Suicide and self-harm in adult survivors of critical illness: population based cohort study

Abstract

Objective To analyse the association between survival from critical illness and suicide or self-harm after hospital discharge. Design Population based cohort study using linked and validated provincial databases. Setting Ontario, Canada between January 2009 and December 2017 (inclusive). Participants Consecutive adult intensive care unit (ICU) survivors (≥18 years) were included. Linked administrative databases were used to compare ICU hospital survivors with hospital survivors who never required ICU admission (non-ICU hospital survivors). Patients were categorised based on their index hospital admission (ICU or non-ICU) during the study period. Main outcome measures The primary outcome was the composite of death by suicide (as noted in provincial death records) and deliberate self-harm events after discharge. Each outcome was also assessed independently. Incidence of suicide was evaluated while accounting for competing risk of death from other causes. Analyses were conducted by using overlap propensity score weighted, cause specific Cox proportional hazard models. Results 423 060 consecutive ICU survivors (mean age 61.7 years, 39% women) were identified. During the study period, the crude incidence (per 100 000 person years) of suicide, self-harm, and the composite of suicide or self-harm among ICU survivors was 41.4, 327.9, and 361.0, respectively, compared with 16.8, 177.3, and 191.6 in non-ICU hospital survivors. Analysis using weighted models showed that ICU survivors ( v non-ICU hospital survivors) had a higher risk of suicide (adjusted hazards ratio 1.22, 95% confidence interval 1.11 to 1.33) and self-harm (1.15, 1.12 to 1.19). Among ICU survivors, several factors were associated with suicide or self-harm: previous depression or anxiety (5.69, 5.38 to 6.02), previous post-traumatic stress disorder (1.87, 1.64 to 2.13), invasive mechanical ventilation (1.45, 1.38 to 1.54), and renal replacement therapy (1.35, 1.17 to 1.56). Conclusions Survivors of critical illness have increased risk of suicide and self-harm, and these outcomes were associated with pre-existing psychiatric illness and receipt of invasive life support. Knowledge of these prognostic factors might allow for earlier intervention to potentially reduce this important public health problem.

Post-Intensive Care Syndrome and Its New Challenges in Coronavirus Disease 2019 (COVID-19) Pandemic: A Review of Recent Advances and Perspectives

“…Joblessness is common, and nearly half of ICU survivors experience financial stress after hospital discharge [27]. The suicide ratio in PICS survivors is two times higher than non-ICU hospital survivors [117], and the support of their lives is essential. In addition to personal care, the impact on society also needs to be described.…”

Mental health morbidity, self-harm, and suicide in ICU survivors and caregivers

“…Among opioid naïve patients experiencing mechanical ventilation, 2.6% were found to have persistent opioid use after discharge, which was higher than matched non-ICU control patients (1.5%) [ 7 ]. Finally, more recent work from Ontario, Canada found that ICU survivors have higher rates of deliberate self-harm and suicide, as compared to matched non-ICU hospitalized patients [ 8 ]. Thus, in addition to the common physical and cognitive sequelae that they experience, survivors of critical illness are at increased risk of new mental health diagnoses, psychotropic medication use, substance misuse, deliberate self-harm, and suicide.…”

“…Delirium is common, and may be associated with a number of mental health sequelae, namely PTSD [ 13 ]. While there has been disagreement on the association between ICU length of stay or severity of illness with mental health morbidity [ 5 , 6 , 8 , 13 ], a number of studies have shown that incidence of new mental health diagnoses is associated with invasive procedures, such as mechanical ventilation [ 5 ]. Similarly, invasive mechanical ventilation and renal replacement therapy were prognostic for self-harm and suicide among ICU survivors [ 8 ].…”

“…Second, critical illness may exacerbate pre-existing mental health morbidity. Existing reports on mental health outcomes among ICU survivors indicate that pre-existing mental health diagnoses prior to ICU admission are common [ 5 , 6 , 8 ], and these diagnoses were significant prognostic factors for future self-harm and suicide [ 8 ]. Among patients with pre-existing mental health diagnoses, psychotropic medications may be held during their admission, or not restarted at the time of discharge.…”

Evaluation of medication changes following severe COVID-19 infection: a multicentre evaluation

“… 7 These issues are not benign and cause significant strain for the individual, such as an inability to return to employment and increased rates of suicide and self-harm. 8 9 …”