Suicide risk high among patients with cancer

Older adults with cancer commit suicide more than adults with other medical illnesses.

The incidence of suicide among patients with cancer is nearly double that among the general population, according to recent data.

A retrospective study was conducted by researchers at the University of Washington, the Fred Hutchinson Cancer Center in Seattle and the University of Minnesota in Minneapolis. The results were published in the Journal of Clinical Oncology. The observed rate of suicide was 31.4 per 100,000 person-years among patients with cancer. The suicide rate in the general U.S. population was 16.7 per 100,000 person-years.

“The psychological experience of cancer survivors deserves further attention, as urged by the Institute of Medicine, particularly because appropriate use of psychosocial interventions in patients with cancer can make a positive impact on quality of life,” the researchers wrote.

According to Walter Baile, MD, psychiatrist and professor of behavioral science at The University of Texas M.D. Anderson Cancer Center and Supportive & Palliative Care section editor for HemOnc Today, there is a common belief that cancer uniformly causes cancer patients to be depressed. While many patients become demoralized at times during their illness, only a minority develop major depression. Those more likely to develop major depression have risk factors, such as a history of major depression, he said.

“It would be helpful for oncologists to pay attention to what patients have risk factors (such as uncontrolled pain or other symptoms, a sense of hopelessness, poor family support and previous antidepressant treatment) and to ask several simple questions,” Baile told HemOnc Today. “How are you coping with your illness? How has your mood been? Those are good questions to encourage patients who are profoundly depressed to talk about their mood. Clinicians should not avoid asking patients who are depressed if they have been having thoughts of 'doing themselves in.'”

Suicidal thoughts

Researchers at the University of Edinburgh in Scotland evaluated suicidal thoughts by conducting a survey of patients who attended outpatient clinics of a regional cancer center in Edinburgh. The results were published in the Journal of Clinical Oncology.

The patients completed a questionnaire that included nine questions to screen for depression. The last question asked how often in the past two weeks the patients thought they were better off dead or thought about hurting themselves. The researchers used the answers to this question for their analysis.

The possible responses were “not at all,” “several days,” “more than half the days” or “nearly every day.” Patients who reported having these thoughts for at least several days were considered positive responders.

Among the 2,924 patients, 7.8% were positive responders. Significant emotional distress, substantial pain and older age were associated with a positive response.

Older patients

After controlling for psychiatric illness and the risk for dying in one year, older patients with cancer were more likely to commit suicide than older patients with other illnesses. This case-control study was conducted by researchers at Harvard University and Rutgers University in New Brunswick, N.J. The results were published in the Journal of Clinical Oncology.

The researchers identified 128 patients who were enrolled in Medicare and in a pharmaceutical insurance program who had died as a result of suicide. Each patient was matched with 10 controls.

On multivariate analysis, cancer was the only illness associated with suicide (OR=2.3; 95% CI, 1.1-4.8). Suicide was also associated with affective disorder, anxiety/personality disorder, treatment with antidepressants and treatment with opioid analgesics. – by Emily Shafer

J Clin Oncol. 2008;doi:10.1200/JCO.2007.14.3990.

J Clin Oncol. 2008;doi:10.1200/JCO.2007.13.8941.

J Clin Oncol. 2008; doi:10.1200/JCO.2007.11.8844.

From Walter Baile, MD

Q: Are suicidal thoughts a common problem among patients with cancer?
A: In a survey conducted last year by the American Institute for Cancer Research, researchers found that 32% of individuals believed that cancer would be the worst thing that ever happened to them. From the standpoint of the fear and anxiety related to cancer, it is not surprising that people had thoughts about ending their lives if their suffering became too great.

Cancer is a disease of loss. People lose their health, their self-esteem and often their ability to work and their connections with their loved ones. The treatments are grueling and often associated with disability. Major depression and demoralization is not an uncommon thing in patients with cancer, at least during periods of treatment. Some of the treatments that we give patients can be responsible for depression, such as steroids. The emotional stress is high, so the findings in these studies are not surprising.

Q: Do you think that oncologists need to be more vigilant in recognizing suicidal patients?
A: Findings of other studies on suicide in patients with medical illnesses often indicated that many patients had visited their physicians in the weeks prior to committing suicide. The psychiatric community has been interested in this topic and has created a pathway for evaluating the distress. Some cancer centers are using a distress questionnaire to screen patients who might be at risk for depression or other psychiatric illnesses associated with the risk for suicide. That has been extremely important.

There is a belief that cancer causes depression in everyone and is thus normal. Nothing could be further from the truth. There are many patients who cope well and do not become suicidal or morbidly depressed. We need to pay attention to two things. One is risk factors. It appears that certain cancers may be associated with a higher risk for depression and suicide, such as pancreatic and certain head and neck cancers. Second, patients with a history of depression are at higher risk for depression and suicide. It would be helpful for oncologists to pay attention to what patients have risk factors and to ask simple questions: How are you coping with your illness? How has your mood been? Those are some good screening questions to encourage patients who are extremely demoralized or clinically depressed to get some help. Ultimately, many of these patients’ depression may be treatable, even in those who have advanced cancer. I see a fair amount of patients who respond well to antidepressants.

Q: How should oncologists respond to these patients? When is referral to a psychiatrist necessary?
A: Patients with major depression should definitely be referred to psychiatrists. An additional question to ask patients is: Is the depression so bad that you thought about committing suicide? Anyone who has suicidal thoughts, who is profoundly depressed to the point where they cannot get out of bed or who feels totally hopeless needs to be referred to a psychiatrist. Other depressed patients who are not suicidal and whose depression is not interfering with everyday activities can be treated with antidepressants. If the oncologist is comfortable with antidepressants, then they can prescribe antidepressants for patients who are depressed but not suicidal. Many oncologists today prescribe antihypertensive medications and other medications that are not necessarily related to cancer treatment. It is not beyond their clinical competence to prescribe antidepressants as long as they monitor the patient. If the patients do not respond to antidepressants, then they should be referred to a psychiatrist.

My recommendation is also that if an oncologist has a patient who is depressed and they are undecided about how to treat, they should seek advice from a psychiatrist. That happens in cancer centers often, especially if the patient does not want to see a psychiatrist.