Suicide Risk in Stroke Survivors

About one in eight survivors of stroke have suicidal ideation, according to a study published online in the Journal of Neurology, Neurosurgery and Psychiatry.¹

The study is the first meta-analysis to evaluate rates and correlates of suicidal ideation in stroke survivors.

Individuals who were single, unemployed, or had lower education levels had 1.5 to 2.0 times increased risk of suicidal ideation. Those with a current or past history of depression, severe or recurrent stroke, or cognitive impairment are at very high risk for suicidal ideation.

“Routine screening of suicidal ideation after stroke, especially targeting subjects with specific characteristics, is needed to plan pharmacological and psychosocial interventions aimed at reducing suicide risk,” wrote first author Francesco Bartoli, MD, PhD, of the University of Milano Bicocca (Monza, Italy), and colleagues.

They emphasized that a substantial number of individuals with suicidal ideation attempt suicide within one year, and they often tell others about their intentions before doing so.

Moreover, a past study has suggested that stroke survivors have double the risk of suicide, with suicide risk greatest during the first five years after stroke.² Studies have also suggested that important risk factors for suicide in stroke survivors include a history of current or past mood disorder, recurrent stroke, and cognitive impairment.

To evaluate the issue, researchers searched Ovid, Medline, Embase and PsycInfo from inception to August 2016 for observational studies that evaluated rates and/or correlates of suicidal ideation among stroke survivors. The analysis included 15 studies covering 10,400 stroke survivors from Brazil, Canada, China, Finland, Hong Kong, Korea, New Zealand, Portugal, and USA.

Key Results:

• Pooled proportion of suicidal ideation: 11.8% (95% CI 7.4%-16.2%)

• Factors associated with increased suicidal ideation:

♦ Current depression: OR 11.50, P<0.001

♦ Past depression: OR 6.96, P<0.001

♦ Recurrent stroke: OR 1.77, P<0.001

♦ Higher stroke severity: SMD=0.58, P=0.01

♦ Cognitive impairment: SMD=0.22, P=0.03

• Factors associated with decreased suicidal ideation:

♦ Marriage: OR=0.63, P<0.001

♦ Employment: OR 0.57, P=0.02

• Higher education level: OR-0.55, P=0.002

♦ A trend toward increased suicidal ideation among female stroke survivors (OR 1.31, P=0.63)

The authors noted very high heterogeneity (I²=97.3%), likely due to methodological differences across studies, different ways of assessing suicidal ideation, and different times of assessment. Few studies used tools developed specifically for assessing suicidal ideation, so the results may include individuals with mild or fleeting suicidal ideation. However, a sensitivity analysis of four studies that used tools designed for evaluating suicidal ideation showed similar results (9.7%; 95% CI: 5.7% to 13.7%; I²=79.0%).

Stroke survivors who lack social support, have lower educational background, or have severe or recurrent stroke should be targeted for suicide prevention, the authors suggested. They advised a “precautionary approach” for women, though more research is needed to clarify the trend identified in this study. They also emphasized that suicidal ideation was highest in stroke survivors with current or past depression, for whom the risk was almost 12 times higher than those without depression.

“Prevention and early treatment of depression after stroke should therefore represent the main components for comprehensive programmes aimed at reducing the risk of suicide-related behaviours,” they stressed.

Take-home Points

• Study suggests one in eight stroke survivors has suicidal ideation.

• Stroke survivors who are single, unemployed, have lower education levels, have severe or recurrent stroke, have depression or cognitive impairment are at increased risk of suicidal ideation.

• The findings support routine screening for suicidal ideation in stroke survivors, with a focus on prevention and early treatment of depression.

The authors report no conflicts of interest.

References:

1. Bartoli F, et al. Rates and correlates of suicidal ideation among stroke survivors: a meta-analysis. J Neurol Neurosurg Psychiatry. 2017 Mar 22.

2. Teasdale TW, Engberg AW. Suicide after a stroke: a population study. J Epidemiol Community Health. 2001;55:863-866.