Journal Article Annotations
2021, 2nd Quarter

Suicide

Annotations by Liliya Gershengoren MD
April, 2021

Suicide and self-harm in adult survivors of critical illness: population based cohort study.
Trajectories of pain during pregnancy predict symptoms of postpartum depression.

PUBLICATION #1 — Suicide

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

Abstract: Observational Study BMJ. 2021 May 5;373:n973. doi: 10.1136/bmj.n973.

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.

Annotation

The finding:
In an analysis of 423,060 critical illness survivors, 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. Patients with an ICU admissions were at an increased risk of suicide and self-harm as compared with patients who were did not require an ICU admission during their hospitalization. Prior mental health diagnoses such as depression, anxiety, post-traumatic stress disorder, schizophrenia and bipolar disorder were associated with suicide or self-harm. Furthermore, patients requiring mechanical ventilation or renal replacement therapy in the ICU were also at an increased risk of suicide or self-harm.

Strength and weaknesses:
A strength of the study is its inclusion of an entire consecutive patient series, ensuring a large cohort of patients, minimal missing data, and lower risk of bias. While the study demonstrated an important inverse association between suicide and socioeconomic status, it did not describe the racial and ethnic background of the patients in reference to suicide and self-harm findings. Considerations of social determinants of health were not included in the study making its data less generalizable in light of issues such as diversity, equity and inclusion in medical and mental healthcare and potential outcomes.

Relevance:
Critically ill patients are a potentially vulnerable patient population and are often evaluated by C-L psychiatrists during their hospitalization. While the reasons for a psychiatric consult may vary, the consultant should keep in mind not only acute psychiatric morbidity in the ICU survivors but also the potential for ongoing psychic distress beyond the critical period of the medical illness. Increased risk of suicide and self-harm during and after hospitalization complicates patients’ prognosis and alters treatment planning for the C-L Psychiatrist.

Type of study (EBM guide):
Case control study

PUBLICATION #2 — Suicide

Trajectories of pain during pregnancy predict symptoms of postpartum depression.

Vani A Mathur, Tristin Nyman, Namrata Nanavaty, Nevita George, Rebecca J Brooker

Abstract: Pain Rep. 2021 Jun 3;6(2):e933. doi: 10.1097/PR9.0000000000000933. eCollection Jul-Aug 2021.

Introduction:
Postpartum depression imparts a significant and long-lasting burden on maternal and child health. Successful prevention or early detection of postpartum depression will rely on the identification of early risk factors. Pain during pregnancy (before childbirth) is a key potential predictor of postpartum depression risk. However, longitudinal studies characterizing pregnancy pain, its normal trajectory over time, and its prospective relations with symptoms of postpartum depression are lacking.

Methods:
We used data from a longitudinal study of maternal emotion that included assessments of pain and depressive symptoms at 3 time points-during the second and third trimester of pregnancy and at 4 months postpartum. Structural equation modelling was used to estimate longitudinal patterns of change in maternal pain over time. Latent growth curve parameters were tested as predictors of symptoms of postpartum depression.

Results:
Ninety-three healthy pregnant women enrolled in this study. Although the sample comprised women with relatively low-risk pregnancies, more than 90% of participants experienced pregnancy pain. Greater linear increases and less negative quadratic change in maternal pain over time were associated with greater levels of postpartum depression, even when controlling for prenatal depressive symptoms. Interpreting both parameters together, pain that increased in late pregnancy, when normative patterns had either levelled off or begun to decline, was associated with greater levels of postpartum depression.

Conclusion:
A developmental trajectory of pain experience that did not subside after childbirth was associated with greater postpartum depressive symptoms, suggesting that atypical trajectories of pain may be a risk factor for postpartum depression.

Annotation

The finding:
This longitudinal study of 93 women found that pain during pregnancy predicted postpartum depression irrespective of a history of antenatal depression. Specifically, increases in pain over the course of pregnancy and lasting into the post-partum period was associated with increased risk of postpartum depression.

Strength and weaknesses:
A significant limitation of the study was the lack of racial and ethnic diversity among its participants. Majority of the participants in the study were white “of those mothers who reported race and ethnicity, 89% were White, 8% Asian, 1% American Indian, 1% African American, and 1% mixed race. Most mothers were also non-Hispanic (96%).” As a result, generalizability of the study results is limited. A key strength of the study is its emphasis on maternal pain trajectories over the 2nd and 3rd trimesters as well as the postpartum period. The study explores the dynamic changes in pain and its implications on maternal mental health.

Relevance:
The relationship between pain and mental health is familiar to any C-L psychiatrist. Patients struggling with pain during pregnancy require closer monitoring during the postpartum period for depression.

Type of study (EBM guide):
Cohort study