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