Almost 8 percent of US stroke survivors may have suicidal thoughts
Andrey Nailor, M.D.·Published 9 February 2013·9 min read
Key points
Nearly one in 12 American stroke survivors may have contemplated suicide or wished themselves dead, according to a study presented at the American Stroke Association's International Stroke Conference 2013.
Depressive symptoms and clinical depression are not uncommon among stroke patients and the phenomenon of post-stroke depression is widely recognised.
Since the majority of cases under study had shown signs of recovery from stroke, persons surrounding these patients were severely shocked by these suicides.
The underlying causes of suicide have generally been associated with social situations, mental problems and genetics.
Nearly one in 12 American stroke survivors may have contemplated suicide or wished themselves dead, according to a study presented at the American Stroke Association's International Stroke Conference 2013.
The proportion of stroke survivors who contemplated suicide was striking, compared with patients with other health conditions, said Amytis Towfighi, M.D., lead author of the study and an assistant professor of Clinical Neurology at the University of Southern California in Los Angeles and chair of the Department of Neurology at Rancho Los Amigos National Rehabilitation Center.
In a nationally representative sample of the U.S. population, 7.8 percent of stroke survivors reported suicidal thoughts, compared to 6.2 percent of heart attack survivors, 5.2 percent of diabetes patients and 4.1 percent of cancer patients. "Given the high prevalence of suicidal thoughts among stroke survivors, perhaps regular screening for suicidal ideation, in addition to depression, is warranted," Towfighi said.
About 7 million U.S. adults have a history of stroke, according to American Stroke Association statistics. About one third of stroke survivors develop depression, but there is little data on suicidal thoughts, Towfighi said.
Researchers investigated how many stroke survivors had recent suicidal thoughts, as well as the characteristics of these patients using data from the National Health and Nutrition Examination Surveys (NHANES) conducted from 2005 to 2010. During that time, an estimated 6.2 million U.S. adults were stroke survivors.
NHANES is an ongoing series of elaborate, cross-sectional surveys providing a snapshot of Americans' health. This study focused on participants' responses to the following question: "Over the past two weeks, how often have you been bothered by thoughts that you would be better off dead, or of hurting yourself in some way?"
Suicide in Patients With Stroke: A Population-Based Study of Suicide Victims During the Years 1988-2007 in Northern Finland The authors studied the prevalence of stroke among suicide victims and whether prestroke depression had influence on suicide process. The authors used a comprehensive database of all suicides (N=2,283) committed in Northern Finland over a period of 15 years with information on all hospital-treated somatic and psychiatric disorders. Of the total suicide data population, 3.4% had suffered from stroke. After adjusting for age and sex, prestroke depression in stroke victims increased the hazard of suicide up to 2.2-fold compared to victims with stroke but without any lifetime depression. The high-risk period for suicide was 2 years after stroke.
Depression is the most common psychiatric complication after stroke. On the other hand, it has been found that patients with depression have an elevated risk for stroke. The prevalence of poststroke depression at 1 month after stroke up to 6 years after stroke has varied from 12% to 60% as largely reviewed by Hackett et al. as well as Paolucci. Risk factors for poststroke depression include: female gender, age younger than 65 years, living alone, having had a recurrent stroke, being dependent on others, and institutional living 3 months after stroke.
Written and revised by
Andrey Nailor, M.D.
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It is well-known that depression is highly associated with suicide. Furthermore, suicidal thoughts after stroke are common; in a follow-up study of 300 patients, up to 11% had suicidal plans during the 2 years following their stroke. A Danish study found that the risk of suicide is strongly increased after stroke, particularly among patients younger than 60 years old and among females. The risk seems to be greatest within the first 5 years after stroke.
The impact of poststroke depression on poorer outcomes among stroke patients is well known, whereas the association between prestroke depression and prognosis among stroke patients has not yet been sufficiently recognized. Recently, a register-based study in the Netherlands with longitudinal data was published in which Nuyen et al. found that patients with prestroke depression had a fivefold risk of being discharged to an institution instead of to their homes compared to patients who were not depressed. However, they did not study the possible effect of depression on the suicide process of these patients.
In this study we used a comprehensive database of all suicides committed in Northern Finland during the years 1988 - 2007 with information on all hospital-treated somatic and psychiatric disorders. We wanted to find out the following: the prevalence of stroke in suicide victims, whether depression is a risk factor for suicide, and the influence of prestroke depression on suicide process among victims.
### Eva Forsström; Helinä Hakko; Tanja Nordström; Pirkko Räsänen; Arja Mainio The Journal of Neuropsychiatry and Clinical Neurosciences 2010;22:182-187.
Stroke survivors were more likely to have suicidal thoughts if they had a higher depression score, were younger, had higher body mass index, lower education level, lower poverty index, were single and were women.
Among the stroke survivors, 17 percent suffered from depression. Depression is the most common psychological complication after stroke. "Post-stroke depression can be associated with poorer functional outcomes, worse quality of life, higher mortality, low psychological well-being, suicidal ideation and suicide," Towfighi said.
Suicide after a stroke: a population study
Depressive symptoms and clinical depression are not uncommon among stroke patients and the phenomenon of post-stroke depression is widely recognised. More seriously, suicide ideation and suicide attempts have also been reported. Because of their relative infrequency however, completed suicides among stroke patients have generally only been reported among single case or small sample studies. A recent exception was a Danish study that reported on 140 suicides occurring among over 37 000 stroke patients across a 17 year period in one county of Denmark; measured against population statistics for suicide. Stenager et al found that standardised mortality ratios were markedly increased for stroke patients, particularly among relatively younger patients and among women. The objectives of this study were to attempt to replicate these findings using a full national cohort of stroke patients and to consider the role of stroke morbidity and potential risk periods for suicide after hospital discharge.
In this study suicides occurred more often among men than among women and were more common among older rather than younger patients. Both of these characteristics are, however, in keeping with international epidemiological evidence for general populations including Denmark. Population suicide rates in Denmark are close to figures reported for Western Europe and somewhat higher than those reported for North America.
The present evidence points to suicide risk being greatest within about the first five years after a stroke. This finding contrasts with that from a parallel study we have conducted on suicide after traumatic brain injury where suicide risk seemed to be relatively constant across the same 15 year period. The di V erence may have come about because suicides among traumatic brain injury patients are to some extent related to risk factors for the injury, for example, alcohol misuse, rather than the injury itself.
In such cases suicide might be expected to be chronologically independent of the injury. In the present case there is little reason to expect that risk factors for stroke may also be risk factors for suicide, and the suicide is more likely to be reactive to the stroke and its consequences.
It would seem, in keeping with findings concerning post-stroke depression, that the risk decreases with increasing years after stroke.
The researchers haven't calculated what percentage of all NHANES participants, stroke survivors or not, might be suicidal. But Towfighi cited previous studies which found an annual suicide rate that was nearly double the expected figure for the population as a whole.
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The cross-sectional design of the study didn't allow researchers to determine cause-and-effect relationships between stroke and suicidal thoughts. Additionally, the NHANES data didn't include information about how recently people's strokes had occurred, or whether the strokes were due to a ruptured blood vessel (hemorrhagic stroke) or a blocked blood vessel in the brain (ischemic stroke). The study also didn't account for patients' varying levels of disability.
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Co-authors are Daniela Markovic, M.S., and Bruce Ovbiagele, M.D., M.Sc., M.A.S. Author disclosures are on the abstract.
Follow news from the ASA International Stroke Conference 2013 via Twitter @HeartNews; #ISC13.
To reach a suicide crisis center in your area call -800-273-TALK or visit hopeline.com. Learn more about life after stroke.
Case Reports of Unexpected Suicides in Patients within Six Months after Stroke
ABSTRACT
Suicide after stroke is a grievous occurrence. Since the majority of cases under study had shown signs of recovery from stroke, persons surrounding these patients were severely shocked by these suicides. Six patients who attempted suicide within six months after stroke were investigated to determine factors following stroke that relate to suicide in order to prevent future post-stroke suicides. Clinical findings in these six cases were retrospectively analyzed in collaboration with stroke neurologists and coworkers caring for these patients. Four of six patients had sustained a recent infarction extending from the temporal cortex to the parietal cortex. Four of six patients showed depression, and five of six patients showed moderate disability after stroke. Physicians should carefully observe patients with infarction extending from the temporal cortex to the parietal cortex, depression and moderate disability, in order to prevent suicidal behavior.
INTRODUCTION
The underlying causes of suicide have generally been associated with social situations, mental problems and genetics. To date, several studies of brain abnormalities related to suicide analyzed postmortem findings in suicide victims. These studies showed that disorders of the serotonergic system in the prefrontal cortex and brain stem are key issues in suicidal behavior. Furthermore, patients with temporal lobe epilepsy have been reported to show a tendency toward suicide attempts. Stroke patients commonly develop depression and may have suicidal ideation, but rarely attempt suicide in the early stage following stroke. We analyzed and compared six patients who attempted suicide within six months after stroke, and discuss measures to prevent suicide.
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It has been reported that the suicide rate increases following stroke. In this regard, one of the authors (MK) became very concerned about suicidal behavior following stroke after encountering a patient who attempted suicide several months after stroke. In discussing this experience with another author (HN), both were surprised that there had been similar experiences in the second author's department almost one year earlier. Thereafter, three of the neurologists (OM, MN, KA) indicated that they had encountered cases of suicide following stroke. While data were being collected from these neurologists, HN encountered another patient who attempted suicide. We analyzed six cases that we presented here over the course of five years, in collaboration with doctors from six hospitals specializing in the care of stroke patients. The number of fresh stroke patients treated in these hospitals was roughly 8000 cases. To investigate the causes underlying attempts at suicide in our series, we compared our cases to previous reports of suicide in the general population and in stroke patients. The suicide rate (per 100,000) in Japan was 17.2 in 1995, 24.1 in 2000, 25.5 in 2003.
If the population size of our case were converted from 8000 to 100,000, the suicide rate (per 100,000) patients 6 months after stroke would reach 75, indicating that the suicide rate in our series was greater than the suicide rate in the general population. MASAHIRO KATAYAMA, HIROAKI NARITOMI, MASAHIRO OOMURA, MASARU NUKATA, SHIRO YAMAMOTO, KEN ARAKI, HIROKI KATO
Statements and conclusions of study authors that are presented at American Stroke Association scientific meetings are solely those of the study authors and do not necessarily reflect association policy or position. The association makes no representation or warranty as to their accuracy or reliability. The association receives funding primarily from individuals; foundations and corporations (including pharmaceutical, device manufacturers and other companies) also make donations and fund specific association programs and events. The association has strict policies to prevent these relationships from influencing the science content.
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Note: Actual presentation of this moderated poster is 4:20 pm HT, Thursday, Feb. 7, 2013.
All downloadable video/audio interviews, B-roll, animation and images related to this news release are located on the right column of the release link. Video clips with researchers/authors of studies will be added to the release links after embargo.
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Karen Astle karen.astle@heart.org 214-706-1173 American Heart Association
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