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Study Identifies Risk Factors for Suicide Following Stroke

ARTICLE IN BRIEF

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THE YOUNGEST PATIENTS (18-54 years) had a six times higher risk for suicide after stroke, and men had an increased risk compared with women.

Swedish investigators found that stroke patients are almost twice as likely to commit suicide as people in the general population. The risk is particularly high for those who live alone, are male, younger, have had a severe stroke, or are depressed.

A large Swedish study found that stroke patients are almost twice as likely to commit suicide as people in the general population, and the risk is particularly high for those who live alone, are male, younger, have had a severe stroke, or are depressed. Other risk factors include lower income and less education.

Suicide after stroke is still a relatively rare phenomenon, but the study points to the need for clinicians to screen and treat patients for depression and to connect them with needed psychosocial support services.

Depression often goes unaddressed in stroke patients, perhaps because it's sometimes assumed that it's natural for patients to feel down after such a life-altering event, the study authors noted. While suicide is the worst-case outcome, depression can also interfere with both physical and cognitive recovery from stroke, they said.

Previous research has shown that “patients with post-stroke depression may be less motivated to participate in rehabilitation and have lowered expectations that rehabilitation will improve their outcome,” lead author Marie Eriksson, PhD, an associate professor at Umea University in Sweden, told Neurology Today. “Patients with post-stroke depression and fatigue also use rehabilitation services less efficiently, have less favorable rehabilitation outcomes, more functional disability, and reduced quality of life.”

Right now there are no universally accepted clinical guidelines on screening stroke patients for depression, although the American Heart Association/American Stroke Association is expected to release recommendations later this year.

STUDY METHODOLOGY, RESULTS

The Swedish study, published in the April 1 online edition of Neurology, included 220,336 stroke patients who were enrolled in a national database called Riksstroke (the Swedish Stroke Register) and followed for up to 12 years. The registry contained information on the severity of stroke and comorbidities and living conditions at the time of stroke, as well as information from a three-month follow-up to assess for depression and general health. Registry data were linked with other national databases to obtain socioeconomic information, post-stroke hospital admissions, and death records.

Of the more than 220,000 stroke patients, there were 1,217 suicide attempts in 985 patients, of which 260 were fatal. Those numbers translated to a rate of 30 suicides per 100,000 person-years — almost double the rate of 16 suicides per 100,000 person-years in the general Swedish population. The risk was highest in the first year after stroke.

“The youngest patients (18-54 years) had six times higher risk compared to patients over 85 years,” the researchers reported. “Men had an increased risk compared to women.”

Patients who had a more severe stroke (measured by the level of consciousness at admission), who lived by themselves, had lower income, or were not college graduates were also at heightened risk for suicide. On the other hand, “the risk is markedly lower in stroke patients born outside Europe compared to patients born in Sweden or other European countries.” They noted that cultural or religious factors may be protective.

Self-reports of poor health and depression at three months seemed to be telling. “A higher proportion of patients who attempted suicide compared to those who did not perceived their health as poor or very poor (42.7% vs. 20.5%), reported that they often or always felt depressed (41.1% vs. 13.0%), and were using antidepressant medication (51.4% vs. 18.8%) at three months after their stroke,” the researchers reported.

The study was not designed to evaluate the role of antidepressants in preventing suicide, “but our findings suggest that — in a majority of patients with suicide attempts — clinical depression had been diagnosed and treated without any preventive effects on suicide attempt.”

Dr. Eriksson told Neurology Today in an email that while a Cochrane review “suggests that SSRIs [selective serotonin reuptake inhibitors] reduce post-stroke depression by more than a half...clearly drug treatment is not enough.”

She also noted it was possible that the use of antidepressants following stroke increased the risk of suicidal thoughts and suicide, an effect that has been observed in the general population.

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DR. MARIE ERIKSSON: “Patients with post-stroke depression may be less motivated to participate in rehabilitation and have lowered expectations that rehabilitation will improve their outcome. Patients with post-stroke depression and fatigue also use rehabilitation services less efficiently, have less favorable rehabilitation outcomes, more functional disability, and reduced quality of life.”

The effect of antidepressants on suicidal behavior is controversial. SSRIs are believed to increase the risk of suicidal thoughts and suicide early after treatment initiation, before there is any effect on mood, but the literature suggests that the increased risk in adults is small in general and outweighed by the benefits, Dr. Eriksson noted. However, she pointed out that the effect of antidepressants on suicidal behavior has not been studied specifically in stroke patients.

EXPERTS COMMENT

Independent experts said the study had limitations, including the fact that a more formal depression screening tool was not used to assess the stroke patients. They were simply asked, “Do you feel depressed?” with responses of “never” or “almost never,” “sometimes,” “often,” “constantly,” or “do not know.” Those who said “often” or “constantly” were considered to have self-reported depression. It's also not clear whether the findings would be similar in other cultures. Sweden in general has a much higher suicide rate than the US and some other countries.

Amytis Towfighi, MD, an assistant professor of neurology at the University of Southern California in Los Angeles, reported in 2013 on a US study of stroke survivors that found that nearly 8 percent had suicidal thoughts or wished they were dead. But in her study, researchers found that women were more likely to have suicidal ideation than men, which ran counter to the findings in the Swedish study.

“Perhaps men are more likely to attempt suicide even though women may be more likely to think of suicide,” Dr. Towfighi told Neurology Today. She said the “exact mechanism for suicidal ideation among stroke survivors remains unclear and is likely due to a combination of neurobiological effects and psychological responses to new disability, loss of function, cognitive and physical impairments, and changes in an individual's life as a result of stroke.”

Dr. Towfighi, who is also chair of the American Heart Association/American Stroke Association writing group drawing up the recommendations for screening, referral, and management of post-stroke depression, said she routinely screens stroke and transient ischemic attack (TIA) patients for depression and suicidal ideation at regular intervals either in person or by phone. She uses the nine-item Patient Health Questionnaire (PHQ-9) for screening, although a number of other questionnaires are available and “it is unclear which tool is best,” she said.

Among the signs clinicians should look out for are changes in sleep and eating habits, loss of interest in hobbies and activities, feelings of guilt, low energy, poor concentration, and suicidal ideation, Dr. Towfighi said. She added that clinicians should consider a multi-prong approach to treating depression including “pharmacotherapy, psychotherapy, enhancing social support, and improving individuals' self-management skills.”

Robert G. Robinson, MD, a professor of psychiatry at the University of Iowa in Iowa City who does research on post-stroke depression, said suicidal ideation is often overlooked because “physicians taking care of patients are focusing more on their physical symptoms. Patients don't tend to tell you unless you specifically ask them.”

Dr. Robinson said untreated depression can greatly interfere with both physical and cognitive recovery, and also increases the risk for overall mortality.

“If you have depression after a stroke, your chances of dying over the next 10 years are between four and five times higher than somebody who does not have depression,” he said.

Dr. Robinson published a 2008 study in the Journal of the American Medical Association that found that stroke patients who were given an antidepressant (escitalopram) as a preventive measure were significantly less likely to develop depression in the first year after a stroke than patients who took a placebo. He predicts that the use of antidepressants will become a more common part of stroke care, particularly since there is also some evidence from animal and human studies that the drugs may promote neurogenesis and neuroplasticity.

Nada El Husseini, MD, an assistant professor of neurology at Wake Forest Baptist Medical Center in Winston-Salem, NC, said research has shown that more than 30 percent of patients will develop depression after a stroke. But she said it's not always easy to predict which patients will be affected, and that is why screening all stroke patients for depression is important.

“Even though stroke-related disability is associated with increased risk for depression, you can find patients who have significant disability but do not feel depressed,” she said. She added that the Swedish study is helpful because it identifies subgroups of patients — those who are young, male, have low education, low income, and so on — who may benefit from additional depression and suicidality screening. Dr. El Husseini said she asks all her patients with stroke whether they are feeling depressed and, like Dr. Towfighi, uses the PHQ-9, which includes a question about suicidality, to screen those who she suspects may be at high risk.

Dr. El Husseini conducted a study published in 2012 in Stroke that found that more than two-thirds of stroke and TIA patients with persistent depression were not being treated with antidepressants at either three or 12 months after stroke. She said it is important for clinicians to let patients and their caregivers know that “depression is a real disease, that it can happen frequently after stroke, and that it can interfere with functional recovery.

“Depression should not be dismissed as simply a ‘normal reaction’ to stroke,” she added.

“I do not think that the conclusion that we should get from the study is that the risk of suicide is increased with SSRIs post-stroke,” she continued. “The study also did not look at what type of antidepressants were used, so we do not know how many were specifically using SSRIs. Also, even though half of the patients who committed suicide were on antidepressants, after adjusting for other factors, antidepressants were not a risk factor for suicide in this study.

“Antidepressants typically carry a warning for increased risk of suicidality, and that should be monitored in all patients on antidepressants, regardless of whether they had a stroke,” she noted. “I am not aware of studies suggesting that SSRIs increase the risk of suicidality in stroke patients more than in the general population.

“As a neurologist, I feel comfortable prescribing an SSRI to stroke patients without baseline suicidal ideations or other significant psychiatric diagnoses, but I warn them of the increased risk of suicidality with antidepressants and instruct them on how to seek care if they develop suicidal ideations,” she said. “I refer patients with suicidal ideations or other significant psychiatric diagnoses to a psychiatrist.”

EXPERTS: ON SUICIDE RISK POST-STROKE

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DR. AMYTIS TOWFIGHI said she routinely screens stroke and transient ischemic attack patients for depression and suicidal ideation at regular intervals either in person or by phone. She uses the nine-item Patient Health Questionnaire, although a number of other questionnaires are available and “it is unclear which tool is best,” she said.

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DR. ROBERT ROBINSON said suicidal ideation is often overlooked because “physicians taking care of patients are focusing more on their physical symptoms. Patients dont tend to tell you unless you specifically ask them.” Dr. Robinson noted that untreated depression can greatly interfere with both physical and cognitive recovery, and also increases the risk for overall mortality.

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DR. NADA EL HUSSEINI noted that although stroke-related disability is associated with an increased risk for depression, some patients who have significant disability do not feel depressed. She said the Swedish study is helpful because it identifies subgroups of patients — those who are young, male, have low education, low income, and so on — who may benefit from additional depression and suicidality screening.

LINK UP FOR MORE INFORMATION:

•. Eriksson M, Glader E-L, Norrving B, et al. Post-stroke suicide attempts: A socioeconomic and nationwide perspective http://www.neurology.org/content/early/2015/04/01/WNL.0000000000001514.short. Neurology 2015: Epub 2015 April 1.
    •. Paolucci S, Ngeh J, et al. Suicide in post-stroke survivors: Frequency and risk factors http://www.neurology.org/content/early/2015/04/01/WNL.0000000000001531.short. Neurology 2015: Epub 2015 April 1.
      •. Robinson RG, Jorge RE, Moser DJ, et al. Escitalopram and problem-solving therapy for prevention of poststroke depression: a randomized controlled trial http://jama.jamanetwork.com/article.aspx?articleid=181981. JAMA 2008; 299(20):2391–400.
      •. El Husseini N, Goldstein LB, Peterson ED, et al.. Depression and antidepressant use after stroke and transient ischemic attack http://stroke.ahajournals.org/content/43/6/1609.full.pdf. Stroke 2012;43(6):1609–1616.