Increased risk of suicide and self-harm in ICU survivors

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Adults with serious illnesses who survive in an intensive care unit (ICU) have a reduced risk for the future suicide and self-harm compared to peers with a non-ICU hospital stay, according to new research.

In addition, the study revealed that younger patients with a history of mental illness may be particularly susceptible to suicide attempts after a stage in the ICU.


Dr. Shannon Fernando

“We don’t miss that these high-risk patients in our study have much in common with the demographics we saw in the last wave of patients with ICU COVID-19: younger, requiring aggressive invasive treatment, and often essential workers with “A socioeconomic status that can’t take time off and therefore ends up being put at risk,” said study researcher Shannon Fernando, MD, Ottawa Hospital, Ontario, Canada. Medscape Medical News.

The study was published online May 5th The BMJ.

Intensive Post-Care Syndrome

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

During follow-up, 750 ICU survivors (0.2%) died by suicide, compared with the 2427 non-hospitalized ICU survivors (0.1%). 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 of suicide compared to hospital survivors who did not belong to the ICU (adjusted risk ratio). [aHR], 1.22; 95% CI, 1.11 – 1.33) and 15% more risk of self-injury (RSH, 1.15; 95% CI, 1.12 – 1.19).

The small increase in risk occurred almost immediately after hospital discharge and persisted for years afterward, according to the researchers.

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

ICU survivors at higher risk of suicide or self-harm are younger patients (18 to 34 years) with mental health problems, depression, anxiety, Post traumatic stress disorder, psychosis) and those undergoing invasive procedures (mechanical ventilation or kidney replacement therapy).

Traumatic experience

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

“ICU care is traumatic,” he explained, “and ICU care can exacerbate feelings of trauma that some patients may already carry with them. After long admission to the ICU, patients may be out. of your psychiatric medications at home for some time or having difficulty. connecting with your family doctors or psychiatrists. We don’t know exactly why, but these are some plausible explanations. “

Fernando believes doctors should be more aware of the risk of suicide or self-harm after a stay in the ICU.

“The truth is that right now we are not sure what is effective in mitigating the risk of suicide in these patients. But what this study shows us is who is at risk, and that is a great starting point,” said Fernando .

“As an ICU doctor, I have to admit that I have often analyzed a patient’s pre-existing psychiatric history. This is not always our approach to the ICU. When a patient has life support, we pay close attention to their function. pre-existing cardiac, lung function, kidney function, ”he said.

“I think detecting these high-risk patients is something we can easily do once their condition has improved, and at least make sure we are considering their mental health.

“It is worth recognizing patients that mental suffering after admission to the ICU is common and, by being aware, as doctors, we can intervene. Sometimes the patient needs to trust their symptoms to know that they are not alone. “It’s certainly no different,” Fernando added.

“Important signal”

Ipsit Vahia, MD, medical director of outpatient geriatric psychiatry programs and medical director of the Institute of Technology and Psychiatry at McLean Hospital, Belmont, Massachusetts, said the study shows “an interesting and important signal” that suggests that ICU survivors have a higher risk of suicide and self-harm.

“It has been previously recognized that hospitalizations in the ICU can cause long-term psychological symptoms, but this study is one of the largest that specifically demonstrates a relationship with increased suicide and self-harm,” Vahia said.

“Beyond this main finding, however, it is important to examine specific predictors of suicide among ICU survivors. It is not surprising that those most at risk tend to be people with a previous history of psychiatric illness, living in high-income neighborhoods. lower and those he received mechanical ventilation or kidney replacement, which indicates a more serious underlying medical condition, ”Vahia noted.

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

“The results of the study are more relevant to show how some populations of patients with ICU, ie those with an existing psychiatric diagnosis, with more social economic disadvantages and those with medical conditions severe enough to require invasive treatment, can being especially predisposed to long-term suicide risk, ”Vahia said.

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

“An extraordinarily large number of people around the world have required and continue to need ICU treatment. We already know that the pandemic has had a devastating impact on mental health, especially among the youngest.

“As we begin the process of unleashing the immediate, short- and long-term mental health impact of COVID-19, studies like this remind us that the full impact of COVID-19 is severe enough to require the ICU hospitalization. recognized in years or even decades, “Vahia said.

Funding for the study was provided by the Institut du Savoir Montfort, Hôpital Montfort, Ottawa, Canada. Fernando and Vahia have not revealed any relevant financial relationship.

BMJ. Published online May 5, 2021. Full text

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