Stroke survivors at increased risk of suicide

Stroke survivors may be at an elevated risk of suicide attempts and deaths, according to results of a systematic review and meta-analysis.

“We anticipated that the risk of suicide in stroke survivors would be high, but we were surprised that it was 73 percent higher,” said study author Dr Manav Vyas from the University of Toronto, Ontario, Canada, at ISC 2021.

“Our findings support the need to recognize stroke as a risk factor for suicide and to develop comprehensive measures to screen and prevent depression and suicidal ideation in stroke survivors,” said Vyas and co-researchers.

The researchers searched the databases of MEDLINE, Embase, PsychINFO, and Google Scholar from inception to September 15, 2020, and identified 23 observational (case-control, cohort, or cross-sectional) studies which compared suicide attempts or deaths among 2.15 million adult stroke survivors (average age 63.5 years, 51.9 percent female) with individuals without a history of stroke or the general population. A total of 5,563 suicide attempts or deaths were documented among the stroke survivors.

There was a 73 percent increased risk of suicide among stroke survivors compared with individuals with no stroke history (adjusted risk ratio [adjRR], 1.73, 95 percent confidence interval [CI], 1.53–1.96; I²=93.5 percent). [ISC 2021, presentation P237; Stroke 2021;52:1460-1464]

Analysis according to suicide outcome showed a significantly higher risk of suicide attempt among stroke survivors (adjRR, 2.11, 95 percent CI, 1.73–2.56) than deaths by suicide (adjRR, 1.61, 95 percent CI, 1.41–1.84; p=0.03) compared with individuals without stroke history.

In cohort studies, suicide rates were more common among stroke survivors than the comparator population (29.3 vs 28.8 per 10,000 people). Meta-regression analysis demonstrated that a longer follow-up period in these studies was associated with a reduced risk of suicide (adjRR, 0.97, 95 percent CI, 0.95–0.99 per 1-year increase; p=0.003), suggesting that the risk of suicide decreased over time.

Subgroup analysis showed that the risk of suicide among stroke survivors was consistent regardless of location (continent), study or stroke type, following adjustment for psychiatric illness, or when the general population was used as a comparator.

“[There was] considerable heterogeneity in our estimates that remained unexplained despite various prespecified analyses,” noted the researchers. One of the reasons for this could be “the stigma associated with mental health reporting” and subsequent bias in self-report of suicide attempt, they suggested.

“[N]early 15 million people worldwide have a stroke each year, of which approximately 10 million survive,” said Vyas. “Recognizing that stroke may increase the risk of suicidal thoughts or suicide attempts will help stroke survivors, their families, and healthcare professionals to identify and hopefully reduce these risks.”

“I hope that this study highlights the need to recognize the scale and impact of disability in stroke survivors and their potential influence on mental health status. Having a conversation about low mood or depressed feelings can be challenging for stroke survivors who are often unable to communicate due to the stroke. Therefore, healthcare professionals should consider routine screening of all stroke patients for symptoms of depression and suicidal thoughts, among other mental health conditions,” he continued.

The observational design of the included studies prevents determination of causality. Some of the studies also did not exclude individuals with a pre-stroke history of suicide attempt.

Vyas called for further research into identifying potential suicide timing following a stroke so that targeted measures for suicide prevention can be developed.