Japanese Journal of Clinical Oncology 32:506-511 (2002)
© 2002 Foundation for Promotion of Cancer Research
Clinical Factors Associated with Suicidality in Cancer Patients
1 Psycho-Oncology Division, National Cancer Center Research Institute East, Kashiwa, Chiba, 2 Psychiatry Division, National Cancer Center Hospital East, Kashiwa, Chiba, 3 Psychiatry Division, National Cancer Center Hospital, Tokyo, 4 Department of Psychiatry, Kashiwa Hospital, Jikei Medical University, Kashiwa, Chiba, 5 Department of Psychiatry, Chiba Hokuso Hospital, Nippon Medical School, Chiba and 6 Health Science, Hiroshima University School of Medicine, Hiroshima
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ABSTRACT |
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 TOP ABSTRACT INTRODUCTIONPATIENTS AND METHODSRESULTSDISCUSSIONAcknowledgmentREFERENCES |
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Background: Previous epidemiological studies have indicated that the risk of suicide in cancer patients is higher than that of the general population. In addition, euthanasia and physician-assisted suicide (PAS) have recently become controversial medical, ethical and legal issues all over the world. Although suicide in cancer patients and appropriate management of cancer patients with suicidality are critical issues in clinical oncology practice, there have been very few studies to understand suicidality in cancer patients. The purpose of this study was to explore the clinical factors associated with suicidality in Japanese patients with cancer.
Methods: We investigated the clinical factors associated with suicidality in cancer patients by analyzing the consultation data of patients referred to the Psychiatry Division, National Cancer Centre Hospital and Hospital East, Japan.
Results: Of 1713 psychiatric referrals, 62 (3.6%) were related to suicidality, including 44 cases with suicidal ideation, 10 suicide attempts and eight cases who had requested euthanasia and/or continuous sedation. Most of the patients suffered from physical distress and/or psychiatric disorders. The results of a multivariate analysis comparing cancer patients with a psychiatric referral related to suicidality and those referred for other reasons indicated that impaired physical functioning and major depression were significant associated factors.
Conclusions: Our findings suggest that early detection and appropriate management of major depression and comprehensive care improving physical functioning may help to prevent suicide and manage suicidality in Japanese cancer patients.
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INTRODUCTION |
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TOPABSTRACTINTRODUCTIONPATIENTS AND METHODSRESULTSDISCUSSIONAcknowledgmentREFERENCES |
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Previous epidemiological studies have indicated that the risk of suicide in cancer patients is higher than that of the general population (1–8). One survey conducted in the UK demonstrated that 38% of palliative care units had experienced suicide of a patient and 71% had experienced suicidal attempts (9). On the other hand, methodological difficulties in clarifying the detailed underlying causes of cancer suicide victims limit findings regarding the questions ‘why do cancer patients commit suicide?’ and ‘is it rational that incurable cancer patients commit suicide?’. To the best of our knowledge, there have been just two psychological autopsy studies investigating suicide victims among cancer patients and they suggested that several physical, psychological and existential distresses, including pain, impairment of physical functioning, depression, loss of independence and loss of autonomy cause suicide in cancer patients (10,11). In addition, euthanasia and physician-assisted suicide (PAS) have recently become controversial medical, ethical and legal issues all over the world (12). In clinical practice, it is not rare for physicians to receive requests for early death from some patients (13); however, many medical staff face a dilemma when confronting these requests. Several surveys have indicated that more than half of the general population supported legalization of euthanasia or PAS for patients with incurable cancer (14). On the other hand, several recent studies investigating the desire for death in terminally ill cancer patients demonstrated that prevalence of the desire for death in these populations was not rare (ranging from 8.5 to 17.4%) (15–18) and pain, weakness, loss of control, depression, hopelessness and social support factors were significantly associated with the desire for death (15–21).
Although suicide in cancer patients and appropriate management of cancer patients with suicidality are critical issues in clinical oncology practice, there have been very few studies to understand suicidality in Japanese cancer patients. Identifying patients with an increased risk of committing suicide and recognition of the underlying factors in cancer patients with suicidality are the first steps in the prevention of suicide and allow appropriate palliative intervention for suicidal cancer patients.
The purpose of this study was to explore the clinical factors associated with suicidality in patients with cancer by reviewing their psychiatric consultation data.
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PATIENTS AND METHODS |
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TOPABSTRACTINTRODUCTIONPATIENTS AND METHODSRESULTSDISCUSSIONAcknowledgmentREFERENCES |
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Database of Psychiatric Consultation
All psychiatric consultations referred to the Psychiatry Division, National Cancer Centre Hospital East from July 1996 (when the Psychiatry Division was established) to December 1999 and to the Psychiatry Division, National Cancer Centre Hospital from January 1998 (when the same database system was established) to December 1999 were reviewed by the authors. A computerized database, custom-made for the Psychiatry Division, National Cancer Centre, was used to identify cancer patients who had been referred for suicidality (e.g., suicidal ideation, request for euthanasia, suicidal attempt, etc.). The database included demographic variables such as age, gender, marital status and employment status; medical factors such as cancer site, disease stage, brain metastasis and performance status (PS) as defined by Eastern Cooperative Oncology Group (ECOG) criteria, disclosure of cancer diagnosis, in- or out-patient status and pain. These data were obtained from the patients’ charts and/or interviews by psychiatrists. The database also includes the reason for psychiatric consultation, classifying 35 different categories involving suicidality and psychiatric diagnoses. The reasons for psychiatric consultation were assessed by multiple choice based on the description of the physician’s request in a patient chart and/or psychiatrists’ judgment regarding the psychiatric referral after communication with physicians and nurses. Regarding psychiatric assessment of presence or absence of suicidality, there are several difficulties among some cases, especially patients with delirium because delirious patients have consciousness disturbance. Some delirious patients become suicidal because of their distorted cognition, emotional instability, lack of behavioral inhibition and so on. In our clinical practice, we judge delirious patient’s suicidality through the evaluation of these symptoms based on synthetic assessment including interviews with a patient, family members, medical staff, reviewing a patient’s chart and so on. In this study, patients referred for suicidality were extracted from this database. Psychiatric diagnoses were evaluated according to the Diagnostic and Statistical Manual of Mental Disorders, 4th edition (DSM-IV) (22).
Patients’ sheets completed by psychiatrists were automatically read by a mark sheet reader and stored in the database.
Statistical Analysis
After a descriptive statistical analysis, the subjects were divided into two groups according to the presence or absence of suicidality. To investigate the associated factors of suicidality, background data (age, gender, marital status, employment status, cancer site, stage, brain metastasis, performance status, pain and psychiatric diagnosis) were compared between the two groups using an appropriate univariate analysis. Spearman’s rank correlation tests were conducted to explore associations among the retained factors by univariate analysis. The final associated factors were determined by a logistic regression analysis, including variables with a significant P-value (see below) in the univariate analysis. To control Type I error rates, the level of significance involved in each univariate analysis was determined by dividing the significance level (0.05) by the number of tests performed. Thus the significance level in demonstrating factors associated with suicidality was 0.0028 because 18 tests were conducted. All P-values were two-tailed. All data analyses were conducted using SAS statistical software (SAS Institute, 2002).
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RESULTS |
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TOPABSTRACTINTRODUCTIONPATIENTS AND METHODSRESULTSDISCUSSIONAcknowledgmentREFERENCES |
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Patient’ Demographics and Medical Characteristics
A total of 1721 cases were referred to the Psychiatry Division during the study period. Because eight family cases were included in this data source, ultimately the data on 1713 cancer patients were used in this study. Of these, 62 (3.6%) were referred for suicidality (Table 1). The most frequent cancer site was the lung, followed by head and neck and colon. Approximately 80% of patients were diagnosed as having metastatic and/or recurrent cancer. More than 25% had a performance status of 4 and approximately 80% had some degree of pain. All patients had been informed of their cancer diagnosis. Most of the patients had been referred for a psychiatric consultation because of suicidal ideation (n = 44, 71.0%), followed by suicidal attempt (n = 10, 16.1%), request for euthanasia (n = 5, 8.1%) and request for continuous sedation (n = 3, 4.8%). The most common psychiatric diagnosis was major depression (n = 25, 40.3%), followed by delirium (n = 14, 22.6%) and adjustment disorders (n = 13, 21.0%). Five patients (8.1%) did not meet the criteria of any psychiatric diagnosis.
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Factors Associated with Suicidality in Referred Cancer Patients
A univariate comparison of referred cancer patients with or without suicidality is shown in Table 2. Impaired performance status, pain, advanced cancer and major depression were significant associated factors of suicidality. There were several significant associations among these variables. Pain was significantly associated with performance status (r = 0.50, P = 0.0001), advanced cancer (r = 0.31, P = 0.0001) and major depression (r = 0.06, P = 0.02). Performance status was significantly associated with advanced cancer (r = 0.34, P = 0.0001) but not associated with major depression (r = 0.0005, P = 0.98). Advanced cancer was not significantly associated with major depression (r = 0.04, P = 0.09). The results of a logistic regression analysis indicated that performance status and major depression were the final significant associated factors while advanced stage and pain were not significant (Table 3).
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DISCUSSION |
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TOPABSTRACTINTRODUCTIONPATIENTS AND METHODSRESULTSDISCUSSIONAcknowledgmentREFERENCES |
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This study examined the associated factors of suicidality in Japanese cancer patients seen in a psychiatric consultation setting. The background characteristics of the patients indicate that most patients referred for suicidality had metastatic and/or recurrent cancer and many suicidal cancer patients suffer from physical distress, such as impaired performance status, pain and/or psychiatric disorders. These findings suggest that suicidal cancer patients suffer from complicated physical and psychological distress.
The results of the univariate and multivariate analyses suggest that biomedical (cancer stage, performance status and pain) and psychiatric factors (major depression) may be significant factors associated with suicidality in Japanese cancer patients.
Regarding the biomedical factors, the patient’s physical function may be the most important factor in suicidality; cancer stage and pain are also potentially important factors, but these items may be confounding. It is interesting that pain was not indicated as a significant associated factor in the multivariate analysis whereas it was indicated as significant in the univariate analysis. Several anecdotal reports have demonstrated the deleterious effect of pain on suicidality in cancer patients (23,24). On the other hand, several other studies failed to show any significant association between pain and suicidal ideation in terminally ill cancer patients receiving palliative care (17,18). Our findings demonstrated that pain was significantly associated with performance status and the correlation coefficient was high. This significant association and the result of the multivariate analysis suggest that declining physical function resulting from presence of pain may contribute to patients’ suicidality in our study subjects. Our findings and those in previous studies suggest that the association between pain and suicidality in cancer patients seems to be complicated; however, this association may be significant in a setting other than palliative care. In addition, pain may influence patients’ suicidality by way of declining physical function. On the other hand, as physical function has been repeatedly shown as a significant suicidality associated factor in cancer patients (16,17), this may be one of the key biomedical elements influencing the suicidality of such patients. As our previous studies indicated a significant association between declining physical function and helplessness/hopelessness in cancer patients (25) and also between the decline of physical functioning and suicidal ideation in cancer patients with major depression (26) and other studies indicated significant association between hopelessness and suicidal ideation (17,21), hopelessness resulting from declining physical functioning may be one of the important cause of suicidal ideation in cancer patients.
Concerning psychiatric disorders, only major depression was a significant associated factor, which is consistent with the findings of previous studies (10,15–18,27). Major depression is known to be the most common psychiatric disorder in cancer patients (28) and also one of the major associated factors for their suicidal ideation (15–18,27). In addition, one study conducting a psychological autopsy of suicidal victims in cancer patients and those without cancer revealed that depressive disorders are a common leading cause of suicide among both populations (10). The experience of legalized euthanasia, in Australia, revealed that depression is common in the population requesting euthanasia under the law (29). Our findings and also previous studies repeatedly emphasize the importance of assessing major depression among cancer patients with suicidal ideations even in those suffering from incurable or terminally ill cancer, although suicidal ideation experienced by cancer patients does not mean a diagnosis of depression itself. On the other hand, several studies have suggested that depression in cancer patients is likely to be underestimated by both their nurses and their physicians (30–32), so efforts at early detection and appropriate management of their depression may be one of the most important ways of preventing suicide. However, because our experience showed that management of depression in cancer patients whose life expectancy is estimated to be extremely short (e.g. less than 2 weeks) is difficult (27), treatability of depression in the terminally ill should be investigated in a future study. Another interest is the quantitative and qualitative differences of suicidality between cancer and physically healthy patients with major depression. Regarding a quantitative difference, no significant difference seems to exist as our previous study suggested that prevalence of suicidal ideation identified among cancer patients with major depression is similar to that among patients with major depression in a usual psychiatric setting (26). On the other hand, concerning qualitative differences, because broader and more multi-dimensional factors have been identified as underlying factors of suicidality among cancer patients (see the Introduction), there may be several qualitative differences in suicidality between cancer and physically healthy patients with major depression. To the best of our knowledge, there have been no studies addressing these qualitative differences. Further studies are needed to clarify whether there are qualitative differences or not between cancer patients and other patients with major depression.
In conclusion, patients with impaired physical functioning and major depression should be carefully monitored and provided with appropriate care to prevent suicide. One study reported the efficacy of palliative care involving multidisciplinary health care professionals for the prevention of suicide in terminally ill cancer patients (33) and comprehensive care may be a key factor in preventing suicide and in the management of suicidality among cancer patients.
This retrospective study has several limitations. Because the referred patient sample may have been influenced by a physician bias and may have not been representative of Japanese cancer patients, this is the most important limitation. In addition, important information, such as physical distress other than pain, past history of suicide ideation and/or attempt, family history of suicide, past history of major depression, social support factors and existential distress, was not included in the analysis.
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Acknowledgment |
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TOPABSTRACTINTRODUCTIONPATIENTS AND METHODSRESULTSDISCUSSIONAcknowledgmentREFERENCES |
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This study was supported in part by a Grant-in-Aid for Cancer Research (11-2, 11-31) from the Japanese Ministry of Labor, Health and Welfare.
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FOOTNOTES |
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+ For reprints and all correspondence: Yosuke Uchitomi, Psycho-Oncology Division, National Cancer Center Research Institute East, 6–5–1 Kashiwanoha, Kashiwa 277-8577, Japan. E-mail: yuchitom@east.ncc.go.jp
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Received July 2, 2002; accepted September 18, 2002
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