Almost 8 percent of US stroke survivors may have suicidal thoughts
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.
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.
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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.
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J Epidemiol Community Health. 2001 December; 55(12): 863–866.
doi: 10.1136/jech.55.12.863
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.