Stroke survivors more likely to commit suicide than stroke-free counterparts

Stroke sufferers are more than twice as likely to attempt suicide within a decade of their infarction than non-stroke patients, according to a nationwide study of more than two million Taiwanese adults.

Though the illness is an immense global presence and the most common cause of disability worldwide, different cultures handle stroke diagnoses in different ways, first author Tomor Harnod, MD, PhD, and colleagues wrote in the Journal of the American Heart Association. In developed Western countries like the U.S., stroke patients are often highly intolerant of their disability, which has led to increased rates of suicidal ideations and attempts in those populations.

“In different countries, cultural heritage and socioeconomic status would usually influence a patient with disability thinking about a suicide attempt,” the authors wrote. “Ethnic and cultural differences from Western countries may make Asian people more tolerant of their impairment, dependence or disability in daily life than their European or American counterparts.”

Taiwan, a. East Asia hub that’s led a successful healthcare program for two decades, still doesn’t have validated data regarding attempted suicide risk in post-stroke patients, according to the paper. Harnod and co-authors drew a sample of 713,690 post-stroke patients and 1,426,009 non-stroke controls from the country’s governmental dataset on the subject. Any patients who had attempted suicide in the past were not included in the trial.

All patients were subject to follow-up until a recorded suicide attempt, death from another cause, withdrawal from Taiwan’s insurance system or the end of 2011, the authors wrote.

Despite baseline similarities in the post-stroke and non-stroke cohorts, including an average age of around 67 and a mean income of between 15,000 and 19,999 New Taiwan dollars—$495 and $660, respectively—per month, post-stroke patients were more than two times as likely as their matched cohort to attempt suicide. Compared with the non-stroke controls, adjusted hazard ratios for suicide attempt in the post-stroke population were 1.87, 2.25 and 2.20 for hemorrhagic, ischemic and total strokes, respectively.

Harnod et al. found the risk of suicide attempt was 1.35-fold higher in stroke sufferers under 50 years old than in patients between 50 and 64. Alongside the age factor, earning a low monthly income, living in less urbanized areas and working in manual labor were the leading risk factors for post-stroke suicide attempt. The researchers also found patients with schizophrenia, depression before stroke, post-stroke depression, alcohol-related illness, insomnia, diabetes mellitus, chronic obstructive pulmonary disease, asthma, coronary artery disease and hypertension were more likely to attempt to kill themselves than others without these comorbidities.

When it came to modes of attempt, post-stroke patients were also 4.22-fold more likely to jump from high places, 2.28-fold more likely to ingest solid or liquid poisoning, 1.93-fold more likely to cut or pierce themselves and 1.73-fold more likely to hang themselves than the non-stroke cohort. These findings are different from Western countries, where firearms and self-poisoning are the most common ways stroke patients attempt suicide.

“Post-stroke patients may feel like they have no hope, are a burden on others or are losing their personal dignity and thus may have a desire for death,” the authors wrote. “The socioeconomic status and social support of patients with disability should be thought as the major factors affecting long-term outcome and lifespan. Patients who survive a stroke may be frustrated to manage the new experience of disability or impairment by themselves.”

Indeed, most patients need special rehabilitation and individualized care following a stroke, and money often becomes a problem that can cause unhealthy stress. Physical damage caused by a stroke can lead to cognitive and interpretive disabilities, leading commonly to depression, anxiety and mental disorders.

“Suicide prevention is a crucial aspect of public health, but no large representative dataset from healthcare systems regarding suicide is yet available in Asian countries,” Harnod and colleagues wrote. “These results convey crucial information to clinicians and governments for preventing suicide attempt in post-stroke patients in Taiwan and other Asian countries.”