This article is more than 5 years old. Information may no longer be current.
Suicide risk and cancer: Treat the mind and body
Asking patients and survivors about suicidal thoughts is important to treatment.
Click Here to Manage Email Alerts
Psycho-oncology — or the psychological effect of cancer — has been gaining attention from oncologists in recent years. Among the psychological factors associated with a cancer diagnosis is an increased risk for suicide among cancer patients and survivors.
In one study of suicide, published in the Journal of Clinical Oncology in 2008, Misono and colleagues found that cancer patients commit suicide at twice the rate of the general population: 31.4 per 100,000 person-years among cancer patients compared with 16.7 per 100,000 person-years among the general population.
Results of a study by Christopher Recklitis, PhD, MPH, and colleagues, published earlier this year in the Journal of Clinical Oncology, showed that adult survivors of childhood cancer were more likely to consider suicide — even decades after treatment.
When examining and treating a patient for a life-threatening illness, as many cancers are, physicians are often more focused on the physical effects of a disease than the psychosocial, according to ASCO. However, a 2007 report released by the Institute of Medicine said caring for the whole cancer patient, including psychosocial issues such as emotional difficulties and anxiety that may lead to suicide, is critical to successful treatment.
|
Photo courtesy of Center to Advance Palliative Care |
The diagnosis and treatment of suicide ideation are not the most traditional roles for an oncologist, but the experts who spoke to HemOnc Today said psychological evaluation is crucial to lowering the rate of suicide in cancer patients and survivors.
Recklitis, director of research with the Perini Family Survivors’ Center at Dana-Farber Cancer Institute, said his institution has tried several suicide screening methods and found that patient self-reporting may be the best place to start.
“All of our survivorship clinics do some kind of patient self-reporting. When patients come into an office, they fill out questionnaires about general health, but there is also a mental health component,” Recklitis told HemOnc Today. “Patients are used to filling out forms in doctors’ waiting rooms, so we include questions asking about feelings of depression, hopelessness, feeling that life isn’t worth living, etc. That is something that can easily be integrated into those sorts of questionnaires and followed-up on during the clinical exam.”
Although self-reporting may be a successful option for some institutions, according to Sharla Wells-DiGregorio, PhD, assistant professor of psychiatry at The Ohio State University Medical Center in Columbus, approaching the topic of mental health in any way may be the most important first step.
“Probably the best way to identify patients at risk is simply to ask, ‘Have you been having thoughts of ending your life as a result of your cancer or problems associated with your cancer?’” Wells-DiGregorio said. “That is the key question.”
Depression
Depression may be an important marker in identifying patients most likely to commit suicide. In a 2008 study, published in the Journal of Clinical Oncology, Walker and colleagues surveyed 2,924 patients with cancer who were treated at Edinburgh Cancer Centre in Scotland. Almost 8% of patients said they sometimes believed they would be better off dead or had considered hurting themselves in the two weeks before being surveyed. Clinically significant emotional distress (P <.001) and substantial pain (P <.001) were found to be associated with these feelings.
In an article published in 1999 in Oncology, William F. Pirl, MD, and Andrew J. Roth, MD, said an estimated 25% of patients with cancer will experience major depression, and these patients are almost twice as likely to develop major depression compared with other hospitalized patients. The prevalence of depression was even higher in patients with cancer with the most distressing physical symptoms, especially uncontrolled pain.
In addition to depression, other clinical signs of suicide ideation include confusion and delirium, loss of control, helplessness and hopelessness. Results of a Japanese study published in 1999 showed that of 362 patients with cancer referred to psychiatric care because of suicide risk or suicide attempt, 86% were diagnosed with a mood disorder or delirium.
“If you look at the statistics, about 30% of cancer patients will have a diagnosable psychological condition that could be treated,” Wells-DiGregorio said. “When you’re looking at patients with more advanced disease, 50% to 60% have a psychological condition that could be treated, and the majority of patients beyond that are dealing with issues of anticipatory grief or loss of functioning. Most patients could benefit from at least an assessment for distress, then additional psychological care.”
|
|
Pirl and Roth wrote that physicians should determine the seriousness of a patient’s depression and suicide ideation and consider whether there are personal factors, such as a previous suicide attempt or substance abuse, or medical factors, such as poorly controlled pain, before referring the patient to psychological care.
Their recommendation is similar to that of Diane E. Meier, MD, director of the Center to Advance Palliative Care, New York, a national organization devoted to increasing the number and quality of palliative care programs in the United States.
“There is a subset of patients with cancer, or with any chronic disease, who clearly need psychiatric expertise. That said, since depression is quite common in patients with chronic disease, the primary treating physician needs to have a baseline level of expertise in identifying and treating depression,” Meier said. “There aren’t enough psychologists out there to handle it. Oncologists, like cardiologists or neurologists, should be able to identify depression and should be able to at least do first-line treatment of depression with safe and effective antidepressant therapy.”
Although depression is treatable, the condition may worsen if left unrecognized and untreated, Pirl and Roth said. Depression can be hard to recognize because the symptoms, such as loss of energy, loss of appetite and sleep disturbance, are common in patients cancer and often appear as adverse effects of cancer treatment.
“Primary care providers and oncologists can benefit their patients by recognizing the signs and symptoms of depression and initiating proper treatment, if warranted,” they wrote. “Mild to moderate depression may be managed with antidepressant medications by a non-psychiatric physician and/or referral for psychotherapy. More severe or complicated depression, especially if accompanied by suicidal ideation, is best managed by referring the patient to a psychiatrist.”
Actions speak louder
Not every patient who considers suicide will follow through, but identifying those who are a serious intention to commit suicide is crucial to saving lives.
“The important thing is to ask the patient if they have a plan,” Meier said, adding that the patient who does not have a plan is a much lower risk than a patient who has gone so far as to hoard pain medication or purchase a weapon.
“Many physicians are hesitant to ask that question for fear that the patient will take that as a suggestion that suicide is a good idea,” she told HemOnc Today. “But, in fact, that question does not push patients toward suicide. To the contrary, it says to the patient, ‘My doctor is taking me seriously.’”
Wells-DiGregorio said physicians must determine if a suicidal patient has the plans, means and intention to kill themselves.
“There used to be the idea of contracting for safety, where the patient would agree not to do anything without contacting their physician, but that hasn’t been borne out as a very effective means of prevention,” she said. “Instead, there has been a turn toward safety planning, which is investing in the other people in the patient’s life to create a supportive environment and help them plan for the patient’s safety.”
Recklitis, however, suggested a different approach with oncologists, focusing their efforts on identifying patients with suicidal thoughts or feelings, and then referring them to mental health professionals for further evaluation and monitoring.
“Assessing an individual patient is something an experienced mental health professional should do,” he said. “For the general medical or oncology physician in that arena, the issue is more about identifying people who need to be referred for mental health or assessment.”
Age, race and pain
In addition to depression and feelings of hopelessness, there are other factors strongly associated with suicide ideation. Older white men, particularly those who are unmarried, are among the patients most likely to have suicidal thoughts.
In the previously mentioned study, Misono and colleagues found that although white men accounted for 92.7% of suicides in the study, they made up only 84.6% of the study population. Standard mortality ratio for white men was 1.88 (95% CI, 1.83-1.93) compared with 1.72 (95% CI, 1.48-2.00) for black men.
About 37% of men in the Misono study were unmarried. These men committed 37.1 suicides per 100,000 person-years compared with married men who committed 31.5 suicides per 100,000 person-years. Standard mortality ratio for unmarried men was 2.18 (95% CI, 2.09-2.28) vs. 1.84 (95% CI, 1.78-1.90) for married men.
|
|
In addition, the suicide rate for men with cancer increased from 57.4 per 100,000 person-years when aged 60 to 64 years to a rate of 67.0 when aged 65 to 69 years. The suicide rate for women aged 60 to 64 years is 11.1 per 100,000 person-years and 11.6 for women aged 65 to 69 years.
Another common factor among suicidal patients is pain, especially untreated pain. Of the patients in the Walker study who acknowledged having suicidal thoughts, 20.2% said they had substantial pain compared with just 5% who said they were not in pain. Of the patients who did not have suicidal thoughts, 95% said they had no pain.
“Pain has been associated with high desire for death in the terminally ill,” the researchers wrote. “And it is the most common reason for suicidal thoughts given by those cancer patients who considered suicide a possible future option.”
Physician training
In 1993, Annals of Internal Medicine published results of a survey conducted by ECOG, which polled 897 oncologists to learn physician attitudes and practice in management of cancer-related pain.
Only 52% of respondents said pain control in their institution was good or very good, and 18% said pain control was poor. When asked to name the top four barriers to good pain management, 76% cited poor pain assessment, 62% indicated patient reluctance to report pain and patient reluctance to take opioids and 61% cited physician reluctance to prescribe pain medication.
When asked about their education in pain management, 52% described their medical school training as poor. Only 12% said medical school training was excellent or good. When asked about residency training in pain management, 46% said the training was fair and 27% said it was poor.
Meier said little has improved since this study.
“Most American physicians in practice today actually have not been trained in how to safely and effectively prescribe opioid analgesics. There is not a clear mandate to demonstrate competency in opioid analgesic management for medical students, interns and residents completing residency, or oncology fellows,” she said. “It is assumed that it is taught somewhere along the line, but there is no mandatory demonstration of competence, and the fact is, most physicians are uncomfortable and unfamiliar with how to safely manage these drugs and their side effects.
“That is a solvable problem by changing the standards of competence required to become a licensed physician, but that has not been done,” Meier said.
Because overdose deaths from prescription drugs now outnumber deaths from street drugs, the FDA is closely scrutinizing physicians who will prescribe powerful painkillers, and that has had a “chilling effect,” she said.
There are patient barriers to effective pain management, as well, Meier said. For example, patients said they sometimes feel as though they deserve to suffer for past sins; some men are less willing to admit to being in pain; and the “just say no to drugs” culture has fostered an overblown fear of painkiller addiction.
“Some patients have the belief that talking to the hematologist/oncologist will distract the doctor from curing them. They don’t want to spend their 15 or 20 minutes with the oncologist talking about pain when they want the oncologist focused on curing disease,” she said. “The time pressure oncologists are under is just unbelievable. The number of patients that need to be seen in a short period of the day is, for many physicians, overwhelming. Long, in-depth discussions about pain or emotional distress are simply not feasible for many practitioners.”
Meier said, however, that it is incumbent upon professionals charged with treating chronically ill patients to educate themselves on the risk factors for suicide.
“The overwhelming majority of patients are seen by their physician within the month before suicide. That suggests that at some level, they are seeking help or a reason to go on and that somehow the opportunity was missed by the provider, probably because the patient wasn’t screened and isn’t going to say ‘I can’t take this anymore,’” she said. “This points to the importance of a very high awareness of the risk factors for suicide on the part of physicians and nurses in these practices. They treat a high-risk group, and spotting high-risk signs and symptoms are just as important as choosing the right kind of chemotherapy.” – by Jason Harris
Is pain
management an overlooked factor in suicide ideation?
For more information:
- Akechi T. Psychiatry Clin Neurosci. 1999:53:569-573.
- Akechi T. Psychosomatics. 2001;42:141-145.
- Fang F. J Natl Cancer Inst. 2010;doi:10.1093/jnci/djp537.
- Filiberi A. Tumori. 2002;88:193-199.
- Hem E. J Clin Oncol. 2004;doi:22:4209-4216.
- Miller M. J Clin Oncol. 2008;26:4720-4724.
- Misono S. J Clin Oncol. 2008;26:4731-4738.
- Quill TE. J Clin Oncol. 2008;26:4705-4707.
- Pirl WF. Oncology. 1999;13:1301-1302.
- Recklitis CJ. J Clin Oncol. 2009;28:655-661.
- Tanaka H. Jpn J Cancer Res. 1999;90:812-817.
- Von Roenn JH. Ann Intern Med. 1993;119:121-126.
- Walker J. J Clin Oncol. 2008;26:4725-4730.