Abstract
BackgroundIt is unclear whether post-traumatic stress disorder [PTSD] is associated with suicide risk in the general population, whether this differs by sex, or what the population impact of PTSD is for suicide. MethodsWe constructed a nationwide cohort of all people living in Sweden, born 1973–1997, followed from their 14th birthday (or immigration, if later) until suicide, other death, emigration or 31 December 2016. We used Cox proportional hazards regression to estimate hazard ratios [HR], and calculated the population impact of PTSD on suicide. We included sensitivity analyses to explore effects of outcome and exposure definitions, and to account for potential competing risks. ResultsOf 3,177,706 participants, 22,361 (0•7%) were diagnosed with PTSD, and 6,319 (0•2%) died by suicide over 49•2 million person-years. Compared with women and men without PTSD, suicide rates were 6•74 (95%CI: 5•61–8•09) and 3•96 (95%CI: 3•12–5•03) times higher in those with PTSD, respectively, after sociodemographic adjustment. Suicide rates remained elevated in women (HR: 2•61; 95%CI: 2•16–3•14) and men (HR: 1•67; 95%CI: 1•31–2•12) after adjustment for previous psychiatric conditions; attenuation was driven by previous non-fatal suicide attempts. Findings were insensitive to definitions or competing risks. If causal, 1•6% (95%CI: 1•2–2•1) of general population suicides could be attributed to PTSD, and up to 53.7% (95%CI: 46.1–60.2) in people with PTSD. LimitationsResidual confounding remains possible due to depressive and anxiety disorders diagnosed in primary care but unrecorded in these registers. ConclusionsClinical guidelines for the management of people with PTSD should recognise increased suicide risks.
Highlights
Post-traumatic stress disorder [PTSD] is a psychiatric diagnosis describing a prolonged or delayed response to a traumatic situation or event(s) of a threatening or catastrophic nature(World Health Organisation, 1992)
Background It is unclear whether post-traumatic stress disorder [PTSD] is associated with suicide risk in the general population, whether this differs by sex, or what the population impact of PTSD is for suicide
Suicide rates remained elevated in women (HR: 2·61; 95%CI: 2·16-3·14) and men (HR: 1·67; 95%CI: 1·31-2·12) after adjustment for previous psychiatric conditions; attenuation was driven by previous nonfatal suicide attempts
Summary
Post-traumatic stress disorder [PTSD] is a psychiatric diagnosis describing a prolonged or delayed response to a traumatic situation or event(s) of a threatening or catastrophic nature(World Health Organisation, 1992). The largest of these studies (Gradus et al, 2015) included over 500,000 participants, given the absolute rarity of both PTSD and death by suicide, it could only include 32 participants with both the exposure and outcome, limiting the ability to detect variation by other characteristics such as sex, or control for all previous major psychiatric conditions or previous non-fatal suicide attempts It is unclear whether post-traumatic stress disorder [PTSD] is associated with suicide risk in the general population, whether this differs by sex, or what the population impact of PTSD is for suicide
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