Psychosomatics 42:382-390, October 2001
© 2001 The Academy of Psychosomatic Medicine
Suicidal Ideation Among Patients With Acute Life-Threatening Physical Illness
Patients With Stroke, Traumatic Brain Injury, Myocardial Infarction, and Spinal Cord Injury
Yasuhiro Kishi, M.D.,
Robert G. Robinson, M.D., and
James T. Kosier, B.S.
Received October 13, 2000; revised March 12, 2000; accepted March 29, 2001. From the Department of Psychiatry, Nippon Medical School Chiba Hokusoh Hospital, Japan; the Department of Psychiatry, University of Iowa College of Medicine, Iowa City, Iowa. Address correspondence and reprint requests to Dr. Robinson, Department of Psychiatry, The University of Iowa, 200 Hawkins Dr, Iowa City, Iowa 52242. E-mail: robert-robinson{at}uiowa.edu
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ABSTRACT
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Suicide is one of the leading causes of death in the community. The risk of suicide is greater among patients with physical illnesses than among the general population. This study was undertaken to evaluate the clinical characteristics and correlates of suicidal ideation in patients with acute life-threatening physical illnesses and to assess the duration of suicidal ideation. The study included a consecutive series of patients admitted with stroke, traumatic brain injury, myocardial infarction, or spinal cord injury (n=496). Study participants were administered a semistructured psychiatric interview as well as a series of standardized quantitative scales of mood, cognitive function, physical impairment, social ties, and social functioning. Follow-up evaluations of up to 24 months were also carried out. This study found that 36 (7.3%) patients with acute medical illness had clinically significant suicidal ideation. The suicidal ideation occurred mostly among patients with major depression and sometimes in those with minor depression. About 25% of patients with major depression and acute physical illnesses developed suicidal ideation. After the improvement of depressive disorders, suicidal ideations were ameliorated. These findings suggest that the detection and treatment of depressive disorders is the most important factor in preventing suicide among this patient population.
Key Words: Suicide • Depression • Brain Injury
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INTRODUCTION
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Suicide is one of the leading causes of death in the community. Physical (medical) illness is a significant risk factor for both suicidal ideation and suicide attempts. Mackenzie and Popkin1 reported that suicide risk is greater among patients with physical illnesses than among the general population. For example, DeVivo and colleagues2,3 reported that 6.3% of all deaths among patients with spinal cord injury were caused by suicide and that persons with spinal cord injury were 4.9 times more likely to commit suicide than the general population. Head trauma is associated with twice the suicide risk as that of the general population.4 Patients with epilepsy are five times more likely that those in the general population to complete or to attempt suicide.5,6 Even with medically ill patients, however, it has been pointed out that most suicidal patients will have depressive and/or alcohol-related disorders if a proper psychiatric examination is conducted.7 In previous studies, we reported that suicidal intentions in patients with stroke or spinal cord injury was associated with the presence of diagnosable mood disorders, history of substance/alcohol abuse, and inadequate social supports.8–10 Furthermore, even in terminally ill patients, the vast majority of patients with suicidal thoughts or suicidal attempts were found to have depressive disorders.11,12 Assessment of depressive disorders including suicide risk is, therefore, an important clinical task not only in psychiatric practice but also in primary care practice.
The present study was undertaken to examine the clinical characteristics and correlates of suicidal ideation in patients with acute life-threatening physical illnesses such as stroke, traumatic brain injury, myocardial infarction, and spinal cord injury. Furthermore, to assess the duration of suicidal ideation, we examined suicidal plans and other relevant variables by use of standardized measurements at follow-up (3, 6, 9, 12, or 24 months) as well as during the acute in-hospital treatment period.
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METHODS
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Study Population
The study included a consecutive series of patients admitted to one of the Baltimore City hospitals (The Johns Hopkins Hospital, the University of Maryland Hospital, Sinai Hospital of Baltimore, or Montebello Hospital Center) with stroke (a diagnosis of either acute intracerebral hemorrhage or cerebral infarction), traumatic brain injury (TBI), myocardial infarction (MI), or spinal cord injury (SCI). The present study included 496 patients (301 stroke, 65 TBI, 70 MI, and 60 SCI) who were evaluated in the hospital for suicidal plans after an acute physical illness. Follow-up evaluations were also carried out; stroke over 24 months (3, 6, 12, and 24 months), TBI and MI over 12 months (3, 6, 9, and 12 months), and SCI over 6 months (3 and 6 months).
Among the 301 patients with stroke, a consecutive series of patients was studied with the exception of 159 who were excluded because of comprehension deficits, 5 who refused participation, and 21 who left the hospital before being evaluated. The 70 MI patients were recruited from 361 consecutive admissions. Patients were excluded because they were too ill to be interviewed (N=28), had dementia or brain injury (N=35), were scheduled for bypass surgery (N=71), and lived too far away or refused follow-up (N=157). There were no refusals among the 60 SCI patients, and patients were excluded only if they had brain injury. Similarly, TBI patients were a consecutive series, excluding only patients with spinal cord or multiple physical injuries or prior psychiatric history. We did not keep track of the number of such exclusions, and we did not collect any data on these excluded patients because they did not sign an informed consent.
Psychiatric Evaluations
After signing an informed consent document, study participants were administered a series of standardized quantitative scales that have been shown to provide valid and reliable measures of mood, cognitive function, and physical impairment in patients who are medically ill.13 Quantitative mood ratings were obtained using the Hamilton Rating Scale for Depression (Ham-D),14 a 17-item interviewer-rated scale used to measure psychological and physiological symptoms of depression. Scores may range from 0 to 54, with higher scores indicating greater severity of depression. Cognitive function was measured using the Mini-Mental State Exam (MMSE),15 which has been shown to be a reliable and valid means of assessing a limited range of cognitive functions in several medically ill populations.16,17 MMSE scores range from 0 to 30, with a score of 23 or below indicative of significant cognitive impairment. Impairment in activities of daily living (ADLs) was measured using the Johns Hopkins Functioning Inventory (JHFI).13 Scores on this scale range from 0 to 27 with higher scores indicating a greater degree of functional impairment. In conjunction with psychiatric evaluation, a quantitative assessment of social functioning was made using the Social Ties Checklist (STC) and the Social Functioning Exam (SFE).18 The STC quantifies the number of social connections available to the patient. Scores range from 0 to 10, with higher scores indicating less social support. The SFE, which has been shown to be reliable and valid,18 assesses patients' satisfaction with their social functioning by means of a semistructured interview. Scores range from 0.00 (great satisfaction) to 1.00 (least satisfaction).
A modified version of the Present State Exam (PSE),19 a semistructured psychiatric interview, was used to elicit symptoms of depression and anxiety. The interview was modified to include symptoms relevant to diagnostic criteria for mood disorders outlined in the DSM-IV.20 After this examination, a diagnosis of major depression, minor depression, or generalized anxiety disorder (GAD) was made using DSM-IV diagnostic criteria. The PSE included information on suicidal ideation including plans or acts. Suicidal ideation was judged to be positive if patients deliberately considered suicide and it was not just a fleeting thought or passive death wish. Interviewers (fully trained psychiatrists) made a clinical judgment about whether there was clinically significant intent to end one's life or not. For the purpose of this study, transient or passive death wishes were considered negative responses.
We divided depressive symptoms (except suicidal plan) into autonomic (vegetative) and psychological subtypes based on the distinctions proposed by Davidson and Turnbull.21 The autonomic symptoms included autonomic anxiety, anxious foreboding, morning depression, weight loss, delayed sleep, subjective anergia, early morning awakening, and loss of libido. The psychological symptoms included worrying, brooding, loss of interest, hopelessness, social withdrawal, self-depreciation, lack of self-confidence, simple idea of reference, guilty ideas of reference, pathological guilt, and irritability. No attempt was made to determine whether the symptoms resulted from the patients' medical illness, medications, hospital environment, depression, or other possible causes because we showed in prior studies that depressive symptoms are almost exclusively associated with depressed mood and not the other previously mentioned factors, which might be hypothesized to cause depressive symptoms.22,23
Statistical Analysis
Several of the rating scale scores and other variables showed non-normal distributions, so we used nonparametric procedures throughout our statistical analyses. The  2 test was used to compare categorical data. When sample sizes were prohibitively small, we used Fisher's exact test. We used the overall 2 tests from logistic regression to test the demographic variables and psychiatric variables as groups. When we analyzed the six rating scales, we used a nonparametric analog of multivariate analysis of variance based on ranks.24 With this approach we analyzed the ranks of the scores instead of the original scoring scales to adjust for non-normal distributions. By using an overall test of significance for the full model, we were able to control for the overall probability of obtaining a significant result by chance (alpha error).
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RESULTS
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Of the 496 patients who were evaluated, 33 patients (4 MI, 7 SCI, 3 TBI, and 19 stroke patients) had a suicidal plan and 3 patients (1 MI, 1 SCI, and 1 stroke) had attempted suicide. These 36 patients (7.3%) who had a suicidal plan or had attempted suicide constituted the suicidal plan group. The remaining 460 patients did not have a suicidal plan and constituted the nonsuicidal group. The median time from injury/illness to interview was 11.0 days (Q3–Q1=17.0). There was no significant difference in the time from injury/illness to interview between the suicidal and nonsuicidal group. There were no differences among the four diagnostic groups in the frequency of their suicidal intentions (MI=5[7.1%], SCI=8[13.3%], TBI=3[4.6%], stroke=20[6.6%]).
Demographic Characteristics and Psychiatric Diagnoses
Table 1 shows the univariate analyses of demographic characteristics and psychiatric diagnoses between suicidal and nonsuicidal patients. There were no statistically significant differences between patients in the two groups in terms of gender, race, education, or family psychiatric history. Suicidal patients were significantly younger than nonsuicidal patients. In addition, there was a significantly lower frequency of married status in the suicidal patients compared with the nonsuicidal patients. There was also a significantly greater frequency of personal psychiatric history and/or alcohol abuse history in the suicidal group compared with the nonsuicidal group. In addition, suicidal patients had a significantly higher frequency of both major depression and GAD than the nonsuicidal patients.
Next, we calculated the association of each potential demographic and psychiatric risk factor with suicidal intention after controlling for other factors (Table 2). Model 1 is the result of multivariate analysis with demographic characteristics only. Being nonmarried was found to be strongly associated with suicidal ideas. We next performed multivariate analyses with both demographic and psychiatric variables (Model 2). In this model, once the psychiatric variables were added, nonmarried was no longer associated with a suicidal plan. Only depressive disorder was strongly associated with the suicidal group. Past personal psychiatric history had a trend toward association with the suicidal group.
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TABLE 2. Logistic regression analyses of demographic variables only (model 1) and demographic and psychiatric variables (model 2) for suicidal patients
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Relationships to Impairment Variables
Median scores of the administered scales are shown in Table 3. Multivariate analysis of variance of the Ham-D, PSE, JHFI, MMSE, STC, and SFE scores showed a significant difference between patients in the two groups. Univariate test statistics disclosed significantly higher (i.e., more impaired) scores on the Ham-D, PSE, JHFI, STC, and SFE.
Next, to assess the interaction effect of suicidal plan and depressive disorders, multivariate two-factor analysis of variance of the Ham-D, PSE, JHFI, MMSE, STC, and SFE scores was performed (Table 4). There was no overall interaction effect of suicidal plan and depressive disorders on the 6 scores (Wilks'  =0.984, df 6,388, P=0.384). Both suicidal plans and depressive disorders significantly influenced the PSE and Ham-D scores. On the JHFI, depressive disorders, not suicidal plans, had a significant association. On the STC and SFE, suicidal plans, not depressive disorders, had a trend toward association.
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TABLE 4. Multivariate two-way layout analysis of variance of Ham-D, PSE, JHFI, MMSE, STC, and SFE scores for suicidal patients and depressed patients
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Comparison of Patients With Major Depression With and Without a Suicidal Plan
In this study, 105 (21.2%) patients (20 MI, 14 SCI, 19 TBI, and 52 stroke) had major depression during the initial in-hospital evaluation. Of those, 26 (24.8%) patients had suicidal plans and 79 patients were nonsuicidal. There was no statistically significant difference in rates of suicidal ideas associated with the type of physical illness (MI=3[15.0%], SCI=4[28.6%], TBI=3[15.8%], stroke=16[30.8%]).
Logistic regression analysis of the background characteristics and psychiatric variables (i.e., age, sex, race, education, marital status, family psychiatric history, personal history of psychiatric illness, and personal history of alcohol abuse) showed no association with suicidal compared with nonsuicidal major depression (-2log likelihood 2=97.596, df=8, P=0.126).
Multivariate analysis of the six psychiatric examination scales (Ham-D, PSE, JHFI, MMSE, STC, SFE) showed a statistically significant difference between patients in the two major depression groups (Wilks' =0.84, df 6;87, P=0.0171). Univariate test statistics disclosed that suicidal depressed patients had greater severity of depressive symptoms (Ham-D; P=0.002). Suicidal depressed patients had a trend toward worse ADL scores (JHFI; p =0.071) and cognitive function (MMSE; P=0.072).
The autonomic (vegetative) and psychological symptoms of depression among patients in the two groups were also examined. Logistic regression analysis showed no association between the existence of vegetative symptoms and the presence of a suicidal plan among patients with major depression (-2log likelihood 2=67.617, df=8, P=0.865). However, logistic analysis of psychological symptoms showed an overall significant association between the existence of psychological symptoms and the presence of a suicidal plan among the patients with major depression (-2log likelihood 2=84.150, df=11, P=0.004). Social withdrawal (P=0.010) and simple ideas of reference (P=0.016) were found to be strongly association with the presence of a suicidal plan among the patients with major depression. Hopelessness was also found to be a trend of association with the presence of a suicidal plan among the patients with major depression (P=0.052).
Follow-Up Evaluation and Suicidal Plan
Of the acute patients, 292 (46 MI, 56 TBI, 51 SCI, and 139 stroke) were assessed at least one time during the 3-, 6-, 9-, 12-, and 24-month follow-up evaluations. Logistic regression analysis of the background characteristics and psychiatric variables (i.e., age, sex, race, education, marital status, family psychiatric history, personal history of psychiatric illness, personal history of alcohol abuse, diagnosis of depressive disorders, and diagnosis of GAD) showed an overall significant difference between patients who were followed up and patients who were not followed up (-2log likelihood 2=545.554, df=10, P<0.001). Younger age was found to be strongly associated with the patients who were followed up (P<0.001). Multivariate analysis of the six psychiatric examination scales (Ham-D, PSE, JHFI, MMSE, STC, SFE) did not show a statistically significant difference between patients who were followed up and those who were not followed up (Wilks' =0.979, df 6,390, P=0.204). At these evaluations, 40 patients expressed suicidal ideation. The existence of major depressive disorder at the initial in-hospital evaluation was a significant risk factor to have a suicidal ideation at the follow-up evaluations. There were 18 (10.1%) patients who were nondepressed, 6(13.7%) who had minor depression, and 16 (22.9%) who had major depression at the initial in-hospital evaluation (2=6.903, df=2;289, P<0.05).
Among 36 suicidal patients at the initial in-hospital evaluation, 22 patients (9 stroke, 2 TBI, 3 MI, and 8 SCI) had at least one follow-up evaluation (Table 5). Among these patients, 16 had mood disorder at the initial in-hospital evaluation (15 major depression and 1 minor depression). Follow-up evaluations revealed that 11 of the 16 patients improved their depressive disorders and were no longer suicidal. The patients, whose depressive disorder did not improve, continued to have suicidal ideation. The mean duration of suicidal ideation was 8.7±2.1 SD months.
Characteristics of Suicidal Patients Without Depressive Disorders
There were 8 nondepressed suicidal patients (2 stroke, 2 MI, and 4 SCI patients) at the in-hospital evaluation. Univariate background characteristics between nonsuicidal (n=313) and suicidal (n=8) nondepressed patients showed that younger age was a risk factor, and higher education and personal history of psychiatric illness were trend associations with suicidal ideation (Table 6). In the follow-ups of these 8 patients, 6 patients were seen at least one time during the 24 months (Table 5). Of these, 5 patients were no longer suicidal while one patient, who had a history of psychiatric illness, continued to have suicidal ideation. The mean duration of suicidal ideation was 10.0±4.5 SD months, which was not significantly different than the nondepressed patients.
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DISCUSSION
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We found that 7.3% of patients with acute life-threatening physical illness had suicidal plans. Prior studies have shown that the prevalence of suicidal ideation among general medical outpatients or primary care patients was 2%–7%.25–27 We also found that suicidal ideation was significantly associated with depressive disorders, especially with major depressive disorder. This finding is consistent with the general consensus in the literature that depression is the most frequent and replicable risk factor for suicide,2,28–30 even in physically ill populations. Furthermore, the existence of major depression in the acute treatment period was a risk factor for developing a suicidal plan even after the acute in-hospital treatment.
Before further discussion of our results, it is important to acknowledge the methodological limitations of this study. First, we were assessing suicidal thoughts and plans, not suicidal behavior. Although this is the kind of data that clinicians assess in practice, we had followed up on many of these and no serious suicide attempts or completed suicides were noted. Some patients, lost to follow-up, may have committed suicide unbeknownst to us. Around 40% of initially assessed patients did not have follow-up evaluation. This may have led to some bias in our findings. Our available data, however, did not show any difference besides age (older age was strongly associated with being lost to follow-up) in clinical characteristics between the follow-up and non-follow-up patients. Patients interviewed at follow-up were predominantly those whose outpatient medical care was provided. The follow-up study was, therefore, conducted among patients who were physically able to return to the hospital's outpatient clinic. This might have influenced the association between age and follow-up status. Second, we excluded patients who had significant deficits in verbal comprehension, and therefore we do not know the rate of suicidal ideation in all patients with brain injury. In addition, we did not include patients with passive suicide thoughts in our "suicidal" group. It has been suggested that a failure to follow medical advice might constitute a form of passive suicide. Our findings, therefore, may not be applicable to all suicidal patients with stroke, TBI, MI, and SCI. Third, in this study, we mixed four physical illnesses together (i.e., stroke, TBI, MI, and SCI) and associations with suicidal ideation that were unique to one group may have been diluted.
Given these caveats, this study identified several significant findings related to suicidal plans following significant physical illnesses. First, in the acute physically ill period, most of the suicidal patients (80%) met diagnostic criteria for depressive disorders. Around 20% of patients with suicidal plans did not meet diagnostic criteria for depressive disorders. These might be included in a category of "philosophical" or "rational" suicidal patients. They presumably had decision-making capacity and no demonstrable psychiatric illness, yet they wished to kill themselves. It is these patients who initiate arguments for euthanasia or physician-assisted suicide. However, our follow-up study demonstrated that 5 out of 6 of these patients no longer were suicidal at the follow-up evaluation. These findings suggest that "rational" suicidal plans were transient, just like those associated with depression, and ameliorated over time. These data support our clinical experience in working with these patients that most do not end up killing themselves. These patients may be helped by addressing their physical needs, including pain control, maximizing clinical, social, and financial support, and discussing the impact on relatives and friends of the decision to take their own life.
Another interesting finding was that most depressed patients with suicidal plans were no longer suicidal after the improvement of their depressive disorder, while depressed suicidal patients whose depressive disorders did not improve tended to remain suicidal. Therefore, educating primary care physicians regarding the relationships between depression and suicide is an important contribution to suicide prevention. In fact, Rutz et al.31 reported that an educational program for general practitioners on an island off the coast of Sweden led to a drop in the suicide rate. Our data are consistent with the hypothesis that better primary care of patients with chronic physical illnesses, particularly the careful assessment of depressive disorders, may reduce the suicide rate.
This study also showed that the severity of illness was not an independent risk factor for developing a suicide plan. This suggests that suicidal plans are not simple psychological reactions to physical impairment after an acute event. Few social ties and poor social functioning were identified as independent risk factors for developing suicidal ideation during the acute physical treatment period. This suggests that social work intervention and identification of depressive disorders in patients with impaired social functioning may be important factors in preventing suicide in the medically ill population.
The prevalence of suicidal plans among patients with major depressive disorder and acute physical illness was around 25%. Is this number higher or smaller than that associated with functional depression? Several studies have reported that over one-third of outpatients with major depression had suicidal plans.32,33 However, these patients were requesting treatment for their depression. Therefore, we could not determine from this study whether the rate of suicidal ideation among all patients with major depression is higher than among physically ill depressed patients. More important perhaps is the fact that several studies have found that the diagnosis of depression is missed in primary care. In general medical hospitals, only 11% of patients with a mental disorder will have a formal diagnosis on discharge.34 Furthermore, Rost and colleagues35 followed 98 primary care patients with undetected major depression and found that 32% remained undetected by their primary care provider for up to 1 year; almost half developed suicidal ideation. In a review examining the health policy implications of studies of the treatment of depression, Wells36 concluded that the quality of care and clinical outcome obtained in general medical practices were inadequate. Given the fact that one-fourth of patients with major depression and acute physical illness in our study had a suicidal plan, the need for systematic identification and effective treatment of depression among acutely physically ill patients is obvious. Therefore, the consultation-liaison psychiatrist must play an essential role in educating general medical providers and improving medical and psychological outcomes. Integrated psychiatric and medical care has been shown in several studies to also improve care37,38
Characteristics, such as greater severity of depression, greater physical and cognitive impairment associated with poor social support, social withdrawal, and suspiciousness, may be useful to clinicians in identifying acute physically ill depressed patients who are most at risk for suicide.
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CONCLUSION
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This study found that about 7% of patients with acute medical illness had suicidal plans. The suicidal plans occurred mostly among patients with major depression and sometimes among those with minor depression. About 25% of major depressed patients developed suicidal plans. After the improvement of depressive disorders, suicidal plans were ameliorated. These findings suggest that the detection and treatment of depressive disorders is probably the most important factor in preventing suicide among this patient population.
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ACKNOWLEDGMENTS
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This work was supported in part by the following grants from the National Institute of Mental Health: MH52879 and MH53592(RGR), and by a grant from the Japanese Ministry of Health and Welfare (YK).
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ABSTRACT
INTRODUCTION
