For individuals who have attempted suicide, life expectancy is dramatically reduced compared to the general public. Deaths are due primarily to physical rather than psychiatric causes, new research shows.
Swedish researchers analyzed a database of more than 185,000 individuals older than 18 years who had attempted suicide and who had been hospitalized during a period of 4 decades.
They found that life expectancy in men and women who had attempted suicide at age 20 was shorter by 18 years and 11 years, respectively, compared to the general population.
For men and women whose suicide attempt took place at age 50, life expectancy was reduced by 10 and 8 years, respectively.
Deaths from suicide or undetermined intent constituted only one fifth of the total mortality within 10 years of the suicide attempt. It was only 5% for those whose deaths occurred at least 4 decades after their first attempt. Most excess deaths were due to somatic comorbidity.
“Suicide risk in early-onset suicide attempters may have a different profile with higher frequency of substance abuse and exposure to childhood sexual abuse as well as unnatural causes, but the risk of dying of natural causes explained the major part of the elevated risk of mortality,” lead author Jussi Jokinen, MD, PhD, psychiatrist and professor at Umeå University and researcher in the Department of Clinical Neuroscience, the Karolinska Institutet, Solna, Sweden, told Medscape Medical News.
“Clinicians should be aware that patients attempting suicide need treatments known to have suicide preventive effects but also better treatment for eventual physical illnesses, as well as social support,” he said.
The study was published online December 14 in Acta Psychiatrica Scandinavica.
“Huge” Reduction in Life Expectancy
“Excess mortality and reduction in life expectancy, explained by both increased risk of natural and unnatural causes of death, have been consistently reported among patients with mental disorders, compared to the general population,” the authors write.
Although many studies have focused on life expectancy for patients with mental disorders, no studies have specifically investigated life expectancy after the first suicide attempt.
“We wanted to see what life expectancy was like after the first suicide attempt and fill the knowledge gap, and we had the possibility to do this kind of study in Sweden because we have a very large database and long-term follow-up,” Dr Jokinen said.
To compare the life expectancy of individuals who attempted suicide for the first time to the life expectancy of the general Swedish population, the researchers studied data from a nationwide, population-based register cohort (the Swedish patient register) of all persons aged 18 years or older who were hospitalized for first-time attempted suicide or self-inflicted injury from January 1, 1971, to December 31, 2010.
Of the 187,894 individuals who made a first suicide attempt or who experienced a self-inflicted injury during the study period, 2.1% died during their hospital stay and were excluded from the study. The final cohort included 184,028 persons. Of these, 77% were alive and residing in Sweden at some point during the follow-up period (January 1, 2001, to December 31, 2010).
The researchers used official population statistics to calculate period life expectancy of the general Swedish population. They used the Swedish Cause of Death Register to determine the date and cause of death of individuals within the cohort.
Those individuals who had attempted suicide were divided into four mutually exclusive subcohorts on the basis of the amount of time since their first suicide attempt: those whose first attempt occurred from 1971-1980; those whose attempt occurred from 1981-1989; those whose attempt occurred from 1991-1999; and those whose attempt occurred from 2001-2010.
The observed cumulative mortality was calculated for each subcohort for those at risk of dying during the follow-up period.
Because 22 years had passed between the end of period for the first subcohort, in 1980, and the start of the follow-up period in 2001, the estimates had to be restricted to patients aged 42 years and older to make them comparable.
The eligible cohort under study included the 142,045 persons alive at some point during the follow-up period, representing 1,042,106 person-years. There were 23,171 deaths during the follow-up period.
Individuals of both sexes who made a first suicide attempt during their lifespan experienced shortened life expectancy, but men and women differed in the length of life expectancy reduction. For men and women whose first suicide attempt took place at age 20 years, life expectancy was reduced by approximately 18 years and 11 years, respectively.
For men and women whose suicide attempt took place at age 50, the reduction was 10 and 8 years respectively. At age 80, it was 2 years for both sexes.
Reduction in life expectancy in those who attempted suicide at younger ages was more pronounced in males than in females, but the sex difference was attenuated in patients whose first suicide attempt took place at age 70 years or older.
Shortened life expectancy was not primarily due to suicide. In patients who made their first suicide attempt in 2001-2010, suicide accounted for only about 17% of deaths in 2001-2010 for men and about 16% for women. Deaths of undetermined intent accounted for about 3% for both men and women.
For patients who had made their first suicide attempt in 1971-1980 and had survived until start of follow-up (2001), suicide accounted for only about 4% of the deaths in 2001-2010 for both men and women. Deaths due to undetermined intent accounted for about 1% to 2%.
The remaining deaths (approximately 80%) were due to natural causes.
The researchers note that the “proportion of suicide as a cause of death was larger in the time period close to the suicide attempt, while for patients who had made their first suicide attempt 20-40 years earlier, natural causes accounted for about 95% of total mortality.”
They explain that the period close to the time at which suicide is attempted is “the high-risk period for subsequent suicide” and that during that period, there should be “a concern for intense treatment efforts to prevent suicide.”
Dr Jokinen acknowledged being surprised by the findings.
“We know that mental disorders reduce life expectancy, and since most suicide attempters suffer from mental disorders, we expected a reduction. However, the huge reduction in life expectancy among young attempters as well as the gender difference, especially among young attempters, was somewhat surprising.”
He attributed the risks of dying of natural causes to the increased physical health problems caused by lifestyle factors (eg, cigarette smoking and alcohol abuse), which can increase the risk for liver and lung cancer, as well as socioeconomic factors.
Clarion Call
Commenting on the study for Medscape Medical News, Roger McIntyre, MD, professor of psychiatry and pharmacology at the University of Toronto and head of the Mood Disorders Psychopharmacology Unit at the University Health Network, Toronto, Canada, who was not involved with the study, described it as a “clarion call to address psychiatric and physical health aspects.”
Dr McIntyre said he liked the study “because not only is it clever, but it’s an unconventional way to look at the question, because the authors took a path of insight or inquiry that was not the usual path.”
He noted that it is “a well-established fact that people who attempt to harm themselves are at higher risk of repeat self-harm or completed suicide, but these researchers looked at it slightly differently, which is that people who attempted suicide had a greater chance of dying of physical health conditions.”
Although the study was conducted in Sweden, the findings can be generalized to North America, he said.
“The take-home message is that in patients who attempted suicide, healthcare providers should provide best practices as relates to a diagnosable mental disorder and should also provide best practices care for physical health comorbidities,” he emphasized.
Dr Jokinen added that, beyond the role of individual healthcare providers, “society should make more effort to address the inequalities concerning access to treatments for patients with psychiatric diagnoses.”
The study was funded by the Swedish Society of Medicine’s Söderström-König Foundation. The study authors have disclosed no relevant financial relationships. During the past 2 years, Dr McIntyre received fees for speaking/consultation from the following pharmaceutical companies: Shire, Purdue, Otsuka, Janssen-Ortho, Lundbeck, Pfizer, Neurocrine, Neuralstem, Sunovion, Takeda, and Allergan. He has received research support from Lundbeck, Shire, Purdue, and Allergan.
Acta Psychiatr Scand. December 14, 2017. Abstract
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