Suicide and self-harm in adult survivors of critical illness: population based cohort study

Shannon M Fernando; Danial Qureshi; Manish M Sood; Michael Pugliese; Robert Talarico; Daniel T Myran; Margaret S Herridge; Dale M Needham; Bram Rochwerg; Deborah J Cook; Hannah Wunsch; Robert A Fowler; Damon C Scales; O Joseph Bienvenu; Kathryn M Rowan; Magdalena Kisilewicz; Laura H Thompson; Peter Tanuseputro; Kwadwo Kyeremanteng

doi:10.1136/bmj.n973

Suicide and self-harm in adult survivors of critical illness: population based cohort study

BMJ. 2021 May 5:373:n973. doi: 10.1136/bmj.n973.

Authors

Shannon M Fernando^{1

2}, Danial Qureshi^{3

4

5

6}, Manish M Sood^{3

4

5

7}, Michael Pugliese^{3

4}, Robert Talarico^{3

4}, Daniel T Myran^{3

4

8}, Margaret S Herridge^{9

10

11}, Dale M Needham^{12

13}, Bram Rochwerg^{14

15}, Deborah J Cook^{14

15}, Hannah Wunsch^{3

9

11

16}, Robert A Fowler^{3

9

11

16}, Damon C Scales^{3

9

11

16

17}, O Joseph Bienvenu¹⁸, Kathryn M Rowan¹⁹, Magdalena Kisilewicz²⁰, Laura H Thompson⁴, Peter Tanuseputro^{3

4

5

6

21}, Kwadwo Kyeremanteng^{22

4

21

23}

Affiliations

¹ Division of Critical Care, Department of Medicine, University of Ottawa, Ottawa, ON, Canada sfernando@qmed.ca.
² Department of Emergency Medicine, University of Ottawa, Ottawa, ON, Canada.
³ ICES, Toronto, ON, Canada.
⁴ Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, ON, Canada.
⁵ School of Epidemiology and Public Health, University of Ottawa, Ottawa, ON, Canada.
⁶ Bruyère Research Institute, Ottawa, ON, Canada.
⁷ Division of Nephrology, Department of Medicine, University of Ottawa, Ottawa, ON, Canada.
⁸ Department of Family Medicine, University of Ottawa, Ottawa, ON, Canada.
⁹ Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, ON, Canada.
¹⁰ Toronto General Hospital Research Institute, University Health Network, Toronto, ON, Canada.
¹¹ Institute of Health Policy, Management and Evaluation, Dalla Lana School of Public Health, University of Toronto, Toronto, ON, Canada.
¹² Department of Medicine, Division of Pulmonary and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA.
¹³ Department of Physical Medicine and Rehabilitation, Johns Hopkins University School of Medicine, Baltimore, MD, USA.
¹⁴ Department of Medicine, Division of Critical Care, McMaster University, Hamilton, ON, Canada.
¹⁵ Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, ON, Canada.
¹⁶ Department of Critical Care Medicine, Sunnybrook Health Sciences Centre, Toronto, ON, Canada.
¹⁷ Li Ka Shing Knowledge Institute, St Michael's Hospital, Toronto, ON, Canada.
¹⁸ Department of Psychiatry and Behavioural Sciences, Johns Hopkins University School of Medicine, Baltimore, MD, USA.
¹⁹ Intensive Care National Audit and Research Centre, Napier House, London, UK.
²⁰ Department of Critical Care, Queensway Carleton Hospital, Ottawa, ON, Canada.
²¹ Division of Palliative Care, Department of Medicine, University of Ottawa, Ottawa, ON, Canada.
²² Division of Critical Care, Department of Medicine, University of Ottawa, Ottawa, ON, Canada.
²³ Institut du Savoir Montfort, Ottawa, ON, Canada.

Abstract

Objective: To analyse the association between survival from critical illness and suicide or self-harm after hospital discharge.

Design: Population based cohort study using linked and validated provincial databases.

Setting: Ontario, Canada between January 2009 and December 2017 (inclusive).

Participants: Consecutive adult intensive care unit (ICU) survivors (≥18 years) were included. Linked administrative databases were used to compare ICU hospital survivors with hospital survivors who never required ICU admission (non-ICU hospital survivors). Patients were categorised based on their index hospital admission (ICU or non-ICU) during the study period.

Main outcome measures: The primary outcome was the composite of death by suicide (as noted in provincial death records) and deliberate self-harm events after discharge. Each outcome was also assessed independently. Incidence of suicide was evaluated while accounting for competing risk of death from other causes. Analyses were conducted by using overlap propensity score weighted, cause specific Cox proportional hazard models.

Results: 423 060 consecutive ICU survivors (mean age 61.7 years, 39% women) were identified. During the study period, the crude incidence (per 100 000 person years) of suicide, self-harm, and the composite of suicide or self-harm among ICU survivors was 41.4, 327.9, and 361.0, respectively, compared with 16.8, 177.3, and 191.6 in non-ICU hospital survivors. Analysis using weighted models showed that ICU survivors (v non-ICU hospital survivors) had a higher risk of suicide (adjusted hazards ratio 1.22, 95% confidence interval 1.11 to 1.33) and self-harm (1.15, 1.12 to 1.19). Among ICU survivors, several factors were associated with suicide or self-harm: previous depression or anxiety (5.69, 5.38 to 6.02), previous post-traumatic stress disorder (1.87, 1.64 to 2.13), invasive mechanical ventilation (1.45, 1.38 to 1.54), and renal replacement therapy (1.35, 1.17 to 1.56).

Conclusions: Survivors of critical illness have increased risk of suicide and self-harm, and these outcomes were associated with pre-existing psychiatric illness and receipt of invasive life support. Knowledge of these prognostic factors might allow for earlier intervention to potentially reduce this important public health problem.

Publication types

Observational Study
Research Support, Non-U.S. Gov't

MeSH terms

Adolescent
Adult
Aged
Aged, 80 and over
Case-Control Studies
Critical Care
Critical Illness / psychology*
Critical Illness / therapy
Female
Follow-Up Studies
Humans
Incidence
Male
Middle Aged
Ontario / epidemiology
Proportional Hazards Models
Retrospective Studies
Risk Factors
Self-Injurious Behavior / diagnosis
Self-Injurious Behavior / epidemiology
Self-Injurious Behavior / etiology*
Self-Injurious Behavior / psychology
Suicide / psychology
Suicide / statistics & numerical data
Survivors / psychology*
Young Adult