Evaluation and Treatment of Suicidal Patients with Cancer
The incidence of suicide in cancer patients may be as much as 10 times higher than the rate of suicide in the general population. One study has shown that the risk of suicide in patients with cancer is highest in the first months after diagnosis, and that this risk decreases significantly over decades. Passive suicidal thoughts are fairly common in patients with cancer. The relationships between suicidal tendency and the desire for hastened death, requests for physician-assisted suicide, and/or euthanasia are complicated and poorly understood. Men with cancer are at an increased risk of suicide compared with the general population, with more than twice the risk. Overdosing with painkillers and sedatives is the most common method of suicide by patients with cancer, with most cancer suicides occurring at home. The occurrence of suicide is higher in patients with oral, pharyngeal, and lung cancers, and in HIV-positive patients with Kaposi sarcoma. The actual incidence of suicide in cancer patients is probably underestimated, since there may be reluctance to report these deaths as suicides.
General risk factors for suicide in a person with cancer include the following:
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A history of mental problems, especially those associated with impulsive behavior (such as borderline personality disorders).
A family history of suicide.
A history of suicide attempts.
Recent death of a friend or spouse.
Having little social support.
Cancer-specific risk factors for suicide include the following:
A diagnosis of oral, throat, or lung cancer (often associated with heavy alcohol and tobacco use).
Advanced stage of disease and poor prognosis.
Poorly controlled pain.
Physical impairments such as the following:
Loss of mobility.
Loss of bowel and bladder control.
Loss of eyesight or hearing.
Inability to eat or swallow.
Patients who are suicidal require careful evaluation. The risk of suicide increases if the patient reports thoughts of suicide and has a plan to carry it out. Risk continues to increase if the plan is "lethal," that is, the plan is likely to cause death. A lethal suicide plan is more likely to be carried out if the way chosen to cause death is available to the person, the attempt cannot be stopped once it is started, and help is unavailable. When a person with cancer reports thoughts of death, it is important to determine whether the underlying cause is depression or a desire to control unbearable symptoms. Prompt identification and treatment of major depression is important in decreasing the risk for suicide. Risk factors, especially hopelessness (which is a better predictor for suicide than depression) should be carefully determined. The assessment of hopelessness is not easy in the person who has advanced cancer with no hope of a cure. It is important to determine the basic reasons for hopelessness, which may be related to cancer symptoms, fears of painful death, or feelings of abandonment.