A recent study looked at data on more than 3.5 million people admitted to the hospital and found that ICU survivors had a 22% higher risk of suicide than patients who spent time in other hospital departments. Their risk of self-harm also increased by 15% and remained elevated for years after their discharge. Here’s what the research shows about mental health outcomes after a stay in the ICU, along with suggestions from experts on improving care.
What the Study Shows
A team of researchers from the U.S. and Canada gathered health records on adults admitted to hospitals in Ontario through the single-payer healthcare system between January 1, 2009, and December 31, 2017. The data included information on 423,060 ICU survivors, 39% of whom were women. People in this group were about 62 years old on average. The median length of their stay in the ICU was 7 days. The data also included records on nearly 3.1 million people who survived after being admitted to other hospital areas (not the ICU). This group skewed younger, with an average age of about 54 years old. Roughly two-thirds of the non-ICU survivors were women. The ICU group tended to have higher rates of other health conditions prior to their hospitalization than those admitted elsewhere in the hospital. For example, around 15% of those in the ICU had at least one mental health condition before their hospital stay. Researchers then gathered information on death by suicide or hospital visits related to intentional self-harm during the time period between the participants’ discharge from the hospital and the end of the study period. After analyzing the data, the researchers found that 0.2% of the ICU survivors died by suicide, compared with 0.1% of the non-ICU patients, in the years after they left the hospital. The results also showed that 1.3% of ICU survivors deliberately harmed themselves after their hospital stay, compared with 0.8% of people in the other group. “Self-injury is a coping skill we can use when we feel overwhelmed, traumatized, and don’t have other healthier ways to deal with all that’s going on. If we consider the patients in this study, we know they just experienced a life-threatening event, and while they did survive, that event is a lot to process. “We can feel scared, hyper-vigilant, possibly be in physical pain as a result, and not know how to cope,” explains Kati Morton, LMFT, a licensed therapist and host of the Ask Kati Anything Podcast. Overall, the ICU survivors experienced a 22% higher risk of suicide and a 15% higher risk of self-harm. The elevated risk of either mental health problem became prevalent immediately after leaving the hospital and continued to remain high for years. “The correlation is not surprising. Medical trauma is trauma and is often overlooked when discussing traumatic events that may impact a person’s mental health,” says Suzanne Galletly, NP, a psychiatric mental health nurse practitioner at the Mind Health Institute in Pasadena, California. “The trauma of being in the intensive care unit is coupled with the physical aftermath (often not regaining full pre-admission functioning) and the financial implications to create a perfect storm of anxiety, depression, and post-traumatic stress disorder (PTSD),” says Galletly. The risk of suicide and self-harm tended to be highest among ICU survivors who were between 18 and 34 years old and/or had a pre-existing diagnosis for a mental illness (such as PTSD, depression, or schizophrenia). The risk was also higher among ICU survivors who received invasive mechanical ventilation or renal replacement therapy. “For a younger person, the healing journey might seem overwhelming, questioning if they will be able to get back on the track they were on before the hospitalization,” says Galletly. “When a person has a baseline of some psychiatric illness, and we add the trauma and stress of hospitalization, the system is overwhelmed. Suicide may seem like the only solution, and self-harm becomes a way to alleviate some pain.”
Strengths and Limitations of the Research
While the findings offer insights into the risks people may face after leaving the ICU, more research is needed. As a data-based study, the research may be missing information on other confounding factors that may further explain the increased risk of suicide and self-harm, says Rashmi Parmar, MD, psychiatrist with Community Psychiatry. “An ICU stay may represent just the tip of the iceberg of a person’s health concerns. There can be several other underlying risks as well as protective factors that can influence the emotional and physical wellbeing of an individual which have not been considered in this study,” she says. The data may also be missing information on some suicide attempts and self-harm episodes, which could mean the true rates are even higher, Dr. Parmar adds. “The actual rate of suicide and self-harm may possibly be higher than that reported in the study given the fact that they only included deaths reported from suicide and self-harm episodes that prompted hospital visits,” she says. “There is a high likelihood of self-harm and suicidal behaviors that may have failed or may not have been severe enough to require medical attention, but nevertheless have a major influence on the study outcome,” says Dr. Parmar. Still, the study is bolstered by a few strengths. It used eight years worth of data, giving the authors a long period of time to evaluate. It also included a huge sample size of more than 3.5 million hospital patients in total, which helps provide a good representation of the population at large.
Improving Care After ICU Stays
Understanding what a patient goes through after an ICU stay is crucial in improving health outcomes. For example, many people experience post-intensive care syndrome (PICS), which can include a range of debilitating physical, cognitive, and mental health challenges. While the likelihood of self-harm and suicide are overall quite low after a person leaves the ICU, taking the slightly elevated risk levels into account during follow-up care could help bring those rates down even further—an especially important task, amid the spike in ICU admissions and higher rates of suicide during the pandemic. “Suicide is a public health emergency which warrants our attention, and it can be potentially prevented with early detection and intervention. Physicians and hospitals should be on high alert with patients admitted to hospitals, especially those with ICU stays,” says Dr. Parmar. Galletly suggests that hospitals have social workers and discharge coordinators connect patients with mental healthcare resources, such as an appointment with a therapist. “Post-ICU patients need to have a thorough and consistent follow-up with primary care providers who are adept at asking about mental health and then referring for specialized treatment if deemed necessary,” she adds. It would also help if emotional support services were as easy as physical healthcare services to get covered by health insurance policies, Morton says. “We like to think that mental health and physical health can be treated differently, but they are inextricably linked, and need to be treated simultaneously,” she adds. “If doctors and mental health professionals can work in tandem with patients, we can help people heal both physically and mentally, and see suicide and self-injury rates go down,” Morton says. Finally, helping the patient tap into their own support network and learn about ways to access emergency support may also help people during their emotional recovery from the ICU. “The patient should be educated about coping skills, including seeking out family and friends for support in times of crisis. Suicide prevention hotline numbers should be provided for easy access,” says Dr. Parmar. “An effort should be made to coordinate care with the patient’s family and other levels of support in the community.” If you or someone you love recently spent time in the ICU, it may be helpful to seek out emotional support from a qualified mental health professional. You can also reach a counselor at the National Suicide Prevention Lifeline anytime by calling 1-800-273-8255 (TALK).
