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Suicide in Cancer Patients: Part 1

Have you encountered patients who have voiced the wish to kill themselves? Or perhaps patients who have said “I wish I could go to sleep and not wake up”? Do you feel comfortable responding to these comments? Are you confident in your ability to distinguish between a patient who may be expressing frustration with treatment and its side effects, and a patient who might be planning to harm themselves? As a nurse, what is your role within the team when working with a patient who may be suicidal? The goal of this blog is not to make you feel responsible for managing a potentially suicidal patient, but to empower you to feel more comfortable if a patient broaches the topic of suicide, and to enable you to accurately describe your concerns when referring the patient to the appropriate mental health services. As a nurse it is not your role to formally assess or treat suicidal ideation or behaviors within your patients. 

This portion of the blog will cover suicide-related terms, statistics on suicide both within the general population and in cancer patients, and warning signs, risk factors, and protective factors. A second blog will discuss how to respond to a patient’s comments regarding suicide, and importantly, how to facilitate a referral.

First:  Cancer-related terms and definitions. There is a continuum of suicide-related thoughts and concepts. 
  • Thoughts of death: This may be a fleeting wish to die, or to have a hastened death. Patients may say “I want to go to sleep and not wake up.” This statement is not unusual among cancer patients, and unless this thought is persistent, it is not particularly worrisome.
  • Suicidal Ideation: Thoughts on how a suicide might be carried out.
  • Plans for suicide: Specific thoughts on how to complete suicidal behavior.
  • Suicide Attempt:  A non-fatal attempt to harm oneself with the intent to die.
  • Completed Suicide: Death caused by self-harm with intent to die.
How common is suicide within the general population? According to the CDC, suicide is the 10th leading cause of death in the US, with slightly more than 1% of deaths being attributed to suicide.1 The table below indicates the frequency of suicidal behaviors along the suicide continuum.

Prevalence of Suicidal Thoughts and Behaviors in US Adults

  Percentage Number
Serious thoughts 3.7 8.3 million
Made plan 1.0 2.3 million
Suicide attempt 0.5 1.1 million
Suicide death 0.01 34,598
Source: CDC; 2007
What factors are associated with suicide? Among the general population, certain characteristics are correlated with a higher risk for suicide2:
  • Having a  chronic disease or chronic pain
  • Being older than 65, or younger than 21
  • Living alone and being unemployed
  • Being male (males are 4 times more likely than females to kill themselves)
  • Having a mental illness (90% of those who complete suicide have depression, mental illness, and/or substance abuse)
Keep in mind that despite known risk factors, there is no consensus as how to predict suicide accurately2. Individuals with several risk factors may continue to persevere through their difficulties, while other individuals who appear to be doing well may suddenly take action to harm themselves.

How does suicide among cancer patients compare with suicide in the general population? Cancer patients have double the rate of suicide compared to the general population.In fact, in a study of people who were ill, cancer was the only illness associated with an elevated level of suicide.Factors correlated with suicidal behavior among cancer patients include4:
  • Site: prostate, lung, head and neck, pancreatic
  • Stage: patients with advanced disease have 3 times the rate of major depression.
  • Depression/Hopelessness: depression is a major risk factor; also, feeling as if they are a “burden to others.”
  • Time since diagnosis:the risk is highest during the first 5 months after diagnosis, and then it decreases.
  • Gender: Male
  • Age: older (over 65) have an elevated risk, and the risk increases as age increases.
  • Race: caucasians have a higher rate
Now that I know my patients are at higher risk for suicide, what should I be looking for? Several factors may help you to identify which patients may be at higher risk for suicide. Risk factors (characteristics or factors that are known to raise the risk of suicide and usually factors that cannot be modified) and warning signs (specific symptoms or behaviors that can be assessed and treated) increase a patient’s risk for suicide. Protective factors may buffer individuals from carrying through with harmful thoughts.

Risk Factors5
  • Personal or family history of suicide attempts or completion
  • Psychiatric diagnosis (especially depression) or a history of alcohol or substance abuse
  • White male
  • Increasing age
  • History of sexual abuse
  • Easy access to lethal methods
  • Divorced
  • Smoker
  • Physician or prisoner
  • Feelings of hopelessness
  • Physical illness
Warning Signs5
  • Threats or plans for suicide
  • Hopelessness
  • Rage, anger
  • Impulsivity
  • Substance use
  • Being in withdrawal from substance abuse
  • Changes in sleep
  • Mood changes
  • Agitation or anxiety
Acute anxiety and agitation are considered critical suicide warning signs6 In one study, hospitalized patients who died by suicide endorsed or exhibited severe anxiety or agitation more often than they endorsed suicidal behavior. In fact, studies have shown that anxiety disorders predict suicidal behaviors more often than other disorders7. Note that while any psychiatric diagnosis raises the risk of suicidal ideation, anxiety and impulse disorders more accurately predict progression to suicidal behavior.  Also, although depression does predict suicidal ideation, it does not predict progression to suicidal behavior.6
 
Protective Factors8
  • Access to effective treatment for mental and physical disorders
  • Support from family and community
  • Effective coping skills
  • Cultural and religious beliefs which discourage suicide
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References
1. Centers for Disease Control and Prevention, National Center for Injury Prevention and Control, Division of Violence Prevention. Available online at http://www.cdc.gov/ViolencePrevention/pdf/Suicide_DataSheet-a.pdf. Accessed June 29, 2015.
2. McDowell AK, Lineberry TW, Bostwick JM. Practical suicide-risk management for the busy primary care physician. Mayo Clin Proc. 2011;86(8):792-800.
3. Miller M, Mogun H, Azrael D, et al. Cancer and the risk of suicide in older americans. J Clin Onc. 2008;26(29):4720-4724.
4. Anguiano L, Mayer DK, Piven ML, et al. A literature review of suicide in cancer patients. Cancer Nursing. 2012;35(4):E14-E26.
5. Rudd MD, Berman AL, Joiner TE Jr, et al. Warning signs for suicide:  theory, research, and clinical applications. Suicide Life Threat Behav. 2006;36:255-262.
6. Fawcett J. Treating impulsivity and anxiety in the suicidal patient.  Ann N Y Acad Sci. 2001;932:94-102.
7. Busch KA, Fawcett J, Jacobs DG.  Clinical correlates of inpatient suicide.  J Clin Psychiatry. 2003;64:14-19.
8. Centers for Disease Control and Prevention, National Center for Injury Prevention and Control, Division of Violence Prevention. Available online at http://www.cdc.gov/violenceprevention/suicide/riskprotectivefactors.html. Accessed June 29, 2015.
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