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Outpatient mental health follow-up and recurrent self-harm and suicide among ICU survivors of self-harm – a population-based cohort study

Fernando SM, Pugliese M, McIsaac DI, Qureshi D, Talarico R, Sood MM, Myran DT, Herridge MS, Needham DM, Munshi L, Rochwerg B, Fiest KM, Milani C, Kisilewicz M, Bienvenu OJ, Brodie D, Fan E, Fowler RA, Ferguson ND, Scales DC, Wunsch H, Tanuseputro P, Kyeremanteng K. Chest. 2022; Oct 28 [Epub ahead of print]. DOI:

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

Research Question — What is the association between post-discharge mental health follow-up and recurrent self-harm among ICU survivors of intentional self-harm?

Study Design and Methods — Population-based cohort study of consecutive adult ICU survivors (≥18 years) from Ontario, Canada between 2009 and 2017, admitted to ICU due to intentional self-harm. We categorized patients as “early follow-up” (1-21 days post-discharge), “late follow-up” (22-60 days post-discharge), and “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 ICU survivors of deliberate self-harm. As compared to patients with no mental health follow-up, both early follow-up (hazard ratio [HR] 1.37, 95% confidence interval (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 to no follow-up, early follow-up (HR 1.10, 95% CI: 0.70-1.73]) was not associated with death by suicide, but late follow-up (HR 1.54, 95% CI: 1.37-1.83) was associated with an increase in death by suicide.

Interpretation — Among ICU survivors of deliberate self-harm, post-discharge mental health follow-up was not associated with reduced risk of recurrent ICU admission for self-harm or death by 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.