Outpatient Mental Health Follow-up and Recurrent Self-harm and Suicide Among Patients Admitted to the ICU for Self-harm: A Population-based Cohort Study

Shannon M Fernando¹, Michael Pugliese², Daniel I McIsaac³, Danial Qureshi⁴, Robert Talarico², Manish M Sood⁵, Daniel T Myran⁶, Margaret S Herridge⁷, Dale M Needham⁸, Laveena Munshi⁹, Bram Rochwerg¹⁰, Kirsten M Fiest¹¹, Christina Milani¹², Magdalena Kisilewicz¹³, O Joseph Bienvenu¹⁴, Daniel Brodie¹⁵, Eddy Fan⁷, Robert A Fowler¹⁶, Niall D Ferguson⁷, Damon C Scales¹⁷, Hannah Wunsch¹⁶, Peter Tanuseputro¹⁸, Kwadwo Kyeremanteng¹⁹

Affiliations

¹ Division of Critical Care, Department of Medicine, University of Ottawa, Ottawa, ON, Canada; Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, ON, Canada; Department of Critical Care, Lakeridge Health Corporation, Oshawa, ON, Canada. Electronic address: sfernando@qmed.ca.
² Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, ON, Canada; ICES, Toronto, ON, Canada.
³ School of Epidemiology and Public Health, University of Ottawa, Ottawa, ON, Canada; Department of Anesthesiology and Pain Medicine, University of Ottawa, Ottawa, ON, Canada; Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, ON, Canada; ICES, Toronto, ON, Canada.
⁴ School of Epidemiology and Public Health, University of Ottawa, Ottawa, ON, Canada; Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, ON, Canada; Bruyère Research Institute, Ottawa, ON, Canada; ICES, Toronto, ON, Canada.
⁵ School of Epidemiology and Public Health, University of Ottawa, Ottawa, ON, Canada; Division of Nephrology, University of Ottawa, Ottawa, ON, Canada; Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, ON, Canada; ICES, Toronto, ON, Canada.
⁶ School of Epidemiology and Public Health, University of Ottawa, Ottawa, ON, Canada; Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, ON, Canada.
⁷ Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, ON, Canada; Institute of Health Policy, Management and Evaluation, Dalla Lana School of Public Health, University of Toronto, Toronto, ON, Canada; Toronto General Hospital Research Institute, University Health Network, Toronto, ON, Canada; Department of Medicine, Sinai Health System and University Health Network, Toronto, ON, Canada.
⁸ Division of Pulmonary and Critical Care Medicine, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD; Department of Physical Medicine and Rehabilitation, Johns Hopkins University School of Medicine, Baltimore, MD.
⁹ Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, ON, Canada; Institute of Health Policy, Management and Evaluation, Dalla Lana School of Public Health, University of Toronto, Toronto, ON, Canada; Department of Medicine, Sinai Health System and University Health Network, Toronto, ON, Canada.
¹⁰ Division of Critical Care, Department of Medicine, McMaster University, Hamilton, ON, Canada; Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, ON.
¹¹ Department of Critical Care Medicine, Cumming School of Medicine, University of Calgary, Calgary AB, Canada; Department of Community Health Sciences and O'Brien Institute for Public Health, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada; Department of Psychiatry, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada.
¹² School of Epidemiology and Public Health, University of Ottawa, Ottawa, ON, Canada; Bruyère Research Institute, Ottawa, ON, Canada; ICES, Toronto, ON, Canada.
¹³ Department of Critical Care, Queensway Carleton Hospital, Ottawa, ON, Canada.
¹⁴ Department of Psychiatry and Behavioural Sciences, Johns Hopkins University School of Medicine, Baltimore, MD.
¹⁵ Division of Pulmonary, Allergy, and Critical Care Medicine, Department of Medicine, Columbia University College of Physicians and Surgeons, New York, NY; Center for Acute Respiratory Failure, New York-Presbyterian Hospital, New York, NY.
¹⁶ ICES, Toronto, ON, Canada; Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, ON, Canada; Institute of Health Policy, Management and Evaluation, Dalla Lana School of Public Health, University of Toronto, Toronto, ON, Canada; Department of Critical Care Medicine, Sunnybrook Health Sciences Centre, Toronto, ON, Canada.
¹⁷ ICES, Toronto, ON, Canada; Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, ON, Canada; Institute of Health Policy, Management and Evaluation, Dalla Lana School of Public Health, University of Toronto, Toronto, ON, Canada; Department of Critical Care Medicine, Sunnybrook Health Sciences Centre, Toronto, ON, Canada; Li Ka Shing Knowledge Institute, St. Michael's Hospital, Toronto, ON, Canada.
¹⁸ School of Epidemiology and Public Health, University of Ottawa, Ottawa, ON, Canada; Division of Palliative Care, Department of Medicine, University of Ottawa, Ottawa, ON, Canada; Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, ON, Canada; Bruyère Research Institute, Ottawa, ON, Canada; ICES, Toronto, ON, Canada.
¹⁹ Division of Critical Care, Department of Medicine, University of Ottawa, Ottawa, ON, Canada; Division of Palliative Care, Department of Medicine, University of Ottawa, Ottawa, ON, Canada; Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, ON, Canada; Institut du Savoir Montfort, Ottawa, ON, Canada.

PMID: 36445799
DOI: 10.1016/j.chest.2022.10.021

Outpatient Mental Health Follow-up and Recurrent Self-harm and Suicide Among Patients Admitted to the ICU for Self-harm: A Population-based Cohort Study

Shannon M Fernando et al. Chest. 2023 Apr.

. 2023 Apr;163(4):815-825.

doi: 10.1016/j.chest.2022.10.021. Epub 2022 Oct 29.

Authors

Affiliations

¹ Division of Critical Care, Department of Medicine, University of Ottawa, Ottawa, ON, Canada; Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, ON, Canada; Department of Critical Care, Lakeridge Health Corporation, Oshawa, ON, Canada. Electronic address: sfernando@qmed.ca.
² Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, ON, Canada; ICES, Toronto, ON, Canada.
³ School of Epidemiology and Public Health, University of Ottawa, Ottawa, ON, Canada; Department of Anesthesiology and Pain Medicine, University of Ottawa, Ottawa, ON, Canada; Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, ON, Canada; ICES, Toronto, ON, Canada.
⁴ School of Epidemiology and Public Health, University of Ottawa, Ottawa, ON, Canada; Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, ON, Canada; Bruyère Research Institute, Ottawa, ON, Canada; ICES, Toronto, ON, Canada.
⁵ School of Epidemiology and Public Health, University of Ottawa, Ottawa, ON, Canada; Division of Nephrology, University of Ottawa, Ottawa, ON, Canada; Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, ON, Canada; ICES, Toronto, ON, Canada.
⁶ School of Epidemiology and Public Health, University of Ottawa, Ottawa, ON, Canada; Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, ON, Canada.
⁷ Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, ON, Canada; Institute of Health Policy, Management and Evaluation, Dalla Lana School of Public Health, University of Toronto, Toronto, ON, Canada; Toronto General Hospital Research Institute, University Health Network, Toronto, ON, Canada; Department of Medicine, Sinai Health System and University Health Network, Toronto, ON, Canada.
⁸ Division of Pulmonary and Critical Care Medicine, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD; Department of Physical Medicine and Rehabilitation, Johns Hopkins University School of Medicine, Baltimore, MD.
⁹ Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, ON, Canada; Institute of Health Policy, Management and Evaluation, Dalla Lana School of Public Health, University of Toronto, Toronto, ON, Canada; Department of Medicine, Sinai Health System and University Health Network, Toronto, ON, Canada.
¹⁰ Division of Critical Care, Department of Medicine, McMaster University, Hamilton, ON, Canada; Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, ON.
¹¹ Department of Critical Care Medicine, Cumming School of Medicine, University of Calgary, Calgary AB, Canada; Department of Community Health Sciences and O'Brien Institute for Public Health, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada; Department of Psychiatry, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada.
¹² School of Epidemiology and Public Health, University of Ottawa, Ottawa, ON, Canada; Bruyère Research Institute, Ottawa, ON, Canada; ICES, Toronto, ON, Canada.
¹³ Department of Critical Care, Queensway Carleton Hospital, Ottawa, ON, Canada.
¹⁴ Department of Psychiatry and Behavioural Sciences, Johns Hopkins University School of Medicine, Baltimore, MD.
¹⁵ Division of Pulmonary, Allergy, and Critical Care Medicine, Department of Medicine, Columbia University College of Physicians and Surgeons, New York, NY; Center for Acute Respiratory Failure, New York-Presbyterian Hospital, New York, NY.
¹⁶ ICES, Toronto, ON, Canada; Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, ON, Canada; Institute of Health Policy, Management and Evaluation, Dalla Lana School of Public Health, University of Toronto, Toronto, ON, Canada; Department of Critical Care Medicine, Sunnybrook Health Sciences Centre, Toronto, ON, Canada.
¹⁷ ICES, Toronto, ON, Canada; Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, ON, Canada; Institute of Health Policy, Management and Evaluation, Dalla Lana School of Public Health, University of Toronto, Toronto, ON, Canada; Department of Critical Care Medicine, Sunnybrook Health Sciences Centre, Toronto, ON, Canada; Li Ka Shing Knowledge Institute, St. Michael's Hospital, Toronto, ON, Canada.
¹⁸ School of Epidemiology and Public Health, University of Ottawa, Ottawa, ON, Canada; Division of Palliative Care, Department of Medicine, University of Ottawa, Ottawa, ON, Canada; Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, ON, Canada; Bruyère Research Institute, Ottawa, ON, Canada; ICES, Toronto, ON, Canada.
¹⁹ Division of Critical Care, Department of Medicine, University of Ottawa, Ottawa, ON, Canada; Division of Palliative Care, Department of Medicine, University of Ottawa, Ottawa, ON, Canada; Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, ON, Canada; Institut du Savoir Montfort, Ottawa, ON, Canada.

PMID: 36445799
DOI: 10.1016/j.chest.2022.10.021

Abstract

Background: Patients surviving an ICU admission for deliberate self-harm are at high risk of recurrent self-harm or suicide after discharge. It is unknown whether mental health follow-up after discharge (with either a family physician or psychiatrist) reduces this risk.

Research question: What is the association between mental health follow-up after discharge and recurrent self-harm among patients admitted to the ICU for intentional self-harm?

Study design and methods: Population-based cohort study of consecutive adults (≥ 18 years of age) from Ontario, Canada, who were admitted to ICU because of intentional self-harm between 2009 and 2017. We categorized patients according to follow-up, with 'early follow-up' indicating 1 to 21 days after discharge, 'late follow-up' indicating 22 to 60 days after discharge, and 'no follow-up' indicating no follow-up within 60 days of discharge. We conducted analyses using a cause-specific extended Cox regression model to account for varying time for mental health follow-up relative to the outcomes of interest. The primary outcome was recurrent ICU admission for self-harm within 1 year of discharge.

Results: We included 9,569 consecutive adults admitted to the ICU for deliberate self-harm. Compared with receiving no mental health follow-up, both early follow-up (hazard ratio [HR], 1.37; 95% CI, 1.07-1.75) and late follow-up (HR, 1.69; 95% CI, 1.22-2.35) were associated with increased risk in recurrent ICU admission for self-harm. As compared with no follow-up, neither early follow-up (HR, 1.10; 95% CI, 0.70-1.73) nor late follow-up (HR, 1.54; 95% CI, 0.84-2.83) were associated with increased risk of death by suicide.

Interpreation: Among adults admitted to the ICU for deliberate self-harm, mental health follow-up after discharge was not associated with reduced risk of recurrent ICU admission for self-harm or death resulting from suicide, and patients seeking outpatient follow-up may be those at highest risk of these outcomes. Future research should focus on additional and novel methods of risk mitigation in this vulnerable population.

Keywords: intensive care; mental health; postintensive care syndrome; self-harm; suicide.

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Comment in

ICU Survivors of Self-Harm: A Call for Follow-Through.
Sayde GE, Prince E. Sayde GE, et al. Chest. 2023 Apr;163(4):738-739. doi: 10.1016/j.chest.2022.12.015. Chest. 2023. PMID: 37031976 No abstract available.

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Outpatient Mental Health Follow-up and Recurrent Self-harm and Suicide Among Patients Admitted to the ICU for Self-harm: A Population-based Cohort Study

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Outpatient Mental Health Follow-up and Recurrent Self-harm and Suicide Among Patients Admitted to the ICU for Self-harm: A Population-based Cohort Study

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