This is part of series of columns on the doctor/cancer patient relationship by Seabrook resident Dr. Roy Sessions, MD, and Fellow of the American Council of Surgeons.
For some time we have discussed matters that swirl around cancer related topics, and today’s topic – suicide – while seeming to be a departure, is actually relevant because cancer victims have a significantly higher rate of suicide then their healthy counterparts. To some of the readership, this may seem like a visit to the dark side, but you have stayed with me through a number of blogs about the scariest of maladies – cancer – and one of the consistent themes throughout my writings has been that honest dialogue, realistic information seeking, and avoidance of false optimism and conversely desperate pessimism are all components of an intelligent and educated approach to the problem. So it is with suicide – sweeping matters under the rug is unwise, and psychologically myopic! My childhood was distorted by a family suicide that affected me immensely. Superstition 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. This essay series has mostly dealt with cancer-related matters, and this writing will continue in that vein by linking the subject of suicide to that disease; however, in order to understand this subset of patients, the reader should first consider suicide generically.
Obviously, suicide does not require physician assistance, and I will not include a discussion of euthanasia. Instead I’ll focus on the act that is spontaneously committed. That said, euthanasia is rapidly becoming more a part of our societal dialogue, and I’ll delve into it in a forthcoming essay.
Much of the information regarding suicide worldwide is neither well reported nor collated; hence, misinformation abounds. Furthermore, because of cultural eccentricities, the global suicide burden can only be estimated. Data sets are undoubtedly distorted in India, for instance, where suicide is actually illegal, and the aftermath of the act can lead to consequences for the surviving family; in fact, the law there is thought to be responsible for a tenfold underestimate of self inflicted death. In China, where 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. Even factoring in the different sizes of the two countries, the difference is striking. The World Health Organization estimates that in the world, there are one million self-inflicted deaths per year. This figure represents approximately a 1.5 percent of all deaths—a number that makes suicide the tenth leading cause of death worldwide, and almost certainly, these are grossly underestimated numbers. For instance, in China as many as 15 percent of all deaths probably go unreported, and one is only left to speculate how little administrative attention is paid to determining what is suicide and what is not. Such embedded 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.
Despite these statistical limitations, there are some consistent facts worthy of noting: rates vary greatly, with the greatest burden in developing countries; throughout the world, men are substantially more likely than women to commit suicide; and the overall suicide rate in the elderly seems to be diminishing while during the last fifty years, that rate has increased substantially in the younger generations.
Certain contributory factors afford some help in risk-factor development: acute psychosocial crises, psychiatric disorders, pessimism 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 die by suicide. Other factors: white Americans over African Americans and Hispanics, both male and female homosexuals over heterosexuals, drug and alcohol dependents, and individuals 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 to it. 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. While it’s a foregone conclusion for psychiatrists and psychologists, for those of us lacking sophistication in this arena, this 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 an intellectual exercise. 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 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 matter, one is struck by the complexity of the issues and with the lack of reliability of controlled data. Translating suicidal ideations into predictive data is tricky business. For example, a substantial percentage of college-age individuals have thought 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 patient’s first outlet for his or her 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 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 early lessons in psychiatric training 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 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 have been referred to in the preceding paragraphs. Of course, all of these thoughts and actions must be blended with the appropriate psychiatric 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 to them.
In the past, I’ve dealt with suicide queries from doomed patients in a variety of ways, but the theme common to 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, discouragement, fear, concern for financial and family compromise, a desperate concern 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 and physical forces. Some patients simply say to themselves, “Who needs all of this?”
The style of this essay – as if speaking mostly to physicians – was intentional. I want you to know how I think physicians should relate to both the subject and to their patients. The superstitions I mentioned in the first paragraph of this piece are not limited to the lay public, and surprisingly, the medical profession – including oncologist – is lacking in sophisticated knowledge of the subject. For reasons that I’ll talk about in next month’s blog, the subject has been one of the taboos of our culture. Next month, I’ll follow this overview with a somewhat deeper probe into this sad but important slice of our societal concerns.
The list of references for all of the relevant data was extensive, and I thought would be a bit too much for this format. If you wish to check my facts or even just to seek information, I will be happy to provide the appropriate references on an individual basis.
Roy B. Sessions, MD, FACS
Seabrook Island, SC