Survivors of intensive care unit admissions may have increased risk of self-harm and suicide

1. Patients with prior episodes of critical illness requiring ICU admission were found to have an elevated risk of suicide and self-harm.

2. Suicide and self-harm were further correlated to the prevalence pre-existing psychiatric conditions as well as the receipt of life support.

Evidence Rating Level: 2 (Good)

Study Rundown: Due to advances in critical care, mortality rates after admission to the intensive care unit (ICU) have improved. However, ICU survivors often experience diminished quality of life after their experience with critical illnesses. Among these post-ICU sequelae may be fatigue, cognitive impairment, pain, and financial hardships. Meanwhile, the relationship between critical illness requiring intensive hospital treatment and mental health has not been thoroughly explored. This population-based cohort study aimed to assess the relationship between such experiences with self-harm and suicide. In retrospectively assessing the outcomes of nearly half a million patients, this study found an increased likelihood of suicide and self-harm among ICU survivors compared to non-ICU hospital survivors. Among ICU survivors, presence of previous mental health conditions, receipt of mechanical ventilation, and receipt of renal replacement were associated with increased rates of self-harm and suicide. This study is most strengthened by its large sample size. Nevertheless, the retrospective nature of this study in the setting of such a complex outcome most often will leads to confounding.

Click to read the study in the BMJ

Relevant Reading: Identifying risk factors for mortality among patients previously hospitalized for a suicide attempt

In-Depth [Retrospective Cohort]: This study employed a retrospective structure in assessing the health records of 423,060 individuals in Ontario, Canada who had previously been admitted to the adult ICU from January 2009 to December 2017. All those admitted to non-intensive care units were considered as control subjects, totaling 3,081,111 subjects. Outcomes were defined as death by suicide or hospital visit for self-harm as defined by ICD-10 codes. Covariates (e.g. age, sex, number of mental health visits in the past year, income fifth, residency, length of stay, pre-existing mental health diagnoses) were noted and incorporated into the Overlap weight method of propensity scoring. Compared with non-ICU hospital survivors, ICU survivors had an increased risk of suicide (adjusted hazard ratio 1.22 [95% CI 1.11-1.33]) and self-harm (1.15 [1.12-1.19]). Mental health diagnoses, such as depression or anxiety (5.69 [5.38 – 6.02], previous post-traumatic stress disorder (1.87, [1.64-2.13]), schizophrenia (1.39, [1.28-1.52]) and bipolar disorder (2.38, [2.20-2.58]), invasive mechanical ventilation (1.45, [1.38-1.54]) and renal replacement therapy (1.35, [1.17-1.56]) were associated with higher rates of self-harm and suicide. Propensity score weighting suggested that ICU admissions were linked to suicide (adjusted hazard ratio 1.22 [1.11-1.33], self-harm (1.15 [1.12-1.19]), and the composite of suicide or self-harm (1.15, [1.12- 1.19]) compared to the non-ICU hospital admission groups.

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