self-harm in ICU Survivors

Megan Brooks

May 10, 2021

Editor's note: Find the latest COVID-19 news and guidance in Medscape's Coronavirus Resource Center.

Critically ill adults who survive a stint in the intensive care unit (ICU) have a small, increased risk for future suicide and self-harm compared to their peers with a non-ICU hospital stay, new research shows.

In addition, the study revealed that younger patients who have a history of mental illness may be particularly susceptible to suicide attempts following a stint in the ICU.

Dr Shannon Fernando

"It's not lost on us that these high-risk patients from our study have a lot in common with the demographics we have seen in the latest wave of COVID-19 ICU patients ― younger, requiring aggressive invasive treatment, and often essential workers with lower socioeconomic status who cannot take time off work and therefore end up putting themselves at risk," study investigator Shannon Fernando, MD, Ottawa Hospital, Ontario, Canada, told Medscape Medical News.

The study was published online May 5 in The BMJ.

Post–Intensive Care Syndrome

Using administrative databases, the investigators matched health records for about 423,000 adult ICU survivors with those of three million non-ICU hospital survivors who had similar risk factors for suicide in Ontario, Canada, from 2009 to 2017.

During follow-up, 750 ICU survivors (0.2%) died by suicide, compared with 2427 (0.1%) non-ICU hospital survivors. Self-harm occurred in 5662 (1.3%) ICU survivors, compared with 24,411 (0.8%) non-ICU hospital survivors.

Analysis using weighted models revealed that ICU survivors had a 22% higher risk for suicide compared with non-ICU hospital survivors (adjusted hazard ratio [aHR], 1.22; 95% CI, 1.11 – 1.33) and a 15% higher risk for self-harm (aHR, 1.15; 95% CI, 1.12 – 1.19).

The small increased risk occurred almost immediately after hospital discharge and persisted for years afterward, the investigators report.

"This study is the first to demonstrate this risk, and we can add it to the constellation of outcomes we need to consider with post–intensive care syndrome," said Fernando.

ICU survivors at highest risk for suicide or self-harm are younger patients (aged 18 to 34 years), those with mental health conditions (depression, anxiety, posttraumatic stress disorder, psychosis), and those who undergo invasive procedures (mechanical ventilation or renal replacement therapy).

Traumatizing Experience

"Why this association exists is unclear," said Fernando, "but, like most things, there are probably multiple factors.

"ICU care itself is traumatizing," he explained, "and ICU care might exacerbate feelings of trauma that some patients might already be carrying with them. After a lengthy ICU admission, patients might be off their home psychiatric medications for some time or have difficulty connecting with their family physicians or psychiatrists. We don't know exactly why, but those are some plausible explanations."

Fernando thinks clinicians should have a heightened awareness of the risk for suicide or self-harm after an ICU stay.

"The truth is, right now, we're not sure what's actually effective at mitigating risk of suicide in these patients. But what this study does show us is who is at risk, and that's a great starting point," Fernando noted.

"As an ICU physician, I have to admit that I have often glossed over a patient's preexisting psychiatric history. This is not always our focus in ICU. When a patient is on life support, we pay close attention to their preexisting heart function, lung function, kidney function," he said.

"I think screening these high-risk patients is something we can easily do once their condition has improved, and at least ensure that we are considering their mental health.

"It is worth acknowledging to patients that mental suffering after ICU admission is common, and by being aware of it, as clinicians, we can potentially intervene. Sometimes knowing that they are not alone is all a patient needs to confide their symptoms. Mental health is certainly no different," Fernando added.

"Important Signal"

Reached for comment, Ipsit Vahia, MD, medical director of geriatric psychiatry outpatient programs and medical director at the Institute for Technology and Psychiatry at McLean Hospital, Belmont, Massachusetts, said the study shows "an interesting and important signal" suggesting that ICU survivors may be at higher risk for suicide and self-harm.

"It has been recognized previously that ICU hospitalizations may lead to longer-term psychological symptoms, but this study is among the largest to specifically demonstrate a relationship with increased suicide and self-harm," said Vahia.

"Beyond this primary finding, however, it is important to look at the specific predictors of suicide among ICU survivors. Unsurprisingly, those at highest risk tended to be persons with a previous history of psychiatric illness, residing in lower-income neighborhoods, and those that received mechanical ventilation or renal replacement, indicating a more serious underlying medical illness," Vahia noted.

He said it's also important to recognize that although rates of self-harm or suicide were higher among ICU survivors, the long-term incidence is relatively low.

"The findings of the study are most relevant in demonstrating how certain populations of ICU patients, ie, those with existing psychiatric diagnosis, with more social economic disadvantages, and those with medical conditions severe enough to require invasive treatment, may be especially predisposed to longer-term suicide risk," said Vahia.

He added that the study takes on heightened importance in light of the COVID-19 pandemic.

"An extraordinarily large number of people worldwide have required and continue to require ICU treatment. We already know that the pandemic has had a devastating impact on mental health, especially among younger people.

"As we begin the process of unraveling the immediate, short-, and longer-term mental health impact from COVID-19, studies such as this remind us that the full impact of COVID-19 severe enough to require ICU hospitalization may not actually be recognized for years or even decades from now," Vahia said.

Funding for the study was provided by the Institut du Savoir Montfort, Hôpital Montfort, Ottawa, Canada. Fernando and Vahia have disclosed no relevant financial relationships.

BMJ. Published online May 5, 2021. Full text

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