Meta-analysis of risk factors associated with suicidal ideation after stroke

Study selection and characteristics of the included studies

The initial search yielded 2056 studies (Embase, n = 956; Web of Science, n = 441; PubMed, n = 235; Cochrane, n = 27; and CNKI, n = 397). After removing duplicate articles, a total of 1359 records were generated. The preliminary screening of titles and abstracts identified 72 potentially eligible studies, and the corresponding full text articles were subjected to final eligibility assessment. Finally, 12 studies (n = 2,693,036) were included for meta-analyses, and all studies were published since 2012 (see the PRISMA flowchart in Fig. 1 and a completed PRISMA Checklist in the second part of Additional file 1).

Fig. 1figure1

Modified PRISMA flow diagram of the included/excluded studies

The median number of the included stroke patients was 1405 (range: 177–228,735). The time from stroke onset ranged from < 48 h (acute phase) to 5 years in the included studies. The follow-up period ranged from 7 days up to 12 years after stroke. Among the 12 included studies, 4 studies used the item suicidal thoughts and related depression scale to evaluate suicidal ideation; 5 studies employed Clinical Interview or questionnaire; and suicidal thought was defined accoding to the International Classification of Diseases (ICD) codes in 3 studies. All studies have a minimum NOS score of 5, indicating the good quality of the included studies. Detailed characteristics of the included studies are summarized in Table 1.

Table 1 Characteristics of the studies included in this meta-analysisIncidence of suicidal ideation in stroke survivors

Of the included 12 studies, 7 reported suicide prevalence and were meta-analyzed. The pooled estimate of the rate of suicidal ideation after stroke was 12%, with substantial heterogeneity between studies (n = 7, 12% suicidal ideation, I2 = 99.6%, 95%CI 1–23%, p < 0.01). The studies conducted in Asia demonstrated higher suicide prevalence (n = 4, 15% suicidal ideation, I2 = 96.9%, 95%CI 7–24%, p < 0.01) than those conducted in all regions, but a high heterogeneity was observed. Figure 2 shows the forest plot, together with cumulative estimates. It has been reported that there are increased rates of suicide after a stroke. Based on the characteristics of the included 12 studies, we analyzed the differences in the incidence and risk factors of PSS with 1 year as the boundary. According to the follow-up time, a subgroup analysis was also performed. The forest plot displayed that the incidence of suicide in less than 1 year was relatively similar to the overall study results (n = 4, 11% suicidal ideation), with moderate heterogeneity (I2 = 64.9%, 95%CI 7–14%, p < 0.05). Interestingly, when the suicidal ideation was assessed for more than 1 year after stroke, the incidence of suicide was not statistically significant, with high heterogeneity (I2 = 99.9%, 95%CI 6–32%, p = 0.178), as shown in the forest plot (Fig. 3). Furthermore, we performed a careful meta-analysis of studies reporting the number of patients who actually committed suicide. There are a total of 4 studies reporting on the incidence of actual suicide attempts and suicide deaths. Our results indicated that approximately 4 out of 1000 stroke survivors would commit suicide, with 3.85% suicide prevalence (I2 = 99.2%; 95%CI 2–5%, p < 0.01). The detailed findings are illustrated in Fig. 4.

Fig. 2figure2

Rates of suicidal ideation among stroke survivors

Fig. 3figure3

Rates of suicidal ideation among stroke survivors according to the follow-up time

Fig. 4figure4

Rates of completed suicide among stroke survivors

Risk factors associated with suicidal ideation after stroke

Eighteen correlates, such as sociodemographic factors (e.g., age, gender, marriage status, education level, employment status and low household income), stroke-related characteristics (e.g., location, left-sided stroke, right-sided stroke, brainstem–cerebellum and previous stroke), physical comorbid conditions (e.g., diabetes mellitus, hypertension, myocardial infarction and sleep disturbance), mental disorders (e.g., depression), and substance-related behaviors (e.g., smoking and alcohol abuse) were taken into account if the data were available from at least three individual studies. Meta-analysis of the association between these risk factors and suicidal ideation after stroke was carried out, and the results are demonstrated in Table 2. All funnel diagrams related to Table 2 are presented in Additional file 1: Appendix S2.

Table 2 Risk factors for suicidal ideation after strokeSociodemographic factors

There were no significant effects of age (OR = 1.17; 95%CI 0.99–1.39; p = 0.07; I2 = 82%), female (OR = 0.86; 95%CI 0.6–1.26; p = 0.45; I2 = 19%), marriage status (OR = 0.81; 95%CI 0.42–1.55; p = 0.53; I2 = 94%) on PSS patients.Interestingly, high suicidal ideation rates were observed for males (OR = 1.07; 95%CI 1.01–1.13; p = 0.02; I2 = 44%)and low household income (OR = 1.96; 95%CI 1.02–3.77; p = 0.04); I2 = 99%, with moderate to high heterogeneity across studies. On the contrary, the rate of suicidal ideation was decreased in stroke survivors who were employed (OR = 0.37; 95%CI 0.16–0.83; p = 0.02; I2 = 69%). However, stroke survivors with low education level were not likely to have suicidal ideation, but the results were not statistically significant (OR = 1.49; 95%CI 0.73–3.02; p = 0.27; I2 = 99%). The detailed results are summarized in Table 2.

Stroke-related characteristics

No significant effects of left-sided stroke (OR = 0.77, 95%CI 0.53–1.11; p = 0.16; I2 = 0), right-sided stroke (OR = 1.37, 95%CI 0.99–1.90; p = 0.06; I2 = 0) and brainstem–cerebellum (OR = 1.25, 95%CI 0.57–2.74; p = 0.58; I2 = 70%) were found on PSS patients, with no or moderate heterogeneity across studies. Interestingly, the results showed that previous stroke was closely associated with PSS (OR = 1.55, 95%CI 1.06–2.28; p < 0.01; I2 = 60%). The detailed findings are presented in Table 2.

Physical comorbid conditions

No obvious effects of diabetes mellitus (OR = 1.22; 95%CI 0.98–1.50; p = 0.07; I2 = 81%), hypertension (OR = 1.36; 95%CI 0.42–4.37; p = 0.6; I2 = 99%) and myocardial infarction (OR = 1.22; 95%CI 0.93–1.61; p = 0.16; I2 = 71%) were found on PSS. The relationship between chronic diseases and PSS is unclear [16,17,18], and more attention should also be paid to the course, severity, and treatment effects of chronic diseases. Notably, sleep disturbance was closely associated with PSS, with no heterogeneity across studies (OR = 2.01; 95%CI 1.69–2.39; p < 0.01; I2 = 0). The detailed findings are shown in Table 2.

Mental disorders

Consistently, a remarkable increasing trend of PSS rates was observed among subjects with anxiety, with high heterogeneity across studies (OR = 2.32; 95%CI 1.73–3.13; p < 0.01, I2 = 96%).

Substance-related behaviors

There was no significant effect of alcohol abuseon PSS (OR = 0.73; 95%CI 0.28–1.93; p = 0.53, I2 = 98%). In contrast, stroke survivors who smoke had increased risk of PSS compared to non-smokers, with low heterogeneity across studies (OR = 1.75; 95%CI 1.35–1.50; p < 0.01; I2 = 15%). The detailed data can be seen in Table 2.

Subgroup analysis

In the subgroup analysis stratified by region, the risk factors of smoking (OR = 1.42; 95%CI 1.35–1.50; p < 0.01, I2 = 32%), low household income(OR = 2.31;95%CI 1.17–4.57; p = 0.02, I2 = 98%), depression (OR = 2.50; 95%CI 1.66–3.76; p < 0.01, I2 = 98%), myocardial infarction (OR = 1.23; 95%CI 1.13–1.35; p < 0.01, I2 = 0), sleep disturbance(OR = 1.80;95%CI 1.55–2.08; p < 0.01, I2 = 0) and alcohol abuse (OR = 2.03; 95%CI 1.70–2.42; p < 0.01, I2 = 0) were all closely associated with PSS in Asian populations, with 1.23–2.5-fold increases in incidence rates. Of these studied factors, the heterogeneity values were low, only those of sleep disturbance (OR = 1.80; 95%CI 1.55–2.08; p < 0.01, I2 = 0) and depression (OR = 2.50; 95%CI 1.66–3.76; p < 0.01, I2 = 98%) were high. The remaining risk factors did not significantly increase the risk of suicide in Asian populations. The detailed findings are presented in Table 2. Typically, the incidence of suicide after stroke varied over time. Therefore, a subgroup analysis was performed according to the follow-up time. Stroke survivors with older age, male, sleep disturbance and alcohol abuse were more likely to have suicidal ideation within 1 year. Besides, the risk of PSS in patients with depression was remarkably increased by 1.89–5.84-fold in less than 1 year, with moderate to high heterogeneity across studies (OR = 3.33; 95%CI 1.89–5.84; p < 0.01, I2 = 88%). Surprisingly, depression also increased the susceptibility of PSS, regardless of stroke duration. The remaining risk factors did not significantly increase the risk of suicide in subgroup analysis stratified by the time course of stroke. The detailed findings are demonstrated in Table 3. All funnel diagrams related to Table 3 are presented in Additional file 1: Appendix S3.

Table 3 Risk factors for suicidal ideation in stroke survivors according to the follow-up time

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