Overlooked and Underestimated: Suicide Risk in Recently Diagnosed ACS Patients

Individuals diagnosed with ACS have about a 15% higher risk of suicide in the 6 months after their diagnosis than do otherwise healthy people. This stands as evidence that depression is being missed among many in this patient population, new research suggests.

“Our results support the recommendation that screening for depression and suicidal ideation should be conducted for all patients with ACS, particularly in the early stage of new diagnosis,” write Jung-Chen Chang, PhD (National Taiwan University, Taipei, Taiwan), and colleagues in their paper published online December 7, 2016, in the Journal of the American Heart Association.

For the study, they examined all cases of completed suicide that occurred in Taiwan between 2000 and 2012. Fully 2.5% of individuals in this group had ACS compared with 1.5% in a comparable population of living persons matched by age, sex, and area of residence.

Before adjustment for potential confounders including psychiatric disorders, individuals with ACS were 200% more likely to commit suicide than were people in the comparison group. Following adjustment, the odds of suicide among ACS patients were 15% higher (OR 1.15; 95% CI 1.05-1.26).

The risk was greatest in the 6 months after a diagnosis of ACS (OR 3.01; 95% CI 2.52-3.60) and increased with frequency of health system utilization. Compared with those who did not commit suicide, those who did were seen for more outpatient and emergency department (ED) visits and were more often hospitalized. On multivariable analysis, likelihood of suicide was increased among those with more than 20 outpatient visits, more than 5 hospital admissions, and any ED visit in the prior year. Increasing age also was associated with greater risk of suicide, with an eight-fold increase seen in those over age 75.

Screening Is Key

According to Chang and colleagues, multiple prior studies have shown “a strong relationship between ACS and psychiatric disorders, particularly depression, anxiety, and panic attacks.” Additionally, they say, accumulating data suggest that about one-third of patients hospitalized with acute MI have psychosocial issues such as anxiety and depression, both of which can contribute to suboptimal treatment response, poor outcomes, and adverse reactions to stressful events in their lives.

Barry Jacobs, PsyD (Crozer-Keystone Family Medicine Residency Program, Springfield, PA), who was not involved in the study, told TCTMD in an interview that it is a reminder “that there is now a very well-established connection between cardiac events, cardiac surgery, and depression. One manifestation of depression, unfortunately, is suicidality, and that is an additional reason why physicians need to be screening routinely for depression as part of aftercare.” Much more work is needed, he added, to ensure that cardiologists and primary care doctors keep the issue on their radar.

Jacobs, an American Heart Association volunteer, also noted that it is important for family members and others in the patient’s life to have “an index of suspicion” with regard to mood changes that could lead to suicidal thoughts.

“This is not uncommon, so part of family education should be letting them know that we expect 15-20% of patients to develop clinical depression following a clinical event or [after] a diagnosis of angina with the accompanying lifestyle changes that it entails,” Jacobs said.

Both the study authors and Jacobs say more study is needed to determine whether the findings in the all-Taiwanese cohort have global generalizability.