A multicentre study on suicide outcomes following subthalamic stimulation for Parkinson's disease
1National Institute of Neurological Disorders and Stroke, National Institutes of Health, Bethesda, MD, USA, 2University of Toronto, UHN, Toronto, ON, Canada, 3University Joseph Fourier, Grenoble, 4Lille University Hospital, Lille, 5National Institute of Health and Medical Research (INSERM), Hôpital de la Pitié-Salpêtrière, Paris, 6Université Lyon I, Hospital Neurologique Pierre Wertheimer, Lyon, France, 7Neurological clinic, Ospedale San Paolo, Italy, 8Christian-Albrechts-Universität Kiel, Kiel, Germany, 9Academic Medical Center of Amsterdam, Amsterdam, The Netherlands, 10University of Arizona, Phoenix, AR and 11The Cleveland Clinic Foundation, OH, USA
Correspondence to: Dr Valerie Voon, National Institute of Neurological Disorders and Stroke, National Institutes of Health, 10 Center Drive, Bldg 10, Rm 5S213, Bethesda, MD 20892-1428, USA E-mail: voonv{at}ninds.nih.gov
Subthalamic nucleus deep brain stimulation improves motor symptoms and quality of life in advanced Parkinson's disease. As after other life-altering surgeries, suicides have been reported following deep brain stimulation for movement disorders. We sought to determine the suicide rate following subthalamic nucleus deep brain stimulation for Parkinson's disease by conducting an international multicentre retrospective survey of movement disorder and surgical centres. We further sought to determine factors associated with suicide attempts through a nested case-control study. In the survey of suicide rate, 55/75 centres participated. The completed suicide percentage was 0.45% (24/5311) and attempted suicide percentage was 0.90% (48/5311). Observed suicide rates in the first postoperative year (263/100 000/year) (0.26%) were higher than the lowest and the highest expected age-, gender- and country-adjusted World Health Organization suicide rates (Standardized Mortality Ratio for suicide: SMR 12.63–15.64; P < 0.001) and remained elevated at the fourth postoperative year (38/100 000/year) (0.04%) (SMR 1.81–2.31; P < 0.05). The excess number of deaths was 13 for the first postoperative year and one for the fourth postoperative year. In the case-control study of associated factors, 10 centres participated. Twenty-seven attempted suicides and nine completed suicides were compared with 70 controls. Postoperative depression (P < 0.001), being single (P = 0.007) and a previous history of impulse control disorders or compulsive medication use (P = 0.005) were independent associated factors accounting for 51% of the variance for attempted suicide risk. Attempted suicides were also associated (P < 0.05) with being younger, younger Parkinson's disease onset and a previous suicide attempt. Completed suicides were associated with postoperative depression (P < 0.001). Postoperative depression remained a significant factor associated with attempted and completed suicides after correction for multiple comparisons using the stringent Bonferroni correction. Mortality in the first year following subthalamic nucleus deep brain stimulation has been reported at 0.4%. Suicide is thus one of the most important potentially preventable risks for mortality following subthalamic nucleus deep brain stimulation for Parkinson's disease. Postoperative depression should be carefully assessed and treated. A multidisciplinary assessment and follow-up is recommended.
Key Words: suicide; deep brain stimulation; Parkinson's disease; depression; subthalamic stimulation
Abbreviations: ICDs, impulse control disorders; LEDD, Levodopa equivalent daily dose; SMR, standardized mortality ratio; STN DBS, subthalamic nucleus deep brain stimulation; UPDRS, Unified Parkinson's Disease Rating Scale
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Received April 7, 2008. Revised June 23, 2008. Accepted July 19, 2008.
*Present address: National Institute of Neurological Disorders and Stroke, National Institutes of Health, Bethesda, MD, USA
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