Suicide in the United States End-Stage Renal Disease Program
Manjula Kurella*,
Paul L. Kimmel,
Belinda S. Young* and
Glenn M. Chertow*
* Division of Nephrology, Moffitt-Long Hospitals and UCSF-Mt. Zion Medical Center, Department of Medicine, University of California San Francisco, San Francisco, California; and Division of Renal Diseases and Hypertension, Department of Medicine, George Washington University Medical Center, Washington, DC
Address correspondence to: Dr. Glenn M. Chertow, Department of Medicine Research, University of California San Francisco, Laurel Heights, 3333 California Street, Suite 430, San Francisco, CA 94118-1211. Phone: 415-476-2173; Fax: 415-476-9531; E-mail: chertowg{at}medicine.ucsf.edu
Although depression and dialysis withdrawal are relatively commonamong individuals with ESRD, there have been few systematicstudies of suicide in this population. The goals of this studywere to compare the incidence of suicide with national ratesand to contrast the factors associated with suicide with thoseassociated with withdrawal in persons with ESRD. All individualswho were aged 15 yr and older and initiated dialysis betweenApril 1, 1995, and November 30, 2000, composed the analyticcohort. Patients were censored at the time of death, transplantation,or October 31, 2001. Death as a result of suicide in the ESRDpopulation and the general US population was ascertained fromthe Death Notification Form and the Centers for Disease Controland Prevention, respectively. Standardized incidence ratiosfor suicide among patient subgroups were computed using nationaldata from the year 2000 as the reference population. The crudesuicide rate from 1995 to 2001 was 24.2 suicides per 100,000patient-years, and the overall standardized incidence ratiofor suicide was 1.84 (95% confidence interval, 1.50 to 2.27).In multivariable models, age 75 yr, male gender, white or Asianrace, geographic region, alcohol or drug dependence, and recenthospitalization with mental illness were significant independentpredictors of death as a result of suicide. Persons with ESRDare significantly more likely to commit suicide than personsin the general population. Although relatively rare, risk assessmentcan be used to identify patients for whom counseling and otherinterventions might be beneficial.
Two of the authors were prompted to conduct this analysis onthe basis of their experience with caring for a patient whowas on dialysis and died of suicide. Certain details of thecase presentation were modified to retain anonymity.
The patient was a white man who was in his late 20s, had a historyof paranoid schizophrenia and tobacco and alcohol abuse, anddeveloped rapidly progressive glomerulonephritis with pulmonaryhemorrhage. Despite aggressive anti-inflammatory and immunosuppressivetherapy, he failed to recover kidney function and required long-termhemodialysis. After a prolonged hospital course complicatedby respiratory failure that required mechanical ventilation,tracheostomy, and multiple infections, he was discharged, ableto ambulate and perform most usual activities. After a briefstay at a "halfway house," he moved to a single-room-occupancyhotel. He continued to receive intermittent counseling at acommunity-based activities center and occasionally saw a psychiatrist.
Two years after initiating dialysis, the patient requested achange in dialysis modality, as he reported paranoid ideationsrelated to other patients and staff at the hemodialysis facility.Despite initial reluctance, we approved his transition to peritonealdialysis on the basis of the excellent understanding and techniquethat he demonstrated during training and his level of enthusiasm,which seemed to provide some focus to his otherwise chaoticbehavior and thinking. The patient did well for >1 yr butdeveloped fungal peritonitis and required a transition backto hemodialysis.
Several months later, the patient was admitted to a communityhospital for acute psychosis with suicidal ideation. After severaldays, he was discharged, having been considered at low suiciderisk. Approximately 2 d later, the patient fell to his deathafter jumping off the roof of an apartment building. On autopsy,there was no evidence of alcohol or drug ingestion.
The earliest reports on suicide in ESRD, published before Medicarebenefits were extended to the ESRD program, suggested extremelyhigh rates of suicide in patients who were treated with hemodialysis(1). These results were attributed to a highly selected populationthat underwent an arduous, heroic procedure and have been disputedby those who argue that withdrawal of dialysis and suicide aredistinct entities (2). Despite the high prevalence of depressionamong individuals with ESRD (3–5), there have been fewsystematic contemporary studies of suicide in this population.It is unclear whether early estimates of suicide risk in ESRDare applicable today. In 1990, the ESRD Death Notification Formwas revised, permitting separation of withdrawal from dialysisfrom suicide and other causes of death. Accordingly, recentdata from the United States Renal Data System (USRDS) indicatethat suicide occurs at a rate of two deaths per 10,000 patient-years,suggesting only a modestly increased risk for suicide comparedwith the general population (6). However, direct comparisonwith general population data may be misleading without adjustmentfor age and other important suicide risk factors. Thus, it remainsuncertain whether persons with ESRD are at increased risk forsuicide.
In contrast to suicide, withdrawal from dialysis before deathis common, occurring approximately 100 times more commonly thansuicide (6). Although risk factors for withdrawal have beenwell characterized (7–9), it is unclear whether patientswho withdraw from dialysis and patients who commit suicide sharesimilar characteristics. Moved by the tragic case presentedabove, we sought to understand better the factors associatedwith suicide in persons with ESRD and to compare the incidenceof suicide in ESRD with national suicide rates by using dataon a full national cohort of ESRD patients and the US population.
We used data from the USRDS on all persons who initiated dialysisbetween April 1, 1995, and November 30, 2000, and were followeduntil death, transplantation, or October 31, 2001. Patientswho were younger than 15 yr were excluded, leaving 465,563 patientsin the analytic cohort. Patient demographics, treatment history,and cause-specific mortality including death from suicide orwithdrawal from dialysis before death were obtained from theStandard Analytic Files (Core CD 1). Twenty-two patients werecoded as both having died from suicide and as having withdrawnfrom dialysis before death. These patients were considered tohave withdrawn from dialysis for the purposes of these analyses.Demographic characteristics, comorbid conditions, insuranceand social history, and selected laboratory data at the timeof dialysis initiation were obtained from the Center for Medicareand Medicaid Services (CMS) Medical Evidence form (form 2728).We merged baseline data elements with data on hospitalizationfor the 12 mo preceding death or the date of last follow-up.We determined the number of hospital admissions, length of stay,and discharge diagnoses for each individual during the 12-mointerval. Hospitalization with a mental illness was indicatedby Diagnosis Related Groups (DRG) codes 424 to 431. Patientswho were hospitalized with drug or alcohol abuse (indicatedby DRG codes 432 to 437) were included with those coded as havingalcohol or drug dependence.
Continuous variables were expressed as mean ± SD or median± interquartile range and compared with t test or theWilcoxon rank sum test, as appropriate. Categorical variableswere expressed as proportions and compared using the 2 test.We calculated age-, gender-, race-, and network-specific suiciderates using the year 2000 US population as the reference population.National suicide data were available from the Centers for DiseaseControl and Prevention Web-Based Injury Statistics Query andReporting System. Standardized incidence ratios (SIR) for suicideamong patient subgroups were computed as the ratio of observedversus expected suicides. We computed confidence intervals (CI)using the normal approximation to the Poisson distribution (10).Data for ESRD networks were condensed into four geographic regionsfor ease of presentation and confidentiality concerns: Northeast(networks 1 to 4), South (networks 5 to 8, 13, and 14), Midwest(networks 9 to 12), and West (networks 15 to 18). Note thatWeb-Based Injury Statistics Query and Reporting System doesnot contain suicide data from Puerto Rico and the US VirginIslands (included in network 3) or from Guam, American Samoa,and Saipan (included in network 17).
We first used simple logistic regression to examine the relationbetween dialysis vintage and suicide. We then used proportionalregression (Cox) models to determine the unadjusted and multivariable-adjustedhazard or relative risk (RR) of suicide for covariates of interest,modeled for censored failure times. Patients were censored withtransplantation or on October 31, 2001. After the initial multivariablemodels were fit, we manually added individual selected variablesto evaluate for residual confounding. We evaluated effect modificationby including selected multiplicative interaction terms in multivariablemodels. We also performed companion analyses using dialysiswithdrawal, rather than suicide, as the outcome of interest.For all analyses, two-tailed P < 0.05 was considered significant.Analyses were conducted using SAS Version 8.2 (SAS Institute,Cary, NC).
Patient Characteristics
Of the 465,563 patients included in the analysis, 44,465 (9.6%)withdrew from dialysis before death and 264 (0.005%) died fromsuicide. Table 1 shows the demographic characteristics of thestudy population. Patients who withdrew from dialysis beforedeath had a mean age of 71 ± 12 yr, 49.2% were male,and 81.1% were white. Patients who died from suicide had a meanage of 63 ± 15 yr, 86.0% were male, and 85.2% were white.Compared with patients who withdrew before death, patients whodied from suicide were younger (P < 0.001); more likely tobe male (P < 0.001), uninsured (P < 0.001), and have alcoholor drug dependency (P < 0.001); and were less likely to beblack (P = 0.04) and nonambulatory (P = 0.02) and have diabetes(P = 0.002), congestive heart failure (P = 0.01), or previousstroke (P = 0.04).
Risk Factors for Suicide
In unadjusted analyses, age 75 yr, male gender, white or Asianrace, residence outside the Northeast, ischemic heart disease,peripheral vascular disease, cancer, chronic obstructive pulmonarydisease, alcohol or drug dependence, serum albumin <3.5 g/dl,and hospitalization within the preceding 12 mo were associatedwith a significantly increased risk for suicide (Table 2). Hospitalizationwith mental illness was associated with a fivefold increasedrisk for suicide. In multivariable models, age 75 yr, male gender,white or Asian race, geographic region, alcohol or drug dependence,and recent hospitalization, particularly hospitalization withmental illness, remained significant, independent predictorsof suicide (Table 2). Age modified the association between mentalillness and suicide risk, as the risk for suicide associatedwith hospitalization for mental illness was accentuated amongyounger patients. Diabetes was associated with a significantlyreduced risk for suicide, even after adjustment for a numberof potential confounders. Considering the combination of findingsfor the patient described in the case presentation (a youngwhite man from the West with a history of alcohol dependenceand recent hospitalization for mental illness), the risk fordeath as a result of suicide could be estimated at 2% annually,a risk >90-fold higher than baseline.
Table 2. Unadjusted and multivariable-adjusted risk for suicide among patients with ESRDa
Suicide versus Dialysis Withdrawal
Suicide and dialysis withdrawal were strongly associated withdialysis vintage, although the pattern of risk differed somewhatbetween the two outcomes. The risk for suicide was highest inthe first 3 mo after dialysis initiation and diminished steadilyover time, whereas the likelihood of dialysis withdrawal wasrelatively high for the first year of dialysis and lessenedconsiderably thereafter. Several patient characteristics wereindependent correlates of both suicide and dialysis withdrawal,although the magnitude of the associations varied between thetwo outcomes (Tables 2 and 3). For example, older age and recenthospitalization were stronger predictors of dialysis withdrawal,whereas white or Asian race, alcohol or drug dependence, andhospitalization for mental illness were stronger predictorsof suicide. Several additional factors that were significantlyassociated with withdrawal were identified, including femalegender, hemodialysis (rather than peritoneal dialysis), anda number of comorbid conditions. The power to detect these andother associations among clinical characteristics and suicidewas considerably lower because of sample size.
Table 3. Multivariable-adjusted risk for dialysis withdrawal among patients with ESRD
Age modified the associations among several comorbid conditionsand the likelihood of dialysis withdrawal. For example, HIVwas associated with a roughly sevenfold increased risk for withdrawalamong patients 15 to 29 yr of age, compared with a roughly twofoldincreased risk among patients 60 to 74 yr of age. Analogousfindings were noted for cancer.
SIR for Suicide in the United States
The crude suicide rate from 1995 to 2001 was 24.2 suicides per100,000 patient-years. The overall SIR for suicide during thisperiod was 1.84 (95% CI, 1.50 to 2.27). In other words, patientswith ESRD had an 84% higher rate of suicide compared with thegeneral US population, after accounting for differences in populationdistribution. The SIR for suicide stratified by age, gender,race, and geographic region are shown in Table 4. The ratesof suicide among ESRD patients were higher for all age groupsrelative to the US population, with the exception of 15- to29-yr-olds, and tended to increase with age. Although crudesuicide rates were higher for men, the gender-stratified SIRsuggest that the association between ESRD and suicide was moreprominent among women (standardized rates were 78% higher forwomen with ESRD and 47% higher for men). Whites and Asians withESRD had a two- to almost fourfold increased rate of suicide,respectively. In contrast, the rate of suicide among blackswith ESRD was similar to national rates for blacks. With theexception of the Northeast region, the SIR across geographicregions were similar to the overall SIR for ESRD, indicatingthat network variation generally conformed to the underlyingnational geographic variation in suicide rates.
Although dialysis withdrawal and its clinical correlates havebeen well described, little is known about suicide in personswith ESRD. Withdrawal from dialysis occurs in 9 to 20% of ESRDpatients and is more likely to occur in older, white, femalepatients (7,8,11). Several studies have also demonstrated thatpatients who withdraw from dialysis have a high burden of illness,including malnutrition, physical impairment, and a high frequencyof dementia, malignancy, and other chronic diseases (7,12,13).Although dialysis withdrawal and suicide are frequently consideredtogether, it is not clear whether these outcomes are indeedrelated. Indeed, some authors have advocated considering themas separate entities (2). No study to our knowledge previouslycompared factors associated with withdrawal from dialysis withthose associated with suicide.
Previous estimates of the risk for suicide among ESRD patientsvary widely. Early data suggesting that suicide rates in ESRDwere 100- to 400-fold greater than in the general populationdid not separate dialysis withdrawal from suicide (1) and mayhave been biased because of the era and the highly selectedpatient population. Neu et al. (8) studied dialysis withdrawaland suicide among 1766 dialysis patients. The incidence of suicidein the study population was 0.2%, approximately 15 times greaterthan the general population rate. More recently, Ojo et al.(14) reported a suicide rate of 15.7 per 1000 patient-yearsamong kidney transplant recipients, 75% higher than the generalpopulation. Self-reported kidney disease has also been associatedwith a threefold increased risk for attempted suicide in theNational Comorbidity Survey (15).
Using data on a national cohort of ESRD patients, we demonstratedan increased risk for death from suicide in persons with ESRD,even after accounting for demographic differences between theESRD population and the general population. These data are consistentwith unadjusted data reported for kidney transplant recipients(14) and similar in magnitude to the risk for suicide associatedwith other chronic or debilitating illnesses, including HIVinfection, chronic lung disease, and stroke (15–17). Suiciderates were uniformly increased in ESRD across most major demographicgroups, with the exception of blacks and patients who were youngerthan 30 yr. The presence of ESRD tended to accentuate existingnational patterns of suicide according to age, race, and geographicregion but not by gender (18). These observations suggest thatESRD acts to exacerbate a preexisting vulnerability or tendencytoward suicidal behavior among certain high-risk groups.
In the general population, the elderly, in particular whitemen who are older than 75 yr, are especially at risk, althoughthe rate of suicide in adolescents and young adults has increasedsharply over the last several years (18). We identified severalindependent predictors of suicide among individuals with ESRD.A number of patient characteristics, including older age, malegender, white race, substance abuse, and geographic region,have been previously identified as predictors of suicide inthe general population (18–20). Although we cannot readilyexplain the observed differences in suicide risk by race amongpatients who are on dialysis, previous studies in other populationshave attributed these differences to cultural factors such asreligious beliefs and social support (21). Similarly, some havespeculated that geographic variation in suicide risk may reflectsocial or environmental factors such as gun ownership or regionaleconomic stability (20). The absence of an increased risk forsuicide in adolescents with ESRD may be attributable to theimproved survival of this subgroup and the higher probabilityof transplantation for adolescents with ESRD (22).
These data also indicate that suicide differs from dialysiswithdrawal with respect to specific risk factors and to a lesserextent by temporal pattern. In contrast to patients who withdrewfrom dialysis, patients who died from suicide were less burdenedwith comorbid conditions, malnutrition (defined by low serumalbumin), and debility (defined by nonambulatory status). Thetemporal pattern and risk profile may suggest that suicide isprompted by a failure to cope with the stress of dialysis inthe context of maladaptive patient and environmental psychosocialfactors, rather than by declining health status.
Several studies have identified mental illness, especially depression,as a risk factor for suicide in many chronic conditions, rangingfrom migraine headaches to cancer (23,24). However, althoughhigher rates of mental illness are observed among persons witha variety of chronic illnesses, increased rates of suicide arenot uniformly observed. For example, diabetes is associatedwith increased rates of depression (25), yet previous studieshave not demonstrated an association between diabetes and suiciderisk in adults (26,27). AIDS and chronic lung disease have beenassociated with an increased risk for suicide independent ofmental illness, suggesting that other psychosocial, environmental,or genetic factors may be linked directly with suicide riskin specific clinical settings (15,28). Some studies have suggestedthat the burden of physical illness is an important risk factorfor suicide (15,29). Although physical impairment is relativelycommon in ESRD, the extent of extrarenal comorbidity did notmarkedly influence suicide risk in this population.
In 1999, the Surgeon General’s Call to Action to PreventSuicide (19) addressed the importance of several psychosocialfactors as risk factors for suicide. These psychosocial factorsinclude substance abuse and mental illness disorders, unwillingnessto seek treatment because of social stigma, barriers to gainingaccess to mental health treatment, social isolation, stressfullife events, and easy access to lethal methods. Indeed, an increasedprevalence of many of these psychosocial factors may mediatesome of the observed increased risk for suicide among personswith ESRD. Depressive symptoms and clinical depression are extremelycommon among ESRD patients, especially at dialysis initiation(4,5). In the National Comorbidity Survey, adjustment for coexistingmental illness significantly attenuated the risk for attemptedsuicide among persons with self-reported kidney disease (15).Substance abuse is also highly prevalent in the ESRD population(5,30). Other psychosocial factors identified in the SurgeonGeneral’s Call to Action, such as stressful life eventsand easy access to lethal methods, apply to almost all ESRDpatients (31). These findings along with the Surgeon General’sCall to Action should help health care professionals who carefor persons with ESRD to identify those who are at greatestrisk for suicide, i.e., socially isolated older white or Asianmen with mental illness or substance abuse, particularly atthe start of dialysis or after other stressful life events.Identifying and addressing risk is an important first step forthe formulation and testing of effective prevention strategies.
This study has several limitations. First, suicides among personswith ESRD could not be separated from the national data thatwe used as a referent group. However, because these deaths represent<1% of all national suicides, the magnitude of this problemis negligible. Second, suicide deaths may be underreported asa result of uncertainty and social stigma. Therefore, thesedata may underestimate the risk for suicide among persons withESRD. Third, we used administrative data for these analyses;thus, these associations are subject to ascertainment bias,and the RR associated with various conditions may be attenuatedas a result of misclassification. For example, persons withless severe substance abuse may not have been captured in thesedata, which would tend to inflate the RR assigned to substanceabuse reported here. Fourth, the USRDS tends to underascertainhospitalization data during the first 90 d after initiation.Thus, we may have underestimated the association between cause-specifichospitalization and death from suicide among patients who diedfrom suicide within 15 mo of dialysis initiation, possibly counterbalancingthe effects of misclassification noted above. Fifth, we wereunable to assess the direct contribution of mental illness ordepressive symptoms, except by the proxy variable mental illnesshospitalization. Other important covariates such as maritalstatus and education are not collected in the USRDS database.Finally, we lacked data on the mechanism of suicide deaths inpersons with ESRD. Such information may have provided insightas to the provoking factors for suicide death among these individualsand potential mechanisms for prevention.
In summary, persons with ESRD are significantly more likelyto commit suicide than persons in the general population. Morethan 30 yr after the organization and expansion of the ESRDprogram, despite major technological advances, the rigors ofthe short- and long-term adjustment to dialysis still exacta heavy toll on patients in terms of mortality and self-destruction.The increased risk for suicide associated with ESRD is seenacross most demographic patient subgroups and tends to accentuatenational suicide patterns. A number of suicide risk factorsare distinct from those of dialysis withdrawal, suggesting thatthese are divergent outcomes rather than a continuum of a similarunderlying process. These data establish a high-risk profilefor suicide in ESRD patients for whom it may be advisable toseek counseling and other interventions in an effort to reducerisk. Further studies are urgently needed to understand thecausal factors for suicide death and determine the best methodsfor suicide prevention in these individuals.
Acknowledgments
M.K. was supported by the American Kidney Fund Clinical Scientistin Nephrology Award. G.M.C. was supported by NIH-NIDDK RO1 DK58411and NIH-NIDDK RO1 DK01005.
The data reported here were supplied by the USRDS. The interpretationand reporting of these data are the responsibility of the authorsand in no way should be seen as an official policy or interpretationof the US government.
We dedicate this article to the memory of our patient. We areextremely grateful to the nurses who provided him with excellentcare during his brief lifetime.
Footnotes
Published online ahead of print. Publication date availableat www.jasn.org.
The data reported here have been supplied by the US Renal DataSystem (USRDS). The interpretation and reporting of these dataare the responsbility of the authors and in no way should beseen as an official policy or interpretation of the US government.
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Received for publication July 13, 2004.
Accepted for publication November 29, 2004.
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Top
Abstract
Introduction
75 yr, male gender, white or Asian race, geographic region, alcohol or drug dependence, and recent hospitalization with mental illness were significant independent predictors of death as a result of suicide. Persons with ESRD are significantly more likely to commit suicide than persons in the general population. Although relatively rare, risk assessment can be used to identify patients for whom counseling and other interventions might be beneficial. 
2 test. We calculated age-, gender-, race-, and network-specific suicide rates using the year 2000 US population as the reference population. National suicide data were available from the Centers for Disease Control and Prevention Web-Based Injury Statistics Query and Reporting System. Standardized incidence ratios (SIR) for suicide among patient subgroups were computed as the ratio of observed versus expected suicides. We computed confidence intervals (CI) using the normal approximation to the Poisson distribution (10). Data for ESRD networks were condensed into four geographic regions for ease of presentation and confidentiality concerns: Northeast (networks 1 to 4), South (networks 5 to 8, 13, and 14), Midwest (networks 9 to 12), and West (networks 15 to 18). Note that Web-Based Injury Statistics Query and Reporting System does not contain suicide data from Puerto Rico and the US Virgin Islands (included in network 3) or from Guam, American Samoa, and Saipan (included in network 17). 
