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In this particular venue my essays have usually discussed psychosocial issues related to cancer. Today’s topic, while seemingly a departure from that pattern, is actually relevant because victims of this dreaded malady have a significantly higher rate of self-inflicted death than do their healthy counterparts.
Consistent throughout my cancer-related blogs has been the theme that honest dialogue, realistic information seeking, and avoidance of both false optimism and desperate pessimism are all components of an intelligent and educated approach to the associated problems. So it is with suicide—sweeping matters under the rug is unwise, and psychologically myopic! My own childhood was distorted by a family suicide that affected me immensely. Religious superstitions and a “stiff upper lip” were in full play in the Sessions’ household—failure to deal with and discuss feelings led to issues that would haunt me throughout my adult life. It wasn’t until much later that I finally dealt with those demons. Wow! What a relief it was to dump that ballast. My own issues aside, come with me now to think about and discuss this subject—after all, it’s sometimes a part of the life experience, and an important part of the overall cancer discussion. Obviously, suicide doesn’t require physician assistance, and I will not address euthanasia; rather the focus will be on the act that is spontaneously committed.
Much of the worldwide information regarding suicide is neither collated nor well reported; hence, misinformation abounds. Furthermore, because of cultural eccentricities, the global suicide burden can only be estimated. Data sets from India, for instance, are undoubtedly distorted, because the act itself was illegal until recently —failed suicide attempts had legal consequences for the person, and the aftermath of the act when successful, led to negative consequences for the surviving family. This long standing law is thought to be responsible for a tenfold underestimate of self-inflicted death in that country. In China, where an estimated 30 percent of worldwide suicides occur, a three to one rural prevalence of its occurrence almost certainly leads to many such deaths going unreported. It is thought that approximately 300,000 suicides occur each year in China, as opposed to the 31,000 in the United States. At first glance, one questions the mathematical power of this comparison because of the relative population differences of the former (1.3 billion) and the latter (330 million). But consider this: the estimated 15% of all deaths going unreported in China and additionally, the likelihood that less attention is paid to determining what is suicide and what is not, together suggest that estimated numbers are likely much higher. Such imbedded data is not limited to Asia—a number of Western countries such as France, several Scandinavian countries, and others have policies in which suicides are not consistently separated from deaths of “unknown” cause. This practice of combining data to record deaths almost certainly alters the true suicide rate that is reported to the World Health Organization. The WHO estimates that in the world, there are one million self-inflicted deaths per year, which is a figure that represents 1.5 percent of all deaths, and the tenth leading cause of death globally. All variables considered, these figures are probably a modest estimate.
Data does help us understand some risk-factor development: acute psychosocial crises, psychiatric disorders, pessimism and/or hopelessness, impulsivity, family history, certain childhood factors—all are associated with a higher overall suicide rate. The most important factor that applies to suicide in both cancer patients and others is that the rate associated with depression is many times the general population risk. In fact, the numbers are staggering: more than 50 percent of all people who die by suicide are clinically depressed. If one looks at the data from the opposite direction, approximately 4 percent of clinically depressed individuals die by suicide, a number that is even higher in males. Importantly, of those individuals afflicted with bipolar disorders, 10-15 percent commit suicide. Other factors are relevant: white Americans over African Americans and Hispanics; both male and female homosexuals over heterosexuals; drug and alcohol dependent individuals; and those who have suffered physical and sexual abuse during childhood all reflect a higher suicide rate than the controls in each respective group. A final daunting statistic is that in 40 percent of suicides, there has been a previous suicide attempt. This last risk factor stands out among all others!
With regard to the older population, if one excludes mental illness and looks only at matters that contribute to suicide, three of life’s problems stand out as constituting risk factors—physical illness, interpersonal problems, and bereavement. Since this series of essays mostly concerns matters pertaining to cancer, let’s look at the first of the three. In an important paper, Harwood and colleagues reported that in fully two-thirds of the older suicide victims studied, physical illness contributed.(1) A similar study of older North American suicide victims and also a study focused on their Scandinavian counterparts both suggest that physical illnesses—especially malignant and neurological disorders—are associated with a particularly high suicide rate in the elderly. Not a small complicating issue in the evaluation of all of these data is the fact that the link between suicide and physical illness, including cancer, may be mediated through depressive symptoms. According to Harwood et al., of those in whom physical illness was thought to be an impetus for their suicide, 60 percent also suffered from depression during the months before the act.(2) While this may be a foregone conclusion for psychiatrists and psychologists, for those of us lacking sophistication in this arena, such information serves to reaffirm the fact that depression is not limited to people with mental illness.
All of this data leads to one of the themes throughout my writings—caring for cancer patients is a uniquely challenging endeavor, and in addition to all of the other risk considerations, the cancer patient is more likely to commit suicide compared to age and gender-matched cohorts. On a number of occasions, cancer patients have approached me with “the possibility” of suicide—some with a sense of desperation, and others coolly, as if conducting a survey. Such probing more often than not reflects an underlying thought process referred to in psychiatric jargon as suicidal ideations. These queries—whether obtuse or direct—should neither shock nor deter cancer doctors from counseling the patient in a realistic and mature manner. Most psychiatric literature suggests that the incidence of suicide ideations—though a significant precursor to the actual act of suicide—is substantially more frequent than completed suicide; the latter does not necessarily follow the former. As I write this, I am reminded of the poignant words of the German philosopher, Friedrich Nietzsche, “The thought of suicide is a great consolation: by means of it one gets successfully through many a bad night.” In reviewing a number of studies regarding this general matter, one is struck by the complexity of the issues as well as the lack of reliably controlled data. Translating suicidal ideations into predictive data is tricky business, however. For example, a substantial percentage of college-age individuals have thoughts (ideations) about committing suicide. In addition to this phenomenon, if one considers the prevalence of mental illness, especially depression - both bipolar and otherwise - the influences of drugs and alcohol, and finally, the whole subculture of patients dying with physician assistance (i.e., terminal sedation), even experts on these matters must often rely on estimates. Despite these flawed methods, many valuable conclusions regarding the relative risk-factor profile have been developed for the various types of suicide.
It is important to recognize that the oncologist is often the first outlet for a patient’s most intimate thoughts; therefore, when suicidal ideations surface, no matter how subtly verbalized, the physician should respond by encouraging, rather than discouraging dialogue. Lest oncologists underrate the importance of this moment in time, I draw attention to the fact that a substantial number of cancer patients who ultimately commit suicide have visited their cancer physician in the month that preceded the act.
The state of alertness to the likelihood of suicide should be heightened even more in individuals with malignancies of certain select organ sites—breast, prostate, and head and neck cancers all seem to be associated with higher rates of suicide than other sites. The patient’s “overture”—no matter how subtle, represents an important juncture, essentially, a reaching out for help. From this point on, the oncologist must uncouple morality and suicide and react as a physician, rather than a theologian. In my opinion, it’s dismissive and condescending to respond to such a trial balloon with triteness: “it’s not a good idea,” “it’s morally wrong,” “that won’t solve anything.” And most unforgivable is to avoid the discussion altogether. Following such a nonproductive visit with the physician, a cancer patient is left with the same questions, the same motivations, and the same sense of desperation that he or she came in with. The major change that results from such psychiatric ignorance is that the physician has largely lost the confidence of the patient and has probably squandered any hope of influencing the course of events. One of the lessons in “Psychiatry 101” is to never underestimate the significance of a patient talking about suicide, no matter how innocent sounding. While not always a prologue to action, it must always be taken seriously. On several occasions, I have had the sad experience of patients actually taking their own life, and even though I recognized their rationale, each evoked within me a sense of having failed in my leadership and guidance of a desperate patient. After the fact, I pondered whether if I had established the correct relationship with the patient or perhaps picked up on certain signals, this might not have happened. For the compulsive, the sense of failed responsibility is like the memory of an odor—amorphous, and pervasive. On the other hand, I am conflicted by my ambivalence in this matter. Vivid recollections of a number of patients linger within me, but two in particular reverberate in my memory. Each was dying of refractory head and neck cancer that was creating unspeakable misery and degradation—odor, drooling, pain, and embarrassment. When they ended their own lives I felt relief; at a minimum, I understood their reasons. This confession may be good for my psyche, but forgetting is another matter.
The mandate for alertness relative to suicide prevention should be more intense in patients with favorable situations and can ethically be looked at with different standards than patients like the ones I just cited with refractory cancer. Regarding the attention given to those with favorable prognoses, it is important to note that the prevalence of suicide is probably highest in the first three months following the diagnosis of cancer, and then peaks again at about one year after treatment. Additionally, there are data suggesting that, for unexplained reasons, the risk for adult survivors of childhood cancer is elevated over non-cancer patients. More understandable is that the risk factor for suicide in cancer patients is higher in the elderly. Finally, we can’t loose sight of the threefold increase in suicide rate among cancer-afflicted widowed men compared with those who are married. The take-home message here is that in dealing with this matter, the oncologist should individualize the situation and tailor the response by considering the risk factors and characteristics that I referred to in the preceding paragraphs. Of course, all of these thoughts and actions must be blended with the appropriate psychiatric / psychological consultation.
In another blog, I stated that psychological support given to the cancer patient should be delivered circumferentially—from all members of the cancer team, but especially from the oncologist to whom the patient extended “the overture.” Essentially, that team member has a greater responsibility in the process by virtue of the fact that the patient apparently feels a stronger connection with them.
In the past, I’ve dealt with suicide queries from doomed patients in a variety of ways, but the theme common in my response has always involved the reassurance that I would be available until the end, and that I would exercise a very liberal use of medications for sedation and pain. It is important to note, however, that pain alone does not frequently explain the motivation to end one’s life. In fact, there is survey data from the Dutch experience that shows pain is responsible for only 5 percent of the inquiries about that country’s euthanasia program. The same is probably true among those who consider suicide in the United States. The motivation is usually not singular, but instead broad based. Consider, if you will, the enormity of what the cancer patient faces—the forces of depression/anxiety, fear, discouragement, concern for financial and family compromise, a desperate search for privacy and dignity, and lastly the avoidance of going through the general misery of the terminal period—all come together in an avalanche of psychic forces. Some patients simply say to themselves, “Who needs all of this?”
The style of this essay, while seemingly presumptuous, i.e. a cancer surgeon delving into critical psychological matters—was intentional. We are the ‘frontline”, therefore a perceptive and thoughtful approach should be at the heart of our professional armamentarium. The superstitions I mentioned in the first paragraph of this writing are not limited to the lay public, and surprisingly, the medical profession—including oncologist—is often lacking in sophisticated knowledge of the subject. For reasons that I’ll talk about in the next blog, suicide has been one of the taboos subjects of our culture. Next time, I’ll follow this overview with a somewhat deeper probe into this sad but important concern.
References:
(1) Michal Harwood, et al, “Life Problems and Physical Illness as Risk Factors for Suicide in Older People ….”, Psychological Medicine, Volume 36, no. 9 (September 2006): 1265-74
(2)Harwood, Hawton, et al. “ Life Factors and Physical Illness as Risk Factors for Suicide.”
